At the bedside, helping my patients die with peace of heart involves doing all that I can, day after day, to alleviate their pain and suffering. But it’s not just about how skilled I am at what I do. It’s as much about how I do what I do. It matters that I listen deeply to my patients, that I act with kindness, and that I am able to wait, knowing that it’s not all up to me, trusting that my patients carry within themselves an innate capacity for healing. When I act in this way, with close attention and care and, above all, with humility, I notice that it lessens both my own and my patient’s anxiety, creates security, and opens up a space where healing may happen. And when this occurs, as it did for James, I am every time as surprised and delighted as my patient is. I know that the patient and I are in the presence of a process that is beyond our intelligence that has its own agency. I appreciate why my Native American teachers speak of this as the work of “The Great Mystery.”
Through the 1990s and into the early years of this millennium, in my own search for healing, I experienced a growing desire to be closer to the natural world. I sought out the work of those who talked about the Earth as animate and intimate, including Irish writer John Moriarty and American writers Barry Lopez, Gary Snyder, and Mary Oliver. I came across the story of the Lakota Holy Man, Nicholas Black Elk. The book about his life coauthored with John Neihardt, Black Elk Speaks, ends with a poignant story that awoke in me what felt like a deep, forgotten grief.
This is the description of what happened when, as an old man, Black Elk returned to Harney Peak in the Black Hills of South Dakota and to the exact spot where, as a child, he had received a powerful vision of the healing of his people. As he stood there holding the sacred pipe and offering prayers to his ancestors, he began to weep. In words of despair he talked about how he believed he had failed in helping to realize what his vision had foretold. John Neihardt, who was with him on that occasion, ends the book with these words:
We who listened now noted that thin clouds had gathered about us. A scant chill rain began to fall and there was low, muttering thunder without lightning. With tears running down his cheeks, the old man raised his voice to a thin high wail, and chanted, ‘In sorrow I am sending a feeble voice, O Six Powers of the World. Hear me in my sorrow, for I may never call again. O make my people live!’ For some minutes the old man stood silent, with face upturned, weeping in the drizzling rain. In a little while the sky was clear again.9
In October 2005, I was sitting in a coffee shop after work with my friend Mario. I had told him the story of Black Elk, and how moved I was by it. I had shared with him how I would love to learn more about Native American ways of seeing and being in the world. Mario told me about a Native American community he had been introduced to by his Buddhist teacher, Shinzen Young, which welcomed anyone who was interested in this way of prayer. He invited me to come with him to a sweat lodge ceremony he was planning to attend at their mountain camp the following weekend.
I was both excited and anxious at the prospect. I also had concerns about coming to an Native American ceremony as a white man and a European, one whose ancestors had done so much damage to Native North American peoples by stealing their lands, killing the animals they depended on, and destroying their way of life. From 1884, when the United States formally outlawed “pagan” ceremonies, until the American Indian Religious Freedom Act in 1978, it was illegal for the Indian people of North America to practice some aspects of their religious rituals; during that time someone who was caught leading or participating in a ceremony such as the one I was about to attend could have been imprisoned. I was aware that to this day some Indians did not want non-Native people to participate in their ceremonies, being justifiably wary and suspicious of their motives.
The following Saturday, Mario and I drove along in silence through the harsh beauty of the high desert. On our arrival, he introduced me to Wolf and Lisa Wahpepah, the leaders of the intertribal spirit camp and keepers of lifelong vows to preserve their Native traditions. They welcomed me warmly, and I joined some other newcomers in a circle in the shade of an old white pine close to the fireplace.
Wolf began, “When we crawl into the lodge, we say ‘For all my relations!’ When we Indians say, ‘All my relations,’ we’re not just referring to our blood relatives or even all other humans; we’re talking about all living beings on Mother Earth, including the plants, and the rocks, and the waters, as well as Grandmother moon, and Grandfather Sun, and all the celestial bodies.”
From then on, I have continued to pray with this fireplace and all who gather there, and I regularly participate in their ceremonies. The fierce and beautiful container that is the sweat lodge ceremony has become a safe place to bring my personal pain and the residues of pain I am carrying in my heart for my patients. I go there to grieve, and to express gratitude, and to pray. On more than one occasion, I have spent time “up on the hill” on vision quest, which has been an opportunity to lie on the earth with my questions and my not knowing, to stay there long enough for the earth’s rhythm to become my rhythm. As a Celt, something in my soul feels deeply at home on the Red Road of Native American spirituality. Through these elemental ways of prayer, I have come into a deeper relationship with the land and with nature. The worldview that is “All my relations” now permeates my work in palliative care and my relationships with others and the world.
At the same time, I was also becoming familiar with the work of Buddhist scholar, deep ecologist, and activist Joanna Macy. Radhule had brought Joanna’s book, Mutual Causality in Buddhism and General Systems Theory, home with her from a retreat she had attended and it became our shared bedtime reading. In the book Joanna explores the core insight in the enlightenment of Siddhartha Gautama, the historical Buddha: what in Pali is called paticca samuppada, meaning “mutual causality” or “dependent co-arising.” She explains that in contrast to our usual ways of understanding causality as a linear process between discrete, solid objects (like billiard balls hitting one another), paticca samuppada implies that what manifests as reality is, in fact, a dynamic, fluid, interconnected, and interdependent process, where “everything arises through mutual conditioning in reciprocal interaction.”10
Radhule had also introduced me to the guided meditations of Buddhist scholar and teacher Alan Wallace some years earlier, and mindfulness of breathing had become an important daily practice for me. I found one detail in Alan’s instructions especially helpful: he asks the meditator to bring particular attention to the exhalation of the breath, and then to, “Release and let go all the way through the exhale and continue to let go even beyond the end of the exhale until the next breath flows in effortlessly, like a wave washing up on shore.”11 Following this guidance to continue in the trajectory of letting go beyond the end of the exhale, something very simple yet profound happens: I discover that the body breathes all by itself, without my having to do anything! This may seem to be stating the obvious, but by consciously noticing my breath and allowing myself to align with it, I find that I am being carried in the effortless flow of the body’s natural rhythms.
As I engaged in this practice daily, I noticed that something unexpected was happening. I was learning to trust the body’s natural autonomy. Allowing the body to breathe like this brought me, at times, to what Sufi mystic Kabir describes as, “The place [inside me] where the world is breathing.”12 From here, every morning, I would walk with our dogs onto the land behind our house. Arriving in the landscape in this way, with a quiet mind, I could vividly sense the light, the birdsong, the coolness of the air on my cheek, the smell of the damp earth. And when I stopped close to where an unseen bird was singing in a tree, and closed my eyes and listened, I realized that I was not just listening with my ears; my whole body was receptive and registering the vibrations of sound.
Up until then, I had a prejudice that Buddhist teachings were dualistic, valuing awareness and detachment over matter and engagement. That is why I was so excited to learn abou
t paticca samuppada and “engaged Buddhism,” from Joanna. Here were Buddhist teachings that did not encourage disassociation or separation from the world. Rather, they showed that we are inextricably linked to our world; indeed, that we are the world.
For over thirty years Joanna Macy has been offering seminars and workshops inspired by the teaching of the radical interdependence of all life, which offer practices to enable us to move from passivity to action on behalf of our suffering world.13 I was struck by how congruent this Buddhist science of mind and heart and the new science of systems thinking are with the indigenous teaching that “all are relatives.”
In the late fall of 2012, I attended one of Joanna’s Work That Reconnects workshops. At the introductory session on the first evening, person after person spoke of their pain and anger, their frustration and despair because of what was happening to our planet. Climate scientist Susanne Moser told us that grief-work is the most relevant emotional work we can do, and spoke of “hospice care for our dying planet.” Nuclear scientists Kathleen Sullivan and Arnie Gundersen talked to us about the ongoing implications of the nuclear meltdown at Fukushima. And artist Chris Jordan spoke of a movie he was making about the albatrosses on Midway Island, as he shared images of dead baby birds, their stomachs ruptured by shards of plastic their parents had skimmed from the surface of the Pacific while hunting for food and unwittingly fed to them.
I was troubled by the dawning awareness of what all this meant for my children, and their children, and for all the grandchildren of our world. Just before I had left for the workshop, my eldest daughter had called to tell me that she was pregnant. As I listened now, some spoke of how we may already have passed a point of no return with climate change, that it may already be too late to prevent the sort of consequences that will make it difficult for complex life forms to survive. A young couple shared their decision not to bring children into such an ailing and uncertain world. What, I asked myself, did all this mean for my little grandchild to be, who, all going well, would take her or his first breath in this world in just a few short months? At that moment, it was as though something within me crumbled and fell to the ground. I remember feeling shocked, exposed, and raw.
In July 2013, I held my newborn first-grandchild, Elliot, in my arms. As I looked at his tiny sleeping body, I wondered what the world would be like in sixty years’ time, when he was my age. I realized that if even a fraction of the predictions I was hearing of environmental, economic, and cultural collapse came true, he would be living in a different and a very much more difficult world.
Whereas before I had dealt with things that happened to the environment with a certain distance and lack of feeling, I found that this was no longer an option. My growing closer to other-than-human nature had sensitized me to its welfare; the birth of my grandchild made everything personal. I was gutted when I saw that the new owners of our previous home had pulled up all the plants I had tended there over the years, including the great white sage whose cuttings I used to bring to the sweat lodge as gifts for Wolf and Lisa. I was shocked and then saddened the day I walked down the road with the dogs and saw that the owners of the new house by the corner had cut down two of their three big ash trees, where flocks of robins used to gather in the Fall. And I was sickened when I read about the beautiful three-year-old female wolf called Echo who had travelled all the way from Wyoming to the brink of the Grand Canyon in Utah only to be killed by a hunter’s bullet. Would Elliot grow up in a world where there were no wolves left in the wild?
As I opened to the pain of the world in this way, I felt at times overwhelmed by a tsunami of suffering. My old self would have liked to block this out, but I realized that denial was no longer an option. I noticed that I was deliberately trying to numb myself by overworking, or by overworrying, or by distracting myself in various ways, but that this, at best, bought temporary relief. I was at a loss. While I had become an expert in managing pain in my professional life, I had no idea what to do with the pain I was now feeling.
RELATING TO PAIN
For as long as I can remember, I have dreaded pain (by which I mean what I experience as distressing and uncomfortable) and done all that I could to avoid it. As the eldest of six boys with one older sister, I tried my hardest to keep things calm and make things better in what I experienced as a mostly loving but at times turbulent home. My father was a surgeon who often drank heavily when he came home in the evenings, leading to arguments between him and my mother. Not infrequently this ended with my mother slamming the door and running out of the house in tears, driving off into the night. It hurt me to see my mother so upset and I tried as hard as I could to make her happy. I became the peacemaker, to the best of my ability, between my parents. I used to sit between them at the dinner table and attempt to mediate a truce when things were tense by leading the conversation in what I thought would be a safe direction.
If this did not work, as it often did not, I would take Bilbo and together we would climb the hill behind our house, where we would walk for hours through fields of corn stubble and little wooded areas, listening to the call of the cock pheasant, or the snipe that Bilbo had flushed from the marshy reed beds. At the top of the hill there was just the wind, more hills as far as I could see to the west, and the meandering silver sash of river. Planes, lights on now as dusk darkened, circled on their approach to Cork Airport. Slowly, imperceptibly, my fluttering heart would drop into a slower, deeper rhythm until eventually I had circled back to where our house was directly down below. There I would pause, and watch, as lights began to flicker on in the windows, and brace myself for my descent.
My fear of pain and my desire to avoid it was certainly a factor (even if an unconscious one) in how I ended up in a medical specialty where the primary focus is on pain and symptom management. Pain is controlled using the traditional medical model by firstly diagnosing its cause, and then treating it by means of evidence-based interventions. The medical model is effective and helpful to many much of the time. It can prevent and cure disease, ease pain and suffering, and improve the quality of life of patients living with chronic and terminal illnesses. It has been a good match for me with my pain phobia, affording me a protective barrier of clinical objectivity as I attend to my patients. What is more, the result of a successful therapeutic encounter is relief all round: a lessening of pain and anxiety—the patient’s, and mine.
However, the medical model does not always work. It has little to offer Ben whose life is coming to an end too soon, and could not comfort those three little children when their mother was dying, as they looked back at me with an expression I could only begin to understand.
When I realized there was no way that I could give Ben the reassurance that he would recover from his illness and get back to life as before, I felt powerless, inadequate, and guilty. I was physically uncomfortable. There was an edgy tension in my body that made it hard for me to stay in the room with him. I desperately wanted to open the door and go outside and get some air. From experience, I recognized these feelings and sensations for what they were: a by now familiar pattern of what happens when I hit the limits of what I can do to ease another’s suffering. Seeing this for what it was helped. It afforded me a choice. I could either leave Ben’s room, as every cell in my body was pleading with me to do (“Let me go and find our social worker to come and sit with you”), or I could, despite my discomfort, choose to stay with him, as one human being to another, hoping that this might bring him some deeper consolation, even if it was not the answer he was hoping for.
From my studies in depth psychology, I had learned that this way of being with another in suffering had a name: this was the path of the wounded healer, the path forged by Chiron. The path of the wounded healer can be summarized as follows: by staying with our woundedness, we encourage the other to stay with theirs; that is where and how healing happens. The wounded healer is one who knows that everyone carries within themselves an innate potential for healing.
The wounded healer is one who knows from experience that, paradoxically, this potential within is realized by staying with what hurts. The wounded healer knows that waiting with our own suffering, while being present and empathic to the other, is what encourages the other to stay with theirs. The wounded healer agrees with Rumi when he says, “Don’t turn your head. Keep looking at the bandaged place. That’s where the light enters you.”1
With the path of the wounded healer, I had found a second way of being with pain. In contrast to the medical model, which only worked when there was a “fixable” pain, the path of the wounded healer offered me another, positive way of being with one whose pain was “unfixable.” I now had a powerful conceptual incentive to stay with patients like Ben with an open heart, waiting, and being present to him in his grief and his despair even when there was nothing left for me to do, hoping that this would help to transform his suffering. The core teaching of the wounded healer is that in suffering our suffering together, we come into the mystery of healing.
In 2008, I was invited to be lead author of an article on self-care for physicians working at the end of life for The Journal of the American Medical Association (JAMA).2 This prompted a year of research and creative collaboration with four coauthors and gave me a deeper understanding of the dynamics of resilience. I learned about burnout, the emotional and physical depletion that results from organizational stress, a form of low-grade suffering that is endemic to caregivers. I learned about secondary traumatic stress disorder, also known as “compassion fatigue,” when we are vicariously traumatized by another’s suffering, and realized that this is what I had experienced all those years before when I first began working at St Christopher’s Hospice.
The Nest in the Stream Page 4
