If you continued practicing, you’d become more aware of how your mind works. You could more readily identify when you are focused or distracted, when you’re being curious and when you’re more shut down. You’d become a connoisseur of types and qualities of your states of attending and distraction—just as the Inuit become connoisseurs of snow and sommeliers become connoisseurs of wine.13 Functional brain imaging might show thickening of the gray matter in the brain, deeper folds of the brain (gyrification), and increased connectivity. Studies done by psychologist Al Kaszniak at the University of Arizona suggest that attention training can reverse the natural decline of cognition with age.14
BEGINNING
Zen teachers often tell beginners, “Don’t meditate, just pay attention.” This is because for some people the word meditation carries with it expectations and associations.
Meditation practice is skill building,15 an education of the mind through first-person inquiry.16 Some people associate meditation with self-absorption, so to make the purpose clear, I call it attention training, awareness training, compassion training, or, simply, practice. I emphasize that the ultimate purpose of meditation is to reduce suffering in the world, not to feel good about yourself. Debate rages about whether meditation is intrinsically “spiritual,” but it depends on how you define “spiritual.” If you see “spiritual” as anything that lends meaning and coherence to the world, then perhaps meditation is. It certainly does not require any particular religious or philosophical belief system, other than believing that by knowing yourself better you can be more effective at realizing what is most important.17
Most practitioners use two or more practices at different points during their training. It’s like exercise—you wouldn’t only do push-ups if you wanted to get fit. We are only beginning to understand the way in which each meditation practice develops a different part of the brain, and no one can say whether one particular method is “better” than another; they are just different.18 In the appendix I describe the two most common and widely studied meditation practices, which are known as focused attention practice and open awareness practice. Briefly, focused attention involves focusing the mind on an “object”—the breath or a mantra. Open awareness is a disciplined practice of being aware of whatever is happening right now, in the present moment, but without attention to any particular object. Other practices, such as body scan and compassion training, were described earlier in the book (see chapters 3 and 8).
But what’s the threshold? How much (or how little) attention training do we need? It seems that even small doses can make a difference, at least in the short run. A few people even say that their first experience with meditation was transformative—they feel that a door had been opened and would never again be closed. Those who practice daily become more adept than those who don’t. And others notice. I was tantalized by a small pilot study by David Schroeder and his colleagues in Portland, Oregon, in which primary care teams who underwent mindfulness training found that their patient ratings were directly proportional to the amount of time they spent practicing.19 It’s not just quantity, though; quality of practice matters too. Just daydreaming won’t get you there.20
THE BODY
I’ve wondered why most contemplative practices start with attention to sensory experiences. Only now, though, are neuroscientists, cognitive scientists, and philosophers converging on an understanding that emotions are fundamentally embodied, inextricably linked to our bodily states.21 We gnash our teeth when working on a difficult problem or grip our seats during a horror movie. Our language is filled with bodily metaphors: a pain in the neck, heartache, and shouldering a burden. We call informative and helpful intuitions gut feelings. We describe people in terms of sensory experience: people who are emotionally distant are cold and those who seem close are warm. We use kinesthetic and spatial expressions: feeling down in the dumps or up to par; on top of things or under the weather. We mentally simulate bodily sensations in order to retrieve memories of events, and during exercises such as the body scan (described in chapter 3), by directing awareness to the body we become more aware of thoughts and emotions.
It works the other way too. We can evoke emotions by assuming different bodily postures and expressions. Standing tall imbues dignity; kneeling and bowing evoke submission. My piano lessons always started with posture. In the military, “attention” is a physical stance, which presumably calls up a certain state of mind. Assuming a dignified sitting posture is the first task for beginner meditation students with the goal of preparing them for awareness, mental stability, and humility.
Francesc Borrell-Carrió, an astute colleague, noticed that doctors smile when they greet a patient, even those that they don’t particularly like.22 He wondered why. In those situations, smiling has nothing to do with being happy. It’s about preparing oneself to be hospitable, to be present, to understand, and to help. It inspires an attitude of welcoming and good humor and not clinging too tenuously to any preconceived ideas one might have. Even a forced smile can make a difference in terms of how you understand your own and someone else’s emotions. In a psychology experiment, psychologist Arthur Glenberg divided participants into two groups; one group held a pencil between the teeth to engage the smile muscles, whereas the other held a pencil between the upper lip and the nose to engage frown muscles. When engaging the smile muscles, participants processed information about pleasant events more readily than about unpleasant events, whereas the reverse was true if they engaged the frown muscles.23 Psychologist Al Kaszniak has demonstrated greater activation of the zygomatic (“smile”) muscles in long-term meditators, perhaps one contribution to their feeling more positive emotions.24 Science has taken twenty-five hundred years to catch up, providing experimental evidence for what practitioners have always held as obvious.25
INTERPERSONAL MINDFULNESS
I asked a recently retired leader at our hospital about his uncanny ability to handle difficult situations. His days were filled with meetings during which he’d often have to tell members of his staff that they had fallen short. After he started the job, his administrative assistant commented to him that whereas physicians leaving his predecessor’s office often looked angry and disgruntled, now the same people leaving the same office were smiling. My colleague knew that he had that talent, but couldn’t articulate how he did it. His colleagues (including me) could see that he would note the other’s distress, acknowledge it, but not give in. If the other person intensified demands, he’d slow down, pause, reflect on what was really important, and then act. He had the presence of mind not to fall into the trap of escalation. His was a clear example of a healthy response to stress; he’d feel that he had done the right thing and he’d sleep well at night.
Not all of us have the natural skill that he did. Some of us need practice. Just as it’s possible to practice mindfulness of your own mind, you can also practice mindfulness in relationships—interpersonal mindfulness. Earlier in the book I described how narratives—stories that doctors write about their difficult moments in practice—and deep listening can promote communication, reflection, and presence. Another dyadic contemplative practice is known as Insight Dialogue;26 participants pair off and have a conversation, usually about a topic that has some personal salience, such as aging or illness or compassion or courage. But it’s not an ordinary conversation. Participants are instructed to speak from the heart: first pause, open, and relax, then speak what comes first to mind, trusting that which comes spontaneously, to “listen deeply” and “speak the truth.” The goal is to bring the clarity and mindfulness of silent meditation practice directly into conversations with others. Just as meditation helps focus the wandering mind through the practice of awareness of one’s interior life, insight dialogues help participants be mindful of their own quality of listening and speaking.
Another interpersonal mindfulness technique is known as Appreciative Inquiry.27 Here, an interviewer elicits from his or her partner a story of success amid adversity—a
time when a positive attribute of the interviewee made a difference. By explicitly focusing on the positive, and having a partner help to maintain that focus, you can bring your strengths to new and unfamiliar situations. Originally conceived as a way of harnessing potential and cohesion in organizations, appreciative interviews start by promoting mindfulness in dialogue. Little is known about how these practices work on a psychological level, much less a neurobiological one. But we do know that people who are in dialogue tend to mirror each other’s physiologies, movements, and even patterns of neural firing, likely mediated through mirror neurons. The frontiers of social neuroscience are now being stretched, and new research is exploring our capacity for shared mind, shared presence,28 and intersubjectivity—and how these human capacities enable us to make deep and healing connections.
EIGHT LEAPS
In this final section of the chapter, I’ll share my eight “leaps.” Much like Zen koans, I carry these leaps with me in practice because they help me refocus, explore, grow, and begin again with each patient. I invite you, whether or not you’re involved in health care, to find your own leaps: What is it that you face every day that is unresolved? What dilemmas and paradoxes do you face? Perhaps you’ll see some parallels with your own work situation or your home life.
THE EIGHT LEAPS
From fragmented self to whole self
From othering to engagement
From objectivity to resonance
From detached concern to tenderness and steadiness
From self-protection to self-suspension
From well-being to resilience
From empathy to compassion
From whole mind to shared mind
The first leap I call “from fragmented self to whole self.” I’ve become increasingly aware that I bring some positive parts of myself to my clinical work—I’m curious, analytic, and I try to be kind. Other parts of me—my artistic side, perhaps—tend to “reside” at my research office, at vacation spots, and at home. I take these divisions—rarely based on any conscious choice—for granted; sometimes they are appropriate, but sometimes they lead to a sense of fragmentation, of loss. I ask myself each day, “What parts of myself am I engaging in my care of this patient, right now?” And then: “Does it have to be that way?”
The second leap is “from othering to engagement.” The physician-poet Jack Coulehan proposes two reasons why clinicians detach emotionally from patients—to maintain objectivity, and to avoid being overwhelmed by the patient’s suffering.29 To detach, I use a “doctorly” voice, construct the patient as an “other,” “the person in the bed,” someone “not like me.” The patient inhabits the world of the sick; we, the world of the well. I’ve even caught myself assuming my doctorly voice with family members, effectively “othering” them, something that wins little affection. While to suggest that I can truly understand someone else’s experience would be arrogant, I still can try to “learn from below,” letting the patient guide me to an understanding of her experience. This is a process of shared imagination. The philosopher G. C. Spivak calls it a “no-holds-barred self-suspending leap into the other’s sea—basically without preparation.”30 When I say, “I can only begin to imagine,” to a patient who is seriously ill or distressed, the patient then becomes my teacher; I feel inquisitive and humble. This moral act opens me up to surprises and leads to new ways of understanding. I ask myself, “In what ways is this patient like me?”
The third leap is “from objectivity to resonance.” In medical school I was trained to be an objective observer. I needed to discern whether a heart murmur is harsh-sounding enough to warrant an echocardiogram, whether a patient’s story is coherent or contradictory, or whether I’ve done enough diagnostic testing for someone with a headache. Objectivity, though, is a stance that I never fully inhabited because it sometimes feels false. Clinical practice is always richer and more satisfying to me and my patients if there is some well-boundaried and heartfelt sharing of emotion.31 I ask myself, “What would happen if I allowed greater emotional resonance, if I allowed myself to feel just a little bit more?” Here, no particular distance is the “correct” distance; rather, it is the asking of the question that is important.
A related leap is one “from detached concern to tenderness and steadiness.” Tenderness is a quality of touch—both literal touch or feeling touched through communication. Steadiness is the mental stability to get one’s work done—and done well. As Jack Coulehan notes, tenderness and steadiness support each other and don’t have to be mutually exclusive.32 I ask myself, “Can I be both tender and steady even if the seas are turbulent?”
The fifth leap, “from self-protection to self-suspension,” has to do with fear. One of my favorite children’s books (and my kids’ too) is Doctor De Soto, about a mouse who is a dentist.33 His patient is a fox. This is clearly a dangerous relationship. While the fox is imagining eating the mouse, the mouse focuses on the painful tooth. The fox’s desire to avoid pain trumps his impulse to eat the mouse. They are able to work together, despite their differences, at least until the pain stops. The mouse, though, doesn’t want to take any chances and glues the fox’s jaw (temporarily) shut just as he is finishing his work.
Children’s books often contain great wisdom. Sometimes our fears as physicians are well justified. A patient of mine who had just completed parole for armed robbery and attempted murder gently requested that I falsify data about his HIV status so that he would be eligible for life insurance. He asked questions about my family; he seemed to know where I lived. I had reason to believe that he had access to a gun. I said no and frankly felt a bit afraid. Even when I’m faced with threats that are illusory, I adopt psychological distance and armor to protect myself.
A few months later I had to give terrible news to this same patient; his headaches and difficulty concentrating were due to progressive multifocal leukoencephalopathy, a rapidly fatal brain disease that is a complication of advanced AIDS. I was bracing for the pain of having to tell him the awfulness of it all; I didn’t sleep well, dreaming that he’d hear the news and turn a gun on me, his family, or himself. Yet, the next day, he said that he knew that something was wrong; he was calm and grateful for my candor. I had become aware of how my self-preoccupation had overshadowed my ability to attend to him. I make a habit of asking myself, “Whom am I trying to protect?”
“From well-being to resilience”—the sixth leap—means that trying to achieve “work-life balance” might be misguided. Rather, by focusing on the task at hand I often find joy in the moment, curiosity amid despair, resilience when I feel I’m going to pieces. I let go of distinctions between work and nonwork and instead ask myself, “What do I need to do right now?” “What am I anticipating, looking forward to, prepared for?” “What if something else happens?”
The seventh leap, “from empathy to compassion,” is a reminder that even if I have an accurate understanding of a patient’s suffering, it doesn’t necessarily mean that I’m addressing it adequately. I make a practice of asking myself, “How can I choose to be compassionate in a way that makes a difference?”
The leaps so far have been about me, my mind, and the ways in which I can bring my whole mind to clinical care. The eighth leap takes me “from whole mind to shared mind.” My clinical life is working with people—patients and their families, clinical teams, health care systems, communities. Shared mind is about being on the same wavelength, adopting a similar frame of reference even when we disagree. This doesn’t always happen. I ask myself, “Is this me working alone or is this us working together?” and “Might greater sharing produce better care?”
12
Imagining a Mindful Health Care System
A cord of three strands is not quickly broken.
—Ecclesiastes 4:12
Imagine that you went to bed tonight and woke tomorrow morning to find that the health care system was transformed. You have a health concern. Perhaps it’s something serious or perhaps it’s something minor.
You call the office. You’re amazed that you can contact your doctor and get an appointment the same day. When you arrive, the staff is attentive and courteous and knows you. You’re astounded at the care you receive; it’s technically proficient, and your clinicians are alert to your concerns. They’re interested in who you are—your work, your home life, what’s important to you. They help you make decisions, guided not only by the latest research but also by your values and clinical situation. You know that the various doctors, nurses, and other health professionals caring for you are talking to one another, anticipating your needs and making sure that the advice you get is consistent. Safety checks are in place so that you are confident that errors will be extraordinarily rare, and when they do occur, you get a full and complete explanation along with confidence that it won’t happen again. Your care is efficient, affordable, and effective.
Imagine that although your doctor is busy, she listens carefully to your concerns. She doesn’t interrupt. You feel cared for as a person, not merely as a case or a problem to be solved. She seeks your opinions and encourages you to ask questions and express concerns. She doesn’t hide behind her expertise and makes you feel that no question is too simple. She talks with you, not at you. Your health care team provides information and support so that you can participate in decisions regarding your care to the degree that you wish. You have a voice in the aspects of health care that matter most and your time isn’t wasted with bureaucratic and administrative hassles. You feel that your health care team provides not only technical expertise but also emotional support when you need it.
Attending Page 20
