A Cry Unheard

Seeking to forget makes exile all the longer; the secret of redemption lies in remembrance.

Richard von Weizsaecker

I picked up a new book last week on the recommendation of a colleague: A Cry Unheard: The Medical Consequences of Loneliness by James J. Lynch. I only wish I'd had this book in hand when I conducted my own research on the effects of social support on women after the death of a baby.  This seminal book is filled with clinical research on the dangers of social isolation, including the effects on the body and health.  Lynch captured data demonstrating the devastating health consequences of shame, anxiety, anger, and fear that was unrecognized, undetected, and most importantly, unheard.  I think this fact, for me, was the most important. It wasn't that the emotions themselves were "bad" or "negative" as contemporary theorists might imply. It was that the person experiencing them, and others too, did not acknowledge the emotions that created the problematic outcomes.  They were abandoned- both by others, and also by themselves.

In sum, he found that such social disenfranchisement can lead to fluctuations in blood pressure and respiration, depressed immune functioning, heart disease, hypertension, and a host of other physiological maladies. He notes that: "Those lacking social support, those who live alone, those who struggle with chronic loneliness, those who lose a loved one, all exhibit sharply increased risks of dying prematurely."

I've posted a great deal about narcissism, grief, and finding gratitude- and how, when the time is right, there is an imperative to move beyond our own suffering and see the suffering of the other.  There are some bereaved who may never move to that space where they are willing, thus able, to do that. Lynch calls this the "black hole". He says:  "Like black holes in space, such individuals absorb all light and all objects around them while emitting nothing back. Nothing escapes their...emptiness."

Conversely, he recommends looking "out into the world beyond the confines of your own skin...listening to a bird sing can lower blood pressure...gazing at the stars" too. "Listening to one's fellow (hu)man in dialogue can lower blood pressure."  Basically, moving beyond the necessary narcissism of early grief.

Lynch believes that "dialogue is the elixir of life and chronic loneliness its lethal poison". But what about the dialogue often aimed at bereaved parents? You know- those promptings to "move on", "God has a plan for you", "at least it wasn't one of the older ones", "you can have more", "everything happen for a reason", "time heals all wounds", and "aren't you done grieving yet"s?  Lynch said that dialogue can also be used to create distance, that it can be used to manipulate. He asserts that "empty language suppresses hope...and is spoken from outside our own hearts...(where) human dialogue is ruptured, destroyed, or reduced to a living hell" when abused in this way.  He termed it toxic talk, and far too many bereaved parents have experienced a litany of such dialogue.

I deeply appreciated Lynch's honest explorations as a medical doctor, professor, and human being.  It confirmed that the bereaved should be sensitive to their own needs; and then, when ready, actively engage in moving beyond the self.  The (temporarily) non-bereaved should engage in dialogue that is comforting and from the heart. They should not seek to cure or heal or absolve. Rather, they should seek only to be with the suffering. They should use words with great care and intention, for it is easy to destroy a fragile other with a few, seemingly benign, syllables. 

Allow them to remember, and invite them warmly back from exile.

Synchronicity

“So when you are listening to somebody, completely, attentively, then you are listening not only to the words, but also to the feeling of what is being conveyed, 

to the whole of it,  not part of it.”

Jiddu Krishnamurti

I met a fascinating man today who approached me, interested in my work with the bereaved. It's amazing how, when you meet a kindred soul, you can listen and exchange for hours upon hours and never tire of the conversation because it is intentional, meaningful, and consequential. 

We spoke about life and loss, trauma and tribulation, reality and relationships, loving and listening.

Listen. Listen. Listen.  

Repeat the word, twenty times. Softer. Listen, listen, listen.

Listening to the other can have powerfully therapeutic effects. Holding a space for the other through silence.  Being fully present, all senses focused on the other, their moment of disclosure- be it filled with suffering, sorrow, despair, or joy- being that which Pine (1985) calls a prepared explorer into another person's life.  Gadamer says that the important thing is to "be aware of one's own bias so that the text may present itself in all its newness and assert its own truth."

Reik (1954) discussed listening with the "third ear."  This is psychoanalytic listening intent on intuition. It requires that full experience of presence with the other.  He says, "...in order to comprehend the unconscious of another, we must, at least for a moment, change ourselves into and become that person.  We only comprehend the spirit whom we resemble."  I might call this true, empathic connectedness.  Freud calls it "listening with evenly suspended attention."  The results can be astonishing- acknowledgement and validation of a person and their place in the world. Thank you, David.

What greater gift can you offer to another than intentionality, consequentiality, and meaning?

And I submit this: Offer this gift, also, to yourself. Listen to the thoughts and the emotions and the memories and the pain and the struggles and the fears and the sounds and the beauty of you.  

Do what you must do to become who you must become.

Getting Through the Human Experience

To be alone is one of the greatest evils.

William James

Psychopharmaceuticals are plentiful here in the United States as a way to help individuals cope with  psychic angst.  Pharmaceuticals are marketed as a means to help anyone who is bereft with depression, PTSD, personality disorders, anxiety, PMS, menopause, postpartum-related depression, mood disorders, dysthymic conditions, and even grief.  

A high number of bereaved parents, in my experience mostly mothers, are also prescribed anti-depressants. For some, these pharmaceutical remedies can bring equilibrium to a person who is fraught with debilitating mental illnesses.  Yet, are we pathologizing normal, albeit painful, human experiences of suffering?

Indeed for others, according to Dr. Elio Frattaroli and psychiatrists critical of the overuse of prescriptions, SSRIs are being used as a shortcut to healing, the McDonald's treatment plan of the 21st Century- the comfortable numbing of a society.  We are afraid to feel suffering.  We are uncertain of our own strengths to cope with loss. We do not know how much we can- and should- rely on one another to help us through the human experience.

Interestingly, while SSRIs can help some selective patients with legitimate mental disorders, there are also long-lasting effects of SSRI use. Researchers at the University of Ottawa have discovered a correlation between stillbirth and other negative birth outcomes and SSRIs.   While other studies have demonstrated inefficacy of some SSRIs, even in the case of the severely depressed wherein SSRIs were no more efficacious than a placebo. In some cases, it's worse than we realize. SSRIs were identified to increase violent thoughts toward self or others, including suicidal thoughts. The FDA has warned of these dangers at least twice; yet so many people remain enslaved in a cycle of medication and remedication.

I am not an expert in the use of psychopharmaceuticals for the severely depressed.  

I do, however, know that there are voluminous studies on the benefits of human connectedness, social support, and compassionate others.  Being connected with and supported by others helps women have healthier babies with higher Apgar scores. It helps women cope with the stress and angst of breast cancer. It reduces the effects of postpartum depression.  It helps the homeless and mentally ill.  It even helps accelerate recovery from a myocardial infarction (heart attack).

We are a society of aloneness, a society afraid of really experiencing our own emotions and the feelings of others. Many are emotionally bankrupt, while others are depleted of the most basic of human empathy. We are rushed, hurried, and harried. We do not have time for pause, or reflection, or grief- we have not scheduled suffering into our calendars. Our lives are consumed and constricted by things that are not real- Hollywood gossip, Blackberries and Palm Pilots, parties, Prada shoes, and consumerism. We are so diverted from what really matters that we hardly recognize that which is real- even real relationships. So few of us really have time for authentic relationships- the types of friendships in which we can entrust our pain and suffering. And it takes a tremendous amount of psychic energy to maintain the fraudulence of empty lives.  Is it any wonder so many in Western society face the types of existential crises that cry out for meaning and purpose and connection?

There is no substitute for human relationships. In the absence of meaningful connections to others, we will not survive as a species nor as individuals. We need one another to help us through suffering. We need guidance through the human experience. The answers do not lie in a bottle or in a pill or in distractions or in diversions. Our salvation from suffering, what will save us from the darkness, is the hope, love, empathy, and compassion we offer and receive from one another. It is the only way through the human experience.

Have you come to that Red Sea place in your life 

where there is no way out but through?

Merritt Malloy

Primum non nocere, prosum beneficum

When my daughter died in 1994, I heard nothing from the hospital staff after our discharge. Instead, I returned to my home where grief had taken residence, and I was left alone.  No social worker or nurse attended to my needs. No pastor or clergy offered aid. No physician called to check on our family. No cards were sent from the medical staff. Nothing. Just the silence of apathy and death, now camped next to my bedstand.

In 1999, five years later, our dog, Bandit, died.  The veterinarian and his staff were gentle, kind, and empathic. They called that same day to check on us and express their sympathy.  And four days later, we received this card in the mail:

To Bandit's Family

Our thoughts are with you, 

when sometimes the hurt is too big for words. 

We are so sorry for the loss of Bandit. 

I know you loved him and that he will be missed. 

Roger William DMV and staff

I was, frankly, both awed and angered.  How is it that years earlier, I had not received this type of care and compassion upon the death of my child?  What gives?

The ethos of primum non nocere, first do no harm, has been a guiding principle of medicine since the mid-nineteenth century.   This axiom quickly becomes familiar to med school students as they endeavor toward epistemic gain and become introduced to the micro-culture of medicine.

But is a postmodern detached, passive interpretation of this canon enough? Do we stop at first, or is there an imperative to do more?And should physicians strive for better than merely doing no harm? Why not strive toward beneficence?

A recent article published in the journal Academic Medicine (Newton, Barber, Clardy, Cleveland, & O'Sullivan, 2008) titled "Is There Hardening of the Heart During Medical School? Physician-Patient Relationship"  explored vicarious empathy during medical education. 

They found that "empathy significantly decreased during medical education (P < .001), especially after the first and third years". The authors concluded that diminished vicarious or emotionally driven empathy occurs after the first year and after the third, clinical years of medical education when students “were seeing patients they had, presumably, looked forward to helping.”

Interestingly, another study conducted by Jean Decety, Professor in Psychology and Yawei Cheng of the Institute of Neuroscience found that physicians unconsciously learn to turn-off the center of the brain that initiates empathic responses. In their 2008 article,  “Expertise Modulates the Perception of Pain in Others,” published in Current Biology, they note that physicians "have learned through their training and practice to keep a detached perspective; without such a mechanism, performing their practice could be overwhelming or distressing, and as a consequence impair their ability to be of assistance to their patients”.

Based on their current and previous research, Decety and Chang affirmed that these physicians are unique: their neural circuitry, which normally registers pain when one person sees another person in pain, experiences no activity during such an exercise. The response in this circuit, which includes the anterior insula, periaqueducal gray, and anterior cingulate cortex, is automatic and likely represents evolutionary panic responses in order to respond to danger. Unlike the control group, the sample group of physicians did experience an increase in the frontal areas of the brain- the medial and superior prefrontal cortices and right tempororparietal junction, where emotions are regulated and cognitive control occurs.  This unconscious training of the brain can incite emotional detachment, which some argue helps physicians avoid their own high levels of personal distress that may incite a host of psychological problems.

But is there a middle ground wherein a physician- or a nurse, social worker, therapist or other helper- can engage in empathy while maintaing important, self-preserving boundaries?  This is an important area for further social and neuro scientific research. For example, we should explore whether or not empathic traits actually do expedite vicarious trauma or perhaps burn out.  In other words, does compassionate and empathic care, in fact, "impair [physicians'] ability to be of assistance to their patients"? We should explore the positive, insulating benefits of relational mutuality for patients, their families, and the physicians as well.  These types of studies may provide more answers to many unaddressed questions about the nature of human relationships during distress.

As a clinician who has helped bereaved parents for thirteen years, many of whom have experienced trauma beyond any normal range of experiences, I would assert that, indeed, we can engage in this way. In fact, I'd go as far as to assert that there is no other way in which to experience authentic, meaningful, and healing human interaction.  It moves beyond the acquiescence of first, do no harm and prompts an imperative to then do good.  How to reach this place is complicated and I cannot teach it in a few words electronically scribbled on these pages.  It takes willingness to learn, and requires an abandonment of academic arrogance and the assumption of humility. They are lessons hard learned. But it is what I teach because it is that in which I believe. It is what I know to be true.  

And I think it is because I do go there with people, because I have trained my brain to remain responsive to and not allow flight during those fearful times, that I have been able to listen to thousands upon thousands of stories of trauma and loss, to watch hundreds of children die in the arms of their parents. 

I have allowed the germination of those meaningful relationships, and I have tried to nurture interconnectedness, even through the vicarious pain and angst.  I am nearly certain that if I'd tried to protect myself, sequestering my heart from these experiences, and not invited those empathic relational interactions, I would have suffered from caregiver burnout long ago.  And, oh what I'd have lost would be far greater than that which I've gained.  

Ref: Academic Medicine. 83(3):244-249, March 2008.
Newton, Bruce W. PhD; Barber, Laurie MD; Clardy, James MD; Cleveland, Elton MD; O'Sullivan, Patricia EdD

Love and Despair

In the abyss 

I saw how love held bound

Into one volume all the lives whose flight

Is scattered through the universe around;

How substance, accident, and mode unite,

Fused, so to speak, together in such wise

That this I tell is one simple light.

-Dante, from the Divine Comedy

Love, or what Bowlby would call attachment, is a phenomenon unique to humans. Or is it? There is neuroscientific evidence to demonstrate that animals display some type of attachment behaviors, most often observed between mothers and their offspring, in the animal kingdom.

And where there is love, there is grief.

Many animals, from cows to dogs to baboons, exhibit fierce grief responses when separated from their mothers. They first enter a phase of protest, pacing back-and-forth, searching and yearning for the object of their affection.  Some mothers, in response to the separation from their babies, begin self-harming behaviors, such as chewing their own limbs or intentionally injuring themselves.  A puppy separated from his mother will "let out a piteous whine, high-pitched and grating as every aspect of his behavior broadcasts his distress" (Lewis & Amini, 2000).   This behavior is even observed in rats.  

Mammalian protests in the animal kingdom mirror human physiologic responses to loss. During protest,  hearts palpate, catecholamines and cortisol flourish, and the body is on high alert and arousal.  High levels of chronic cortisol, the stress hormone, can compromise the immune system, interrupting important processes for the body. In sum, intense disequilibrium to the homeostatic condition can occur- very dangerous, not just psychologically, but biologically too.

This is the state of despair.  The anchored weight of grief turned inward. Apathy, lack of focus, anhedonism, bleakness...hopeless and helpless...alone in the world.   

If separating animals from their offspring can cause disruption, just imagine- in the human relationship- the depth of emotional responses to such separation. The architecture of attachment is complex, particularly the attachment between a human mother and her child. Woven into the relationship are generations of evolutionary adaptations tailor-suited to accommodate the unique relationship that will require bonding like no other relationship on the planet. What happens when that bond is prematurely broken? Despair. A state of despair.

Yet, human beings also have the capacity to help one another. Studies suggest that connectedness with like others has powerful effects on the brain- mainly, the limbic system- as well as our experiences of loss. Being helped by and helping others is a powerful healer. No, it isn't magic- there is no panacea- no voodoo that can cure a mother's grieving heart. But both social support and social outreach have powerful effects on a person.  

The MISS Foundation  provides a safe place for grieving families in despair.  It's a place to first find help, then later to provide hope to another. Family and friends- communities- should also strive to provide a safety net to help. Something so unspeakable- something so tragic- should never be endured alone.

Just as despair can come to one only from other human beings, 

hope, too, can be given to one only by other human beings.

- Elie Wiesel