From the Gallows of Grief to Gratitude

There is nothing so whole as a broken heart.

Mendel of Kotzk

This quote reminds me of what I've learned during my grief journey. 

I've learned that in brokenness, there can be wholeness. In the darkness, there can be light. In egoism, there can be selflessness. In despair, there can be hope. In ungratefulness, there must, eventually, be gratitude. 

This isn't just psychobabble; for many, it is their survivalist reality. It is the only way that so many bereaved have moved beyond mere suspension.  Those who allow themselves to experience gratitude are often able to transcend their former place in the world. They not only become whole again, but they have reached a threshold of completeness they would never have known would it have not been for their confinement to the gallows.

These are individuals who, despite incapacitating trauma and turmoil, manage to find gratitude for the goodness in their lives. This is not a magical moment of epiphany for many of them. Rather, it evolves over time and with intense cognitive effort.  I believe that finding gratitude- even crumbs or morsels at first- requires emotional maturation, practice, and mindfulness. 

It requires us  to first focus on the self- to take personal responsibility for our own suffering. To acknowledge it. To tell and retell our story. To know ourselves well. It requires us to acknowledge that there is healing in our suffering. It requires that we silence our minds, respect our body's response to the grief, and be gentle with ourselves. It commands patience, intentionality, and commitment to the insufferable pain that radiates from the tips of our hair to the tips of our toes...the agony that causes every cell in our bodies to ache. It requires that we reach out for help from others, sometimes strangers, and that we accept the outreached hand with grace.

Then, when we are ready, we must move beyond the self. We must see the suffering of others. We must acknowledge the other's pain sans the fear of losing or diminishing our own suffering. We must be able to sit compassionately with another, abandoning for a moment our own grief's narcissistic exigence. We must  widen our circle of compassion for all beings suffering. We must see the world through others' eyes.  

We must recognize the acts of kindness, courage, and sacrifice that others have offered along our journey, and extend that droplet of hope to another. It requires that we honor even ill-fated attempts to comfort, and that we reconsider exchanging alienation, anger, and resentment for tolerance, empathy, and acceptance. We must seek gratitude daily, even for the 'small' things in life, like a dandelion dancing on the warm breeze, shadows playing in the park, or a fiery sun setting against a mountainous silhouette- or perhaps, a simple kind word of support from a friend...

Like threads in a garment, grief runs in and out of our daily lives from the instant of Death, one moment often indistinguishable from the next for many days and months. There is a time for this. There is a time to wallow in the mud, a time to pause for the entangling. The garment is unravelling and grief has patterned your life, against your will, in an unfamiliar mosaic.  Yet, gratitude can truly help us to heal from our suffering when the time is right to reconvene our lives. 

And when that time comes, consider your complaints and revisit your expectations. Take the time to fill your heart with gratitude. You can be grateful for what you have without taking away from that which you have lost. 

So, tell someone who has helped you how grateful you are for their presence in your life. Hug someone you love and tell them three things you admire about them. Write a letter or send a card to someone who is making a difference in your community. Leave an anonymous gift for a teacher, doctor, or other "carer". Reach out to another person in mourning.  Let gratitude hang in the shadows, parallel to your grief. It is not magic, but it is transformative. 

When we allow the experience of gratitude, the heart may still be broken but the heart is also most full, most whole, and most complete. Mendel of Kotzk also said, "Where is God to be found? In the place where He is given entry".  Where is gratitude to be found? It can be found in the very place where you have also given it entry. Grief and gratitude can coexist.

I dedicate this posting to our wonderful MISS Foundation moderators, volunteers, and facilitators.  For your commitment to helping others, I am so incredibly grateful.

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

People Green

The current political current has turned green: Attention has turned toward Mother Earth, taking care of the planet- it's what I've always thought of as walking gently on our planet.

I've been a gentle walker since I can remember. When I was in the 6th grade, I went house-to-house garnering signatures for a Save the Whales campaign. I wrote letters to the-then-President Jimmy Carter about the need to recycle waste.  I refused to eat animals or kill bugs (see the below ladybug blog).  Back then, it wasn't vogue, and they didn't call it being green. They had other, less prepossessing, names for people who held those values.  

Today, many more people and institutions have gone green. We're realizing the impact that human beings have on our environment, from factory farming to the massively unethical corporatization of food to the decimation of the rain forests. Even churches have jumped on board the green wagon.  This is such an important time in history for people-- time to connect with our Mother Earth-- time to take care of this beautiful planet our children's children will inherit from us. Time to walk gently on this planet. It's long overdue.

In a society of consumerism and selfish indulgences, I was thinking how, as our Green IQ rises in society, we can translate that over to being people green. Being earth-friendly is necessary: But how do we walk gently with others? How do we see ourselves in the world in relationship with others.  Our People IQ suffers a lot in the West. 

I see this particularly with the bereaved. One mother who lost her son to suicide began telling people he died in a car crash. Why? Because others flooded her with painful remarks, assigning guilt to her as a mother and excusing his death because it was perceived as self-inflicted. I see this when a young baby dies and someone responds recklessly with, "At least you're young. You can have another", as if children are interchangeable and replaceable. I even see it in day-to-day relationships when one person's feelings or opinions are rejected by another, rather than respected.

What brought our society around to an increased sensitivity to the environment is an awareness about the earth and it's vulnerability.  Awareness triggers mindfulness. When we are mindful we are in the moment. Really in the moment. Aware of ourselves, our surroundings, our actions and inactions, and mostly our effects on our surroundings. Other human beings are a part of those surroundings. Are human beings not also worthy of this mindfulness? Should we not also be mindful how what we say and do- how we treat others- affects them?

Mindful living with one another may help improve our relationships, even those transitory in nature. Even the way we interact with the grocery clerk or a fellow driver can have a lasting effect- it's Physics 101- every action has an effect. Will the effect I have on both the earth and those with whom I share it be one worthy of pride or of shame?  Imagine if, in every interaction we considered this...what would the world look like?

Really, it begins with paying attention. How are you in this world? Once you recognize yourself in this world, see yourself for who you are, actions can then follow. It's the power of presence, and it benefits both nature and humanity. While for me, it can be a challenge to really live this mantra each day, I try to stay in the moment and value every interaction, both with nature and with human beings. It's something for which I try to remain mindful, each and every day. 

Turn your attention toward Mother Earth and walk gently on her. She is worthy. 

And also, turn your attention toward your fellow humans and walk gently with them. They, too, are worthy.

Be gentle and not cruel.

Embrace humility more than arrogance.

Thank others more than you accept thanks.

Feel compassion more than apathy.

See what others ignore.

Hold others close more than you push them aside.

Learn more than you teach.

Be present more than absent.

Give more than you take.

-Joanne Cacciatore

So, mindfulness will not conflict with any beliefs or traditions — religious or for that matter scientific — nor is it trying to sell you anything, especially not a new belief system or ideology. It is simply a practical way to be more in touch with the fullness of your being through a systematic process of self-observation, self-inquiry, and mindful action. There is nothing cold, analytical, or unfeeling about it. The overall tenor of mindfulness is gentle, appreciative, and nurturing. Another way to think of it would be “heartfulness.”

— Wherever You Go, There You Are