Professional Documents
Culture Documents
2123
Editor
Patricia Lynn Dobkin
Associate Professor
McGill University
Department of Medicine
Affiliated with McGill Programs in Whole Person Care
Montreal, Qubec
Canada
http://www.mcgill.ca/wholepersoncare
Kindness
Acknowledgments
I wish to extend my gratitude to people who have enabled me to conceive of and complete
this book. First, Dr. Tom Hutchinson, the Director of McGill Programs in Whole Person
Care, encouraged me to develop mindfulness programs at McGill University in the Faculty
of Medicine. He is an inspirational world-class leader of Whole Person Care. Second, my
brother, Dr. Dennis Dobkin, has always counseled me to abide by my inclinations even in
those heady hippy days when at 19 years old I trekked off to India and discovered Auroville, a
UNESCO recognized model city of peace. Aurobindo, the sage who founded the Pondicherry
Ashram, taught that work can be a spiritual practice. His vision led me to here, now. Dr. Paul
M. Jurkowski ignited my heart with loving kindness this was instrumental in transforming
my life.
My mindfulness teachers have been essential to my being able to teach MSBR and Mindful Medical Practice. They are: Dr. Jon Kabat-Zinn, Dr. Saki Santorelli, and Florence MeleoMeyer at the Center for Mindfulness in Medicine, Health Care, and Society; Dr. Gregory
Kramer, whose Insight Dialogue retreats have touched me deeply; Dr. Ronald Epstein and his
colleagues who are world leaders in Mindful Practice. Various instructors at the Insight Meditation Society in Barre, Massachusetts have been guides along the way as well. His Holiness
the Dala Lama has been a model of engaged social justice; his writings and visits to Canada
have been vital to my awakening.
Ms. Portia Wong at Springer Press has been helpful in transforming chapters into one coherent book. Ms. Angelica Todireanu at McGill Programs in Whole Person Care has provided
excellent technical support as well.
I dedicate this book to Mark S. Smith. I am grateful for his deep understanding me and this
work. He has offered me the inner and outer space to write in peace, dream in colour, and
share the joys of life together. His love is a precious jewel that adorns my heart.
ix
Foreword
Ronald M. Epstein, MD
University of Rochester Medical Center
A monk asked Zhaozhou to teach him.
Zhaozhou asked, Have you eaten your meal?
The monk replied, Yes, I have.
Then go wash your bowl, said Zhaozhou.
At that moment, the monk understood.
Wisdom, William James once said, is about a large acquaintance with particulars more than
overarching principles [1]. It is about finding our way in not just any situation, but this situation in which we encounter ourselves, right now. In medicine, these situations involve patients
and their families, with their sufferings and misfortunes. Overarching principles of clinical
practicethe teachingsprovide a beacon to help us know when we are off course, but the
wisdom of clinical practice lies beyond our general knowledge of diagnoses and treatments;
it has more to do with how we respond to the exigencies of the momentthe contexts, the
individual players and the range of outcomes that are possible for and desired by this patient.
Zhaozhous answer to the young monk seeking wisdom was to wash his bowlthe task that
the moment demands of us. In that way, each patient encounter is also in the present moment;
each encounter might be part of a long-range strategy informed by knowledge and evidence,
but is always a drama that is being written, enacted and interpreted in the moment.
This book is about being mindful in clinical practice. Importantly, mindfulness is emergentit manifests as a desired attitude of mind without having been willed into being. Like
love, empathy and many other things that are important in life, mindfulness is something that
we value and can make space for, but can never fully define nor evince because the act of overspecifying its shape, form, dynamism and trajectory limits it to something less than it isas
Laozi said some 2500 years ago, the Tao that can be named is not the real (or eternal) Tao. I
wont argue here what the Tao is, nor mindfulness, but those who have picked up this book
have some idea that mindful practice is an intentional attitude of mind that strives for clarity
and compassionby adding the qualifier medical it defines the context and the protagoniststhose who heal and those who seek healing.
The immediacy of clinical care is seen and enacted through stories that we tell ourselves
and others, stories that reveal our own perspectives. Reading stories about healers and patients
teaches us about the lenses through which theyand wesee the world. Stories are a vehicle
for wisdom. Narratives, as Rita Charon reminds us, serve to enlighten and to heal [2]. The
stories in this book have a particular focus and a particular purpose. They recount clinicians
experiences of being attentive and present in ways that are heartfelt, revelatory and insightful.
Yet, they do more. They invite the reader to think and construct narratives about their own
clinical lives with the purpose of deepening their self-understanding, become better listeners,
appreciate that stories unfold and almost never take the linear form that dominates medical
case histories. A good clinical story brings to light the dual purpose of the clinician-patient
xi
xii
relationshipbroadly defined, to interpret and categorize disease on the one hand and to interact with a suffering human being in a way that restores health on the other.
Thanks to the work of pioneers such as Jon Kabat-Zinn, mindfulness is a household word
in North America, enshrined on the cover of Time magazine, discussed in earnest in corporate
boardrooms and schools, infused into psychotherapy and engaged in practice by millions who
want to experience greater balance, health and wellbeing. Since 1999, when the Journal of the
American Medical Association first published Mindful Practice [3], the word mindful has
also entered the lexicon of mainstream medical practice. It has a positive valence, even for
those who doubt that it is possible to achieve. Starting in 2006, with colleagues at the University of Rochester, I have tried to answer the challenge of how to help clinicians become more
mindful. This is no small task. Building on the work of philosophers, reflective physicians
and cognitive scientists, I have also drawn on my own experienceas a student of Zen Buddhism (fortunately still a beginner after 42 years of practice), as a musician (my first attempt
at a career), as a chef (mindlessness manifests as burnt pine nuts) and as a healer. What has
emerged is that to cultivate mindfulness in action in clinical settingswhat I call mindful
practice and which Patricia Dobkin and colleagues now call mindful medical practice
requires preparation outside the workplace and enactment within it [49]. Usually, preparation
means some form of contemplative practice including but not limited to meditation, and the
enactment means some way to situate a practice of mindfulness in the context of healing.
Yet, meditationwith all its variations, power and allureis not enough. Moving from
mindfulness to mindful practice requires grounding in what the educator Donald Schn calls
the swampy lowlandsthe muddy amorphousness of everyday being in and with the world
[10]. Here is where stories come instories about, written by, told by, elicited from and listened to by clinicians about life experiences in health care contexts, full of their contradictions
and paradoxes, memory lapses, misapprehensions, emotional overlays and painfully poignant
turns of events; things that could never be captured in any other way. These stories are not
pretty and mindfulness does not flow from them like honeythese are pithy stories, infused
with grit and passion, foibles and humor, desperation and redemption.
This brings me to wonderwhat is a mindful story? Medical journals are filled with narrativesabout hope and loss, connection and unfulfilled promises, transformation and the
relentless unfolding of fate. All stories are meant to change how you look at the world. But,
do they all reveal mindfulness? I raise the question because I dont have the answer. Yet,
close reading sometimes provides clues. Does a mindful story have to involve transformation
in some way? Does it involve a revolutionary change in thinking or experienceor does it
simply uncover what has always been there but has remained unknown and unseen? Does the
protagonistwhen it is the patienthave to be, in Arthur Franks words, successfully ill,
and find meaning in his or her suffering? Does the healer have to be moved in some emotional
way? Can a mindful story be about placing a suture, reading an x-ray or responding to a medication alert on the computer screenthings that have little intrinsic emotional content? Does
the self-reflection implicit in the modern incarnations of the concept of mindfulness have to
be conscious, verbal and explicit? Or can it remain outside of everyday awareness, unspoken
and mysterious? Can mindfulness be humdrum? Does mindfulness have to be unexpected?
Can presence amid dissolution, destruction and disaster be mindful even though the outcome
is worse than anyone could possibly have imagined? Can mindfulness be giddy, silly, superficial, transient, fleeting? Does mindful intentionality have to involve forethought, or can our
intentions reveal themselves after the fact? Can you think youre being mindfully present and
be dead wrong, engaging in an elaborate self-deception? Do you really have to slow down to
be mindful? These questions are not necessarily issues to debate, but rather questions to hold
closely, to jiggle your thinking, to make sure youre not too sure of yourself.
Stories are important because they expand awareness. While general principles and ideals
can be monochromatic, good stories are always ambiguous. They always have several sides
to them. They never answer all the questions they raise. Is John Kearsleys Carmens Story
Foreword
Foreword
xiii
really just about Carmen? The way it is writtenand many others in this volumeit has multiple protagonistsclinicians, patients, family members, others. Is mindful practice about
any one of them, or is the emergent mindfulness the space that their interaction reveals as each
member of the quartet (or duo or trio) tacitly takes a new view of an evolving situation? Is
mindfulness contagious, as it seemed to be in The Opera of Medicine, Mick Krasners story
about his relationship with his father and the person whose presence brought them together in
unexpected ways? You see where I am going: asking reflective questions leads us deeper into
ourselves and opens up the possibility to see the ordinary with new eyes.
Stories require a teller and a listener. Today I read an article showing that electronic devices,
including the one that I am using right now, activate the same brain circuits as do addictions.
Ironically, I read the article on the screen. Thats okay for research articles, but when Im reading stories in a deeper way, I realize that reading on the screen requires a focus beyond my own
capacity, so I print them out. Reading them out loud demands another kind of attentionauditory information is qualitatively different from that which comes in just through the eyes. This
is to say that these stories are an invitation to read them mindfully, in whatever way you have
to in order to have them reveal themselves to you. These stories by health professionals, mostly
physicians, were written with the willing or unwitting help of patients and their families, and
in some cases, colleagues and trainees. As a reader, you are part of the community of listeners, witnesses and re-tellers of the stories, in whatever transformed or imperfect ways you can
imagine.
As you read, when you think you have come up with an interpretation of whats going ona
label, a categoryperhaps stop for a moment and pay attention to the difference between the
words on the page and the evolving story in your mind. This is much the same activity as we
engage in with patients in order to hear them and help them disclose their suffering to us. In
that way, the mindful practice of reading can inform the mindful practice of doctoring. The
other day, I saw a patient who reported a funny sensation right here while walking up stairs,
gesturing to a large area of the anterior chest and upper abdomen, and yet when I was on the
phone to the emergency department (ED), I said that the patient was having chest pressure.
Only later did I recognize the unconscious distortion; the patient never used either of those
wordschest or pressureto describe her symptoms. It was too late. I didnt call the ED
back. I knew that the words chest pressure would paradoxically result in her getting better
care, even though they were not quite true to what the patient said. It makes me anxious to
think about trying to explain to a rushed humorless triage nurse about the funny sensation
right there; chest pressure is so much more convenient. A mindful moment, not shared with
those who mattered to the patient, so now you are the witnesses. In that way, we witness each
others foibles and inspirations. A good story records these kinds of events in a deep way, often
compassionate, sometimes funny, or just plain sad.
Perhaps mindful practice is just remembering who you are and focusing on what is important. Giving space for the telling of and listening to stories of mindful practice can transform
medicine by helping clinicians gain a deeper awareness of who they are, and by opening up
new possibilities of how they can offer what patients want and need. And, by creating a sense
of community, the telling of stories is the way that humans have always transformed their
individual visions into a shared enterprise.
1 James W. The Varieties of Religious Experience: A Study in Human Nature, reprint edition
1961. New York: W.W. Norton & Co.; 1902.
2 Charon R. Narrative medicine: form, function, and ethics. Ann Intern Med. 1/2/2001
2001;134(1):8387.
3 Epstein RM. Mindful practice. Jama. 9/1/1999 1999;282(9):833839.
4 Epstein RM. Mindful practice in action (I): technical competence, evidence-based medicine
and relationship-centered care. Families Systems and Health. 2003 2003;21:110.
5 Epstein RM. Mindful practice in action (II): cultivating habits of mind. Families Systems
and Health. 2003 2003;21(1):1117.
xiv
6 Epstein RM, Siegel DJ, Silberman J. Self-monitoring in clinical practice: a challenge for
medical educators. J Contin.Educ Health Prof. 2008 2008;28(1):513.
7 Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary
care physicians. JAMA: The Journal of the American Medical Association. 9/23/2009
2009;302(12):12841293.
8 Epstein RM. Mindful Practice: A Key to Patient Safety. Focus on Patient Safety. 2011
2011;14(2):37.
9 Beckman HB, Wendland M, Mooney C, etal. The impact of a program in mindful communciationon primary care physicians. Academic Medicine. 6/2012 2012;87(6):15.
10 Schon DA. Educating the reflective practitioner. San Francisco: Jossey-Bass; 1987.
Foreword
Preface
The idea for this book surfaced with the wail of a loon. She was swimming without a splash
across a lake that mirrored the evergreens bordering its shores. Summer is a matter of weeks
rather than months in Canadatradition has it that we, like birds, migrate to the countryside
where moose, grizzlies, herons, and if we are lucky, loons are found. While their cries evoke a
sense of loneliness, loons are loyal mates, protective of their chicks and thrive in a close-knit
family.
The summer is a time when I allow my mind, heart and spirit to wander in the woods
and across the waters. An observer may presume that I am doing nothing, but truth be told,
I am being more than doing. Being human, that is. My meditation practice opens me to the
elementsthey are my teachers.
While listening to the loons, I wondered how I could gather other voicesthose of clinicians who exemplify whole person care. I have been teaching mindful medical practice, along
with my colleague Dr. Tom Hutchinsonthe director of McGill Programs for Whole Person
Carefor 8 years in various formats (8-week programs, half-day and full-day workshops and
weekend retreats). We published numerous papers (113) on the topic and presented our work
at conferencesthe conventional way of communicating the value of mindful medical practice
from our point of view. It occurred to me, that the 200 plus articulate and compassionate physicians and allied health care professionals we have encountered over the years have as much to
say about being present, bearing witness to pain and suffering and creating a space for healing
in their patients and themselves as we do. I realized that they often work in silos and seem
lonely, like the loons whose haunting cries permeate the lake I sat next to. Yet, I was aware that
there are many mindful practitioners who support one another. Similar to loons, they thrive in
groups. I thought by compiling their narratives they and you (the reader) would know that we
form a community. Shortly thereafter, I invited physicians and other clinicians working in various settings with different specialties to showcase how and why mindfulness matters.
Patients tales of illness and how it has altered their lives has become a genre in and of itself.
Less common are chronicles that emerge from the consciousness of their clinicians who treat
them. The narratives herein provide a window into their experiences1. The book is intended
for medical students and residents, physicians and other clinicians who aspire to bring mindfulness into their lives and work. It may also be of interest to patients, their families and the
general public given the broad interest in the relationship between mindfulness and wellbeing.
We are fortunate that the co-authors of this book were generous enough to share their insights
with us. Their narratives are inspiring and remind us that the tender gravity of kindness (14)
may guide our interventions.
Patricia Lynn Dobkin PhD
1 In all cases we have changed names and details to protect patient identities unless patients provided consent
to have their stories told.
xv
xvi
References
Dobkin PL. Mindfulness-Based Stress Reduction: What processes are at work? Complement Ther Clin Pract.
2008;14(1):816.
Dobkin PL. Fostering healing through mindfulness in the context of medical practice [Guest Editorial]. Curr
Oncol. 2009;16(2):46.
Irving JA, Dobkin PL, Park J. Cultivating mindfulness in health care professionals: A review of empirical
studies of Mindfulness-Based Stress Reduction (MBSR). Complement Ther Clin Pract. 2009;15(2):6166.
Hutchinson TA, Dobkin PL. Mindful Medical Practice: Just another fad? Can Fam Phys. 2009;55(8):77879.
Dobkin PL, Hutchinson TA. Primary prevention for future doctors: promoting well-being in trainees. Med
Educ. 2010;44(3):22426.
Dobkin PL, Zhao Q. Increased mindfulness-the active component of the Mindfulness-Based Stress Reduction
program? Complement Ther Clin Pract. 2011;17(1):227.
Dobkin PL. Mindfulness and Whole Person Care. In: Hutchinson, TA. (ed.). Whole Person Care: A New Paradigm for the 21st Century. 1st ed. New York, NY: Springer; 2011. p.6982.
Dobkin PL, Irving JA, Amar S. For whom may participation in a Mindfulness-Based Stress Reduction program
be contraindicated? Mindfulness. 2011;3(1):4450.
Irving J, Park J, Fitzpatrick M, Dobkin PL, Chen, A, Hutchinson T. Experiences of Health Care Professionals Enrolled in Mindfulness-Based Medical Practice: A Grounded Theory Model. Mindfulness. 2012. doi:
10.1007/s12671-012-0147-9.
Dobkin PL, Hutchinson T. Teaching mindfulness in medical school: Where are we now and where are we
going? Med Educ; 2013;47:76879.
Dobkin PL, Hickman S, Monshat K. Holding the heart of MBSR: Balancing fidelity and imagination when
adapting MBSR. Mindfulness. 2013. doi:10.1007/s12671-013-0225-7.
Garneau K, Hutchinson T, Zhao Q, Dobkin PL. Cultivating Person-Centered Medicine in Future Physicians.
Euro J Person-Centred Healthcare. 2013;1(2):46877.
Dobkin PL, Lalibert V. Being a mindful clinical teacher: Can mindfulness enhance education in a clinical setting? Med Teach. 2014;36(4):34752.
Nye NS. Kindness. In: The words under the words: Selected poems. 1995. The Eighth Mountain Press; 1st
edition. http://www.poets.org/poetsorg/poem/kindness. Accessed 27 Jun 2014
Preface
Contents
xviii
Contents
Contributors
Michelle L. Bailey Department of Pediatrics, Duke Health Center at Roxboro Street, Duke
University Medical Center, Durham, NC, USA
Emmanuelle Baron Department of Family Medicine and Emergency Medicine, Universit
de Sherbrooke, Saint-Lambert, QC, Canada
Ted Bober Physician Health Program, Ontario Medical Association, Toronto, ON, Canada
Christian Boukaram Maisonneuve-Rosemont Hospital, Universit de Montreal, Montreal,
QC, Canada
Linda E. Carlson Department of Oncology, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
Department of Psychosocial Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada
Tara Coles University of Maryland, Baltimore, MD, USA
Medical Emergency Professionals, Rockville, MD, USA
Kathy DeKoven Department of Anesthesiology and Pain Clinic, Centre Hospitalier Universitaire Sainte-Justine, Universit de Montral, Montreal, QC, Canada
Dennis L. Dobkin Waterbury Hospital Health Center, Waterbury, CT, USA
Patricia Lynn Dobkin Department of Medicine, McGill Programs in Whole Person Care,
McGill University, Montreal, QC, Canada
Andrea N. Frolic Office of Clinical & Organizational Ethics, Hamilton Health Sciences,
McMaster University Medical Center, Hamilton, ON, Canada
Elisabeth Gold Family Medicine and Division of Medical Education, Dalhousie University,
Halifax, NS, Canada
Carol Gonsalves Department of Medicine, Division of Hematology, Ottawa Blood Disease
Centre, Ottawa Hospital, Ottawa, ON, Canada
Craig Hassed Department of General Practice, Monash University, Notting Hill, Victoria,
Australia
xix
xx
Tom A. Hutchinson McGill Programs in Whole Person Care, Faculty of Medicine, McGill
University, Montreal, QC, Canada
Cory Ingram Family and Palliative Medicine, Mayo Clinic, College of Medicine, Mankato,
MN, USA
Corinne Isnard Bagnis Service de Nphrologie, Institut dEducation Thrapeutique, Universit Pierre et Marie Curie, Hpital Piti-Salptrire, Paris, France
John H. Kearsley Department of Radiation Oncology, St. George Hospital, University of
New South Wales, Kogarah, NSW, Australia
Michael S. Krasner University of Rochester School of Medicine and Dentistry, Rochester,
NY, USA
Stephen Liben McGill Programs in Whole Person Care, Faculty of medicine, Paediatric Palliative Medicine, Montreal Childrens Hospital, McGill University, Montreal, QC, Canada
Ricardo J. M. Lucena Department of Internal Medicine, Centre of Medical Sciences, Universidade Federal da Paraba, Tamba, Joao Pessoa-PB, Brazil
Sonia Osorio Private Practice Outremont, QC, Canada
Catherine L. PhillipsDepartment of Psychiatry, University of Alberta, The Mindfulness
Institute.ca, Edmonton, AB, Canada
Maureen Rappaport Department of Family Medicine, McGill University, Montreal West,
QC, Canada
Joyce Schachter Harmony Health, Ottawa Hospital, Ottawa, ON, Canada
Mark SmilovitchCardiology Division, Faculty of Medicine, McGill Programs in Whole
Person Care, McGill University, Montreal, QC, Canada
Kimberly Sogge University of Ottawa, Ottawa, ON, Canada
Contributors
Mindfulness
Mindfulness is a way of being in which an individual maintains attitudes such as, openness, curiosity, patience, and
acceptance, while focusing attention on a situation as it unfolds. Mindfulness is influenced by ones intention, for example, to act with kindness, and attention, i.e., being aware
of what is occurring in the present moment. It is an innate
universal human capacity that can be cultivated with specific
practices (e.g., meditation, journaling); it both fosters and is
fostered by insight, presence, and reflection.
Mindfulness in Medicine Clinicians need to be skilled in
listening fully to and being totally present to their patients/
clients to foster healing [1]. Even the most seasoned clinicians face ongoing challenges relative to shifting between the
automaticity demanded by fast-paced environments which
require multitasking and deliberate, focused attention necessary for monitoring and clinical decision making [2]. In order
to make mindfulness relevant to these specific concerns and
constraints, as well as to engage health-care professionals
more fully in the process, mindful medical practice programs
have been developed. For example, Krasner etal. [3] conducted an open trial of a modified mindfulness-based stress
reduction (MBSR) program that included aspects of appreciative inquiry [4] and narrative medicine [5] with primary
care physicians. One year following the 8-week program
with monthly follow-up classes, mindfulness, empathy, and
emotional stability were enhanced while physician burnout
decreased. Moreover, increases in mindfulness were significantly correlated with physician self-reports of improved
mood, perspective taking, and decreased burnout. McGill
Programs in Whole Person Care has offered mindfulnessbased medical practice since 2006. The program is closely
P.L.Dobkin()
Department of Medicine, McGill Programs in Whole Person Care,
McGill University, Room: M/5, 3640 University Street,
Montreal, QC H3A 0C7, Canada
e-mail: patricia.dobkin@mcgill.ca
modeled after MBSR but includes role-plays, based on Satirs communication stances [6], other exercises emphasizing
communication skills and interpersonal mindfulness, based
on insight dialogue [7] and emphasizes self-care. It aims to
help clinicians integrate mindfulness into working relationships with patients and colleagues. In a sample of 110 healthcare professionals (half of whom were MDs), following the
8-week course, significant decreases were observed in participants perceived stress, depression, and burnout, as well
as significant increases in mindfulness, self-compassion,
and well-being. Hierarchical regression analyses showed
that decreases in stress predicted well-being; as did increases
in mindfulness and self-compassion [8, 9]. Moreover, 93%
reported increased awareness and continued meditation
practice following the program; 85% indicated that they had
a meaningful experience of lasting value [10]. Fortney etal.
[11] studied an abbreviated mindful intervention for 30 primary physicians who attended 18h of classes with access to
a web site that was designed to support their practice; they
reported similar improvements both immediately following
the intervention and 9 months later.
Mindfulness and the Therapeutic RelationshipTwo
decades ago, Stewart [12] published a review showing that
the quality of physicianpatient communication was linked
to better patient outcomes (e.g., emotional health, symptom resolution, pain control). Soon thereafter, physicians
began exploring how mindfulness could positively influence medical practice [13, 14]. Hick and Biens [15] edited
book highlights how mindfulness can enhance the therapeutic relationship by cultivating crucial therapeutic skills
such as unconditional positive regard, empathetic understanding, and improve different therapeutic interventions
(e.g., substance abuse, psychoanalytic psychotherapy). It is
hypothesized that positive patient outcomes are due to the
therapists own attention and affect regulation, acceptance,
trust, and nonjudgment of patient experiences, and their ability to tolerate patient emotional reactivity. Two qualitative
studies [8, 16] found that when physicians and clinicians
P. L. Dobkin
took a mindful medical practice course, they felt less isolated professionally. Moreover, they indicated that mindfulness improved their capacity to be attentive while listening
deeply to patient concerns. In the first study to examine if
practitioners mindfulness influenced the medical encounter,
Beach etal. conducted an observational study of 45 clinicians caring for patients infected with the HIV virus [17].
Medical visits were audiotaped and coded by raters blinded
to mindfulness scores; patients independently rated their perceptions following the visit. Clinicians who scored high on
mindfulness were more likely to engage in patient-centered
communication (e.g., they discussed psychosocial issues,
built rapport) and they displayed more positive emotional
tone with patients. Patients reported better communication
with the more mindful physicians and they were more satisfied with their care.
Escuriex and Labb [18] reviewed the relationship between clinicians mindfulness and treatment outcomes.
Much like the research cited herein, clinicians benefited
from mindfulness training personally and professionally.
They reported increased capacity for empathy and ability to
be present without becoming defensive or reactive. Nonetheless, in this review the link to patient outcomes was mixed.
While their interpretation indicated that there is not a simple
correlation between clinician mindfulness and mental health
outcomes, this may be because they assumed that the clinician is responsible for prompting patient improvements. In a
subtle way, this fails to recognize that patients have to take
responsibility for coping with illness in partnership with the
clinician (as shown in Fig.1.1).
Evidently, mindfulness allows for a trusting relationship
to develop between the clinician and the patient. This, is the
space in which healing can take place with the clinician
who accompanies the patient on the journey towards wholeness, even when no cure is possible. She/he invites the patient to approach the illness experience in a deeper way, exploring its meaning and opportunities. This is accomplished
through an analogic form of communication. In addition
to the words spoken, the clinicians genuine concern for the
patient is shown through his or her posture, gestures, facial
expression, voice inflection, sequence, rhythm, and cadence
in speech. Clinicians who intuit when to be silent, when to
allow time for integration of information, or when to use
touch reassure the patient that he/she is not abandoned to
his/her fate. Being present in this way provides a safety zone
in which the dark side of illness can be explored: the fears,
losses, and implications. To be able to be receptive to suffering, the clinician needs to be able to tolerate uncertainties,
strong emotions, and address existential issues. This is much
more than bedside manner; rather, it is true empathy in action. Herein lays the heart of medicine.
6RFLDO6\VWHP
0HGLFDO6\VWHP
+HDOWKFDUH
SURIHVVLRQDO
&
$
%
3DWLHQW3HUVRQ
'
'LVHDVH
Fig. 1.1 A clinical encounter. Numerous factors influence the encounter when a person/patient seeks treatment for a disease or illness. There
are three intersecting foreground elements: the health-care professional,
the patient/person, and the disease. These are embedded in two overlapping contexts, i.e., the medical and social systems. In the left circle is
the doctor who arrives with her/his professional know-how and personal history. She/he meets the patient in A, encounters the patient and
disease together in B, and the disease itself in C. A is a place where healing may be fostered. B is the intersection of the clinician, patient, and
disease; this is where curing may occur. C contains the professionals
tool box containing medical knowledge, procedures, diagnostic tests,
surgery, and medications. The person, in the circle on the right, arrives
with his/her genetic loading, psychosocial characteristics, personal and
medical history, as well as health-related behaviors. These will impact
the disease in D (e.g., obesity, smoking with coronary heart disease).
Moreover, the patient/person brings to the disease or illness certain beliefs, expectations and hopes
(his need to relate his stories), and the context (two hungry
medical students who seemed impatient and confused about
why the visit was taking so long). Significantly, Dr. Kearsley shares with us the truth of how exquisite presence can
provide a memorable and sublime silent encounter that
provided unexpected sustenance and meaning to the daily
routine (p.2283).
To approach all this from a mindful perspective, the clinician may open a dialogue with the patient that includes the
medical aspects of the presenting problem (e.g., fibromyalgia) and encourage patient coping strategies that may be useful to help her live as fully as possible with the disease or
illness. The clinician would listen with an open, clear mind
to the patients views and observe his/her own as well as the
patients reactions. The patient, in turn, would communicate
honestly with the clinician, understand her role, and engage
in self-care behaviors (e.g., pacing, adherence to exercise)
that impact her quality of life [20]. Mindfulness is the skill
set that facilitates these healing aspects of the clinicianpatient encounter.
References
1. Dobkin PL. Fostering healing through mindfulness in the context
of medical practice. Curr Oncol. 2009;16(2):46.
2. Epstein RM, Seigel DJ, Silberman J. Self-monitoring in clinical
practice: a challenge for medical educators. J Contin Educ Health
Prof. 2008;28(1):513.
3. Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B,
Mooney CJ, etal. Association of an educational program in mindful communication with burnout, empathy, and attitudes among
primary care physicians. JAMA. 2009 Sep 23;302(12):128493.
4. Cooperrider D, Whitney D. Appreciative inquiry: a positive revolution in change. San Francisco: Berrett-Koehler; 2012.
5. Connelly JE. Narrative possibilities: using mindfulness in clinical
practice. Perspect Biol Med. 2005;48(1):8494.
6. Satir V. The new peoplemaking. Palo Alto: Science and Behaviour
Books Inc; 1988.
7. Kramer G. Insight dialogue: the interpersonal path to freedom.
Boston: Shambhala Publications; 2007.
8. Irving J, Park J, Fitzpatrick M, Dobkin PL, Chen A, Hutchinson T.
Experiences of health care professionals enrolled in mindfulnessbased medical practice: a grounded theory model. Mindfulness.
2014. doi:10.1007/s12671-012-0147-9.
9. Irving JA, Williams G, Chen A, Park J, Dobkin PL. Mindfulnessbased medical practice (MBMP): a mixed-methods study exploring benefits for physicians enrolled in an 8-week adapted MBSR
program. In: 2012 AMA-CMA-BMA International Conference on
Physician Health (ICPH); 2527 Oct 2012; Montreal, QC; 2012.
10. Irving JA, Dobkin PL, Park-Saltzman J, Fitzpatrick M, Hutchinson TA. Mindfulness-based medical practice: exploring the link
between self-compassion and wellness. Int J Whole Person Care.
2014;1(1). http://ijwpc.mcgill.ca/. Accessed: 27 June 2014.
11. Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D.
Abbreviated mindfulness intervention for job satisfaction, quality
of life, and compassion in primary care clinicians: a pilot study.
Ann Fam Med. 2013 Sep;11(5):41220.
12. Stewart MA. Effective physician-patient communication and health
outcomes: a review. Can Med Assoc J. 1995;152(9):142333.
13.
Epstein RM. Mindful practice. J Am Med Assoc.
1999;282(9):8339.
14. Connelly J. Being in the present moment: developing the capacity
for mindfulness in medicine. Acad Med. 1999 Apr;74(4):4204.
15. Hick SF, Bien T, editors. Mindfulness and the therapeutic relationship. New York: Guilford Press; 2008.
16. Beckman HB, Wendland M, Mooney C, Krasner MS, Quill
TE, Suchman AL, etal. The impact of a program in mindful
4
communication on primary care physicians. Acad Med. 2012
June;87(6):8159.
17. Beach MC, Roter D, Korthuis PT, Epstein RM, Sharp V, Ratanawongsa N, etal. A multicenter study of physician mindfulness and
health care quality. Ann Fam Med. 2013 Sept;11(5):4218.
18. Escuriex BF, Labb EE. Health care providers mindfulness and
treatment outcomes: a critical review of the research literature.
Mindfulness. 2011;2(4):24253.
19. Kearsley JH. Wals story: reflections on presence. J Clin Oncol.
2012 June 20;30(18):22835.
20. Dobkin, PL. Mindfulness and whole person care. In: Hutchinson
TA, editor. Whole person care: a new paradigm for the 21st century. New York: Springer Science + Business Media, LLC; 2011.
pp.6982.
21. Charon R. The patientphysician relationship. Narrative medicine:
a model for empathy, reflection, profession, and trust. J Am Med
Assoc. 2001 Oct 17;286(15):1897902.
22. Charon R. Narrative medicine: honoring the stories of illness. New
York: Oxford University Press; 2006.
P. L. Dobkin
23. Charon R. What to do with stories: the sciences of narrative medicine. Can Fam Physician. 2007;53(8):12657.
24. Hutchinson TA, Hutchinson N, Arnaert A. Whole person care: encompassing the two faces of medicine. CMAJ.
2009;180(8):8456.
Patricia Lynn Dobkin PhD is a clinical psychologist specializing in
chronic illness and chronic pain. She is an associate professor in the
Department of Medicine at McGill University. As a certified mindfulness-based stress reduction (MBSR) instructor, she spearheaded the
mindfulness programs for patients, medical students, residents, physicians, and allied health-care professionals at McGill Programs in
Whole Person Care. Dr. Dobkin collaborates closely with Drs. Hutchinson, Liben, and Smilovitch to ensure the quality and integrity of the
mindfulness courses and workshops offered at McGill University and
other venues (e.g., conference workshops, weekend training retreats).
M.Rappaport()
Department of Family Medicine, McGill University, 211 Ballantyne
Avenue North, Montreal West, QC H4X2C3, Canada
e-mail: maureen.rappaport@gmail.com
P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_2,
Springer International Publishing Switzerland 2015
M. Rappaport
A Litany of Discomforts
Mrs. H. was not physically attractive; she had a cushingoid,
fish-like face, and beady little eyes. Her lips looked like she
sucked on a lemon all day and now wanted to spit them in
my face. She was built like an overstuffed salami.
She was double-booked for a cough and I was running
2 hours late. I saw her scowling at me every time I rushed
through the waiting room to get another patient. When I finally called Mrs. H. in, she slowly collected her coat, hat,
and cane, which she carried like a weapon, and installed herself into a chair in my office as if she was ready to dig in
there for the entire winter.
A cough is usually a quickie. I need only ask a few
questions about fever, phlegm, shortness of breath, and then
listen to the lungs. I could do it in one shot, in less than 5
min, if only she would cooperate.
I wheebr ghunt chichi.
Were those words or wheezes? I could hear air struggling
to exit her constricted mucous filled bronchioles as the guttural grunts assaulted my tympanic membranes.
I have other, overweight, moustached old lady patients
who I love to hug, who even smell a bit of urge incontinence.
What is it about Mrs. H. that rubs me like fibrosed pus in
diseased pleura?
Is it her obnoxious son, Marcus, who at that moment
barged in the office, yelling into his cell phone? He is an
accountant who makes sure I balance his mothers litany of
complaints and neatly arrange them like the myriad of coloured pills in her dosette box.
Or is it because she never makes a proper appointment to
present me with glucose and creatinine levels, her sore back,
and obstructed lungs but is not fluent in any of the languages
I speak, and Marcus is a lousy interpreter (they spend half
the time arguing in Arabic)?
After I got through the ordeal of slipping my stethoscope
through a crack between her corpulent flesh and full body
girdle; when I was nose to thorax, skin to skin, I remembered
she had another son who was a paranoid schizophrenic, who
she still took care of, through his violent outbursts and despair.
She was a mother, like I was.
The air between us opened like a puff of ventolin to her
lungs. It did not last long but I took a few deep breathes in
the middle of a chaotic day.
William Carlos Williams unleashed my inhibitions towards writings about situations which, or patients who stir
up anger, shame, and what I perceive as unprofessional behaviour.
My writing practice includes my mistakes, the dark side
of my all too human nature, critical incidents [4] that are
given shape and form through prose and poetry. The practice consists of three phases: (1) the actual writing, (2) the
reflecting, in public, which can take many forms, such as
parallel chart sessions or small group responsive reading sessions, and (3) private redrafting of the story.
A Litany of Discomforts was written in response to the
trigger to write about someone you dislike so the first draft
consisted of my litany of complaints against Mrs. H., a fat,
ugly, difficult historian, with an aggressive family member.
The next exercise was to rewrite it in from the patients point
of view.
The draft reproduced here is a third draft, a story that
came out of my experiences of patients like her, in a similar
situation, where the metaphors of connection, in the last two
paragraphs healed the metaphor of congestion and inflammation. In the story with Mrs. H., it took physical touch, getting, nose to thorax, skin to skin to awaken the distracted
doctor to a memory of their humanity, to compassion from
one mother to another. The physical exam, facilitated a visceral conversation to occur where a verbal one was impossible, gently returning the doctor, as in meditation, back to
a present reality of non-judgement and awareness where
actions may occur more skilfully. It took me years to write
the way I did about Mrs. H., because it was hard to pierce
through my mask of professionalism to find repulsion in the
sacred doctorpatient relationship.
She proceeds to tell me the whole thing again, about the stiffness and numb back, the funny movements in her right leg,
the falling in the kitchen, and if she does not drive, she will
be worse because she will fall on the bus.
But, Francine I say, I also have to make sure youre a
safe driver and wont kill anyone else. Maybe you need some
time off work?
My pills are so expensive, over $400 a month! Are they
even doing me any good or are they slowly killing me? she
despairs.
Its almost 11:00 a.m.
The skin around her eyes reddens and crumbles, as I stiffen more to keep from falling.
Robert Frost says we do not look to poetry for solutions
to problems but a pathway through. This is equally true in
clinical narratives, and mindful practice.
Dr. Charon is an internist as well as a literary theorist. She
has coined the term Narrative Medicine and legitimized
something ephemeral in an evidence-based medical education world by using the precision, structure, and validity
found within literary theory. This allows for a certain objectivity, distance, or nonattachment of the self in an exercise of
self-reflection, self-awareness, and awareness of the other.
I see Charons treatment of the parallel chart [5] much as
I see the mindful approach to our thoughts. She asks us to
focus on the text, to honour the text not to focus initially
on the clinical situation or arising emotions. It is a work of
fiction, and Charon first comments on genre, temporality,
metaphors, narrative situation, and structure. She then asks
her students to listen for the writers voice, and invites them
to respond to the text, in their own individual way.
Stiff and falling is a first-person clinical narrative, written in the doctors voice, but the voice in this story is very
different than the first. It is written in an almost clinically,
detached way, a forty year old, complicated neurological
problemParkinsons, on Comptan. A specialist is consulted, and a family medicine guideline, feelings, ideas, functions, and expectations (FIFE) [6] is used, all to no avail. The
time is reported three times. Metaphor and image are used
only twice, both in reference to Parkinsons.
Wetness begins to seep through her stony features. Shes
a humid wall with lips.
The skin around her eyes redden and crumble, as I stiffen
more
My response to this story is that the doctor is uneasy with
the patients request for a drivers license, yet does not want
to be perceived as the bad guy, so she tries different stalling
techniques all morning, and takes on a stony face persona, to
become an emotional wall, mirroring the emotionally Parkinson stiffness, to do what she must.
In reflective practice, Bolton [7] states that this type of
writing is more than confession, and more than examination
of personal experience. Writing becomes a method of inqui-
ry, not just a way to tell, but a way of knowing. It will not
directly answer the question, What should I have done?,
but allow one to stay present with the realities of uncertainty,
difficult, and painful issues.
There is no easy solution, or answer, to some clinical
situations, but perhaps allowing herself to feel and act on
her unease with authenticity, would have allowed the doctor
to show more empathy towards her patient and soften their
stiffness.
Parkinsons disease is so visual and visceral for me perhaps because my father struggled with this disease for many
years. I have written many narratives about this disease.
M. Rappaport
July 1999
Mrs. W. was an 88-year-old woman, with diabetes, among
other things. I had never met her before. It was a beautiful
summer day when I visited, to assess a foot ulcer. I am wearing sandals and I remove my footwear before entering her
house. Mrs. W. can hardly move, and it takes all her energy
to finally plop her weight down on an easy chair.
She wants to show me something under her left heel. She
lifts her leg as I try to support her calf. I squat on her living
room carpet (baby blue broadloom), holding an old ladys
leg, trying to position the heel, my eyes, and the light source
strategically. I cannot see. She shifts, I change angles, and
another lamp is lit.
Sitting crossed legged on the blue broadloom, I hold her
foot, assess the callous and surrounding red skin. I press
here and there (it hurt a bit), wondering if I should lance the
wound. It looks and feels okay. I pack up, say my farewells,
and leave.
Back at the clinic, writing my note I feel like a dummy.
With all the shifting, holding, and manoeuvring of lights, I
forgot the foot I was holding was a diabetic one. I did not
test for sensation, or feel for a pulse. I blame it on the blue
broadloom, the feel of it on my naked toes.
And then I remembered the warmth of her foot in my
hand.
I will apply the drill Charon uses (frame, form, time,
plot, and desire) with her students in parallel chart sessions,
more to enhance and illustrate a mindful process, than to
offer an explanation of the texts. Recognizing that without a
group of astute readers to help me, the self-awareness, selfreflective, and mindful aspects of writing are compromised
because writers need readers who can reveal what the writer
himself or herself cannot see [5].
So I ask you, attentive readers, to let yourselves respond
to the text independently of my offerings and to continually
ask these questions, in addition to the drill.
What do you see? What do you hear? What do you want
to learn more about? [5].
In the opening story with Mrs. W., the narrator starts out
being very busy and focused on trying to see something that
ultimately remains hidden for all sorts of reasons. I cant
see. I shift, change angles, and another lamp is lit.
The doctors desire of perfect physical exam, perfect
note, and harsh self-judgment, I feel like a dummy, probably sounds familiar to many clinicians. Then through the
unconscious use of metaphor, she was literally taken back
to her senses, to feel the lush broadloom on naked toes. This
feeling, this way of being, brought her to another way of
seeing her patients body. And then I remembered the
warmth of her foot in my hand. The metaphor of a patients
warm foot likely refers to more than the presence of a pulse,
but the ability of a patients innate humanity to heal the doctor, to help the author of this short piece let go of her imperfections as a doctor, and still be whole.
When I first sat down to write this story, I had no idea it
would come out this way. The writing process, then reading
it with some distance, using Charons framework achieved
mindfulness of body sensation, awareness of self-denigration, to transcendence through human connection.
Molly
Doctor, I never imagined me, who has always been so
strong, to be so weak and slow. Dont get old. Ninety-six,
ech who needs it?
What, I ask, Do you want me to die young?
Mollys lips, chapped but still generous, press together as
she paused for a second.
Doctor, I love you like a friend, God forbid you should
die young. Thats it, lifes a mystery and its a terrible thing
when God takes a young person and leaves someone old
like me! A friend of mine, much younger than me, a second
cousin, died suddenly. I was at the funeral yesterday. She
was only 74!
Mollys muzzle was whitened. She wore badly fitted
dentures stained with bits of lipstick. I could imagine her
face and body rounded out in health in her prime. Today she
looked frailer than usual, old and skinny. She shuffled to
greet me at the door of her room schlepping her sunken jowls
and droopy eyes along with her walker and old beige purse.
That old wrinkled bag looked exactly like the one my bubby
had, the one she would let me rummage through in search of
candy. Mollys Yiddish flavoured diction, the lipstick smear,
the clean, yet simple red woollen jersey over nylon black
pants were all familiar.
I dont think Ill survive till Rosh Hashanah, she says,
making sure to stress that the pain in her left ankle is particularly bad. The Jewish New Year is 3 days away and Molly
is over 95.
When I first wrote the poem, I was not aware of how much
I identified with Molly, and all my geriatric patients in general. I saw my past, my wonderful grandparents; my present,
the reflection off the cataract; and my future, my little old
lady self.
Girls
Girls, girls, everybody in.
I was in the elevator at Mollys residence, angry at the
speaker calling a group of four or five white haired, ladies
with walkers and granny purses, girls. The speaker was the
last one in; she had a dowager hump, crowned with a white
pouf. Oh, its okay then, I thought. A 30-something Russian companion, thin, tight tee shirt, Capri pants, well-heeled
sandals, sexy polished toes, lots of young tanned skin, also
entered.
Wheres Nathan? asked one of the white perms.
I killed himchuckled the Russian. She looked around.
No one was noticing her despite the cropped metallic red
hair.
I said I killed Nathan!
Its kind of funny and I smile, feeling less like a foreigner
in a land of octogenarians.
What, says a little lady, not on the Sabbath, I hope!
Jeannie
Jeannie is a 60-year-old schizophrenic. I am making this
house call more for her elderly mother, Beryl, also my patient, who cares for her. It is too cold, icy, and challenging,
for mom to bring Jeannie to see me. I have seen Jeannie only
a few times through the years, though I know a great deal
about her from the stories Beryl has told me.
A brown slime oozes out of Jeannies broken teeth. Her
wrinkles contain crumbs, bits of toast or old boiled egg. Her
clothes that are way too big for her shrinking frame of bones,
smell like cabbage and wet blanket. She has lost over 30lb
in the past few months.
It is clear to me she must have a tumour somewhere. Her
sister who lives on the other side of town told me to leave it
alone. Do not investigate, do not treat.
When mom dies shes going in a home, anyways. I cant
take care of her like she does. Her life is awful. Shed be
better off dead.
Mama Beryl, with her orange hair, is still a spitfire at 86.
She wears pearls and lipstick for every one of my visits but
the state of things at home are pointing to Beryls difficulty
coping.
What do we need those tests for Doctor? Jeannies got
no pain? Going up to hospital for her treatments is hard
enough.
Jeannies been getting electroconvulsive therapy (ECT)
monthly for years now. The family insists on my secrecy
with Jeannie. Her understanding and grasp of things are at a
juvenile level and she reassures me she wants her mother to
decide on everything.
M. Rappaport
10
December 5, 2000
Jeannie spent another month at home with her mom before
her bowel ruptured. It was a clean, hidden rupture that walled
itself up, so though bedridden, hospitalized, and terminal,
Jeannie was still able to eat a bit. I found myself visiting her
bedside in hospital, guilt ridden over an outcome that was
inevitable. We were alone, and I heard myself asking Jeannie
if she knew she was dying?
Jeannie looked at me, bewildered.
Oh, what have I just done? I searched through my mind
for a way to fix things, because in my mind I had erred in my
care for this patient in so many ways.
Are you afraid? I asked, trying to see if she understood
anything.
Oh, not so much, but I just want to get the dying part
over with.
A Medical Intervention
She is a body between
White sheets labouring
Like all the rest on the
Oncology ward. Comfort
Measures only. Nothing
More to do. The grey tubes
Of my stethoscope, lie
Limp round my neck.
I notice her staring
At her food tray.
The cool steel of a
Teaspoon connects us.
Peaches in syrup slip
Between parched lips.
Nourishment in this sea
Of bowel disease.
Writing and reading my own poems evokes something profound in me, something I cannot explain in words, but similar
to what a poetry lover experiences when reading a favourite
poet. I am totally present and in the moment, while writing
and rereading my poems. My professional and personal egos
are of no concern.
Poetic form does not have to follow narrative or cognitive
logic, line breaks can defy grammatical rules, the interpretations can vary, yet we can learn how certain words and images trigger certain thoughts and emotions [9].
The doctor could not let Jeannie go without doing some
sort of medical intervention, so she asked her if, she knew
she was dying. It did not take long for the doctor to recognize her error and that it was time to focus on the patient
and the patients needs, which came in the form of peaches
in syrup.
11
References
1. Williams WC. The doctor stories. Compiled by Robert Coles. New
York: New Directions; 1984.
2. Goldberg N. Writing down the bones. Boston: Shambhala; 1986.
3. Goldberg N. Wind mind: ling the writers life. New York: Bantam;
1990.
4. Epstein RM. Mindful practice. JAMA. 1999;282(9):83339.
5. Charon R. Narrative medicine: honoring the stories of illness. New
York: Oxford University Press; 2006.
6. Weston WW, Brown JB, Stewart MA. Patient centered interviewing Part I: understanding patients experiences. Can Fam Physician. 1989;35:14751.
7. Bolton G. Reflective practice. London: Paul Chapman; 2001.
8. Williams WC. Asphodel, that greeny flower (excerpt). New York:
New Directions; 1962.
9. Connelly J. Being in the present moment: developing the capacity
for mindfulness in medicine. Acad Med. 1999;74(4):4204.
10. Kabat-Zinn J. Wherever you go there you are. New York: Hyperion; 2005.
Maureen Rappaport MD, FCCFPhas been a community family
physician for more than 25 years. Although she has a soft spot for the
elderly, her practice encompasses prenatal and newborns up to end-oflife care. She is an associate professor of medicine at McGill University
where she teaches clinically at both the undergraduate and graduate
levels, and shares her love of creative writing. She is also a wife, and a
mother of two young adults.
Epstein [2] adapted the core aspect of mindfulness to clinical practice and described the four habits of mind of the
mindful practitioner. First, she engages in attentive observation of the self, the patient, and the problem. This awareness
includes ones own perceptual biases and filtering processes
such as when the therapists residual developmental issues
influence how she/he interprets a patients words or behaviours [3]. The second habit is curiosity. For example, the clinician may wonder why certain facts do not add up. The
third habit has been referred to as the beginners mind, i.e.
the ability to see things as if for the first time. The fourth
habit is termed presence; by being fully with the patient,
ones work can be guided by insight and compassion.
In the first part of this narrative, I will highlight how
these habits of mind were instrumental in my work with
Monique. In the second part, Monique will reveal her
perceptions of what transpired within her as she faced her
issues in therapy.
Keeping Mary Olivers poem in mind while reading this
narrative, one may ponder what gift (if any) was lurking in
the box full of darkness she opened during our psychotherapy sessions.
Following a flurry of back and forth e-mail correspondences, a mutual decision was made for Monique to start
individual psychotherapy rather than belatedly join my
mindfulness-based stress reduction (MBSR) program for
P.L. Dobkin()
Department of Medicine, McGill Programs in Whole Person Care,
McGill University, Strathcona Dentistry and Anatomy Building,
Room: M/5, 3640 University Street, Montreal, QC H3A 0C7, Canada
e-mail: Patricia.dobkin@mcgill.ca
Attentive Observation
Self
I noticed myself listening intently to Moniques expos of
the weighty problems she was experiencing with an open
mind. As she described how distraught she felt when the
technician called in the doctor once the ultrasound test indicated that her 13-week-old foetus no longer had a heartbeat,
I was thrown back to the moment when an oblivious resident
turned to me 22 years earlier. I was then 7 months pregnant
following 6 years of infertility treatment when he bluntly
stated, This is the worst stress test I have ever seen. I can
still see his face, one that expressed no emotion whatsoever.
I too had been alone, like Monique; our respective husbands
not there to help us bear the brunt of these words.
When Monique related how hard it was for her to cope
with a miscarriage that occurred the year before, I recalled
being equally disheartened following two miscarriages prior
to and yet another one following my infant son Nicolas
death. Being keenly aware of these phantom memories, I
made a mental note to accept them, but not permit them to
intrude. I wondered if my own heavy history would help me
relate better to Monique or if it would trigger counter-transference. I chose not to give voice to my past in the context
of our sessions because self-disclosure would not have been
appropriate or helpful. Nonetheless, I recognized that what I
lived through would influence how I listened and related to
Monique. Some of the parallels were uncanny.
During the session, my thoughts returned to the time
when, like Monique, I was focused on my career, while my
biological alarm clock signalled that procreation time was
running out. She being 35 years old now, I, 36 thencommitted to reaching academic milestones at a respected medical
school. In retrospect, I realize that I too sometimes worked
13
P. L. Dobkin
14
Other
Monique entered my office with a sense of urgency the first
time we met. A tall woman dressed in dark colours accented
by bright scarves and an impressive handbagshe sported
pitch-black hair cropped close to her skull showing off her
chiselled facial features. As a professional, Monique gives
the distinct impression that she has a way with words, yet
her speech in French and Englishwhich she switched from
one to the other without hesitationwas pressured (more so
in her mother tongue, French).
From sessions to session, scarves became attractive
necklaces and various handbags were set down behind her
chair.
Im a big shopper, she admitted in passing.
I admired her taste in accessories. They suggested that her
appearance mattered, yet she was not ostentatious or affected
in her manner. The dark sweaters and trousers hinted that
something was concealed underneath it all.
Presenting Problem(s)
Monique has a history of various anxiety disorders (e.g.
phobias; obsessions and compulsions); she reported that her
mind races (e.g. during meditation, she experienced her mind
as a river rushing forward) and that she harbours distressing thoughts that clutter her mind (e.g. my body is broken)
and envisions terrible things happening.
Four years earlier, she gave birth to a son who has autism. Several sessions that focused on her feelings regarding him revealed a mlange of hot emotions: guilt, rage (in
the face of others reactions to him), along with harsh judgments of herself as a mother compounded by worry for his
future.
Monique had had a miscarriage a year earlier and her
fourth pregnancy ended therapeutically when the babys
heartbeat was lost a few weeks prior to our first session. She
experienced continual bleeding that required yet another
medical procedure. These multiple medical problems convinced her that her body was broken.
Curiosity
I was curious about what Monique was not talking about:
How she managed to work full time in a demanding job, while
raising a special needs child; what her work meant to her; if
religion or a philosophy helped her make sense of her multiple
losses. Little to nothing was mentioned about her husband
other than the fact that they had sought counselling following
their sons diagnosis to assist them in making the decision to
have another baby. Moreover, I wondered what it was like to
be the oldest of a large family and how this influenced her
ardent desire to be a mother. Did she help raise her siblings?
I knew she was close to two of her sisters, a physicist and a
painter, but what of the others? No mention was made of them.
Nor did I get a sense of her having friends or a social network.
Was she isolated by having a child unlike the others? Did having a special needs child drive her desire have a normal
one? Could Monique accept to have only one, this one?
Beginners Mind
Each patient who crosses the threshold into my office affords
me the opportunity to meet a new person; one I know absolutely nothing about. I rarely read a medical chart before the
first session, as I want the person to reveal to me what I need
to know, from her perspective. Thus, as I usually do, I opened
the session with the question, What brings you here now? I
was ready for the not knowing to slowly evolve into knowing.
Presence
Siegel [3] defines presence as, how we are fully open to
what is emerging within and between us, a state of receptivity to what arises as it is happening. He continues by explaining that it enables us to focus our attention on the internal experience of another persona process called attunement; we honour differences and promote compassionate
linksintegrative acts. Interpersonal attunement may give
way to resonance, i.e. whereby the other feels felt by us
deepening our connection, arousing trust, and encouraging
social engagement. This process is crucial to psychotherapy.
It is likely that our ability to be at ease together was related to our earlier, respective experiences in relationships in
which we could be open and honest. Also, my role as Dr.
Dobkinher psychotherapistprovided a context and safe
space for her to explore her innermost experiences.
As our relationship deepened and we became comfortable with one another, I began to feel un-at-ease with her use
of my title Dr. Dobkin. It was as if there was a glass wall
between us, transparent but obstructing the space that invites
healing. Moreover, my own use of the word patient rather
than human being (Dr. Paul Jurkowski, personal communication, July 23, 2006) clouded the glass with a mist contributing to the illusion of separation. Having worked as a
psychologist amongst physicians for 25 years, I had long ago
adopted this jargon as a means of gaining acceptance into the
exclusive club of medicine. My research and publications
were aimed at demonstrating empirically that psychosocial
factors were crucial to patients mental and physical health.
But now, with integrative medicine gaining ground in the
finest of medical faculties, is this still necessary, I wonder.
More importantly, could I drop it in the context of Moniques
therapy? Was it not more professional to maintain my role
as her doctor? Could I shift midstream from Dr. Dobkin to
Patricia? Would this invite Monique to meet the whole person that she is; the one who is complete just as she is? While
these reflections were not voiced, they became my homework, in between our sessions. I decided to keep the title.
I also paid more attention to the use of self-disclosures
of any kind. As is typical of an MBSR instructor, sometimes
one shares insights from ones own practice. For example, I
have practiced yoga for the past 18 years, and I mentioned
how it helped me to see the direct relationship between body
pain and emotional suffering. I spoke of how it helped me to
stay with rather than avoid not only body sensations but
also lifes challenges. As Epstein made clear in his book, The
Trauma of Everyday Life [4], all experiences are recorded in
our bodies, and we can learn to work with them. Nonetheless, before speaking of me or my experiences, I asked myself three questions: (1) What is my intention? (2) What may
be the impact? (3) Is it appropriate?
Treatment
Monique needed to probe the disconcerting experiences
lurking in her consciousness. Much like snow melting in
springtime, they filled rivers with wet emotions once she
took the plunge.
Outside of our sessions, she began a meditation course
with a well-respected French-speaking meditation teacher.
Her sister, who has been meditating for 10 years, accompanied her, and she found this support helpful. Given her
attendance to these classes, I chose not to teach her, as I do
with some patients, how to meditate. Monique found these
classes worthwhile yet she had some difficulty not judging
her practice since her mind, like most minds, wandered endlessly during the sitting-meditation practices.
Even though Monique did not take my MBSR course, I
introduced elements of it when they were called for. I gave
her compact discs (CDs) for home practice of the body scan
and hatha yoga. Most patients, including Monique, find
the diagram depicting the triangle of awareness (Fig.3.1)
helpful in understanding how mindfulness can elucidate
the mindbody connection. For example, when Monique
15
16
P. L. Dobkin
She was beginning to have some clarity about this by identifying less with her thoughts. Monique questioned whether her
thoughts were based in truth. While she called this detachment in psychology, we refer to this process as decentring.
Given Moniques proclivity for words several months
into her work with me, when we were seeing each other less
often (as she recovered and returned to work full time), I
read to her the poem by Rumi, The Guest House [7]. Something occurred that reminded me never to assume you know
anothers mindheart. While I supposed that the uninvited
guests that arrived at her door were her pregnancy losses
and her sons autistic condition, this was not what came up
for her. Instead, Monique spoke of anxious and sometimes
threatening thoughts that were most disconcerting. She expressed love for her son and related that her relationship
with him had improved over the past 3 months. Once more, I
needed to examine if and how my losses were loitering in the
room with us. I reminded myself that one cannot know what
lurks in the heartmind of another person. Not knowing is
another important attitude that mindfulness encourages. By
not being the expert, one can listen better and learn from the
other person.
Excerpts from Moniques journal (her identity is masked;
this is reproduced with her written consent):
December 9th, 2013the events that brought Monique to
the edge and to psychotherapy
On October 11, pregnant 13 weeks, I went for an ultrasound,
the one that screens for Downs syndrome, a routine test, a
detail almost, and then there was no heartbeat. And as much as
I always enter ultrasound rooms with the conviction that things
will end badly, I can now confirm that it still feels terrible when
they do. Right then and there, watching the technicians Adams
apple go up and down in her neck, the way you swallow just
before you have to deliver bad news, I knew even before she said
it, I knew in the way some things come to you almost through
your skin, skipping the brain altogether, that something had gone
wrong. And at that moment I felt like everything was caving in,
all the previous months of craziness at work, of tension over the
pregnancy with Martin, of feeling sick, not nauseous per se but
just overall tired and queasy and heavy and bloated and generally very much not myself, and the idea that this would stop in
the second trimester, that people would soon see that I had been
pregnant for three months, would praise me for having worked
so hard while in the first trimester, would take care of me, all
of it came to a brutal halt and I felt as if I had hit a wall. Over
the last three years I have had cancera benign one mind you,
not the kind you die ofthen an autism diagnosis for my only
son. Then I had a miscarriage at 11 weeks, after a difficult first
trimester of tension between my husband and me, over the next
kid being autistic as well. Finally, this second miscarriage at 13
weeks, this time after having been at the first ultrasound, and
having seen the heart beat. So this is where I hit a wall: on
the morning of October 11, 2013, in the dark and warm hospital
room with the technician being polite, passing me the box of
Kleenexes that I realized are not only useful to wipe off the blue
gel they use for ultrasounds.
17
I have to be careful not to see it as a huge departure from what I
have been doing, like a new life, because that is a lot of expectations. What I take from all of this process since the fall is
really take it one day at a time and see what comes out of it. The
observing, the seeing that comes out of it, is really the part of
the MBSR program that resonates the most with me, as it is an
approach (the curious, observing, scientific-like approach) that
I value in my life in general, so the idea of turning it on myself
and using it to curiously observe myself and my thoughts and
my feelings feels like a comfortable, reassuring, and interesting
path. Combine this with the yoga that lets you appreciate, every
time you do it, the various aches or stiffness in your body, and
you have a succession of scenes of you own life, snapshots of
every single mood and moment, very revealing when you start
really paying attention.
P. L. Dobkin
18
So maybe this is what I need to do with these guests: invite them
in, sit them down, talk to them, learn more about them, get to
know where they come from, their story, their purpose, their
background.
But I need to sit down with them, to let them in, to welcome them
almost, because otherwise they leave me with a terrible feeling,
a bad taste in my mouth, that lingering ominous dreadful feeling
of the kind that comes back to you just after you wake up, right
after the moment where everything is new, that same feeling I
imagine you would have if you had killed someone, you would
wake up in the morning and have a brief respite before reality
sank in, before the truth came back and dragged you down.
So these guests, standing on the other side of the door, I need
to know them, need to understand them, to digest them almost,
lest their standing on the other side of the closed door makes
me sick.
Spring is coming, and with it light and with it renewal and hopefully reconciliation, and calm.
I long for calm, for peace, for unison.
Conclusion
Monique and I were gifted with a deep sense of connection
during our work together. We are simply two women who
have turned toward multiples losses (the box full of darkness) rather than avoid or deny them. This being with and
acceptance of what is welcomes us into the human family.
References
1. Oliver M. The uses of sorrow. Thirst. Boston: Beacon; 2006. p.52.
2. Epstein RM. Mindful practice in action (I): technical competence,
evidence-based medicine, and relationship-centered care. Fam Sys
Health. 2003;21(1):19.
3. Siegel DJ. Therapeutic presence: mindful awareness and the person of the therapist. In: Siegel DJ, Solomon M, editors. Healing
moments in psychotherapy. New York: W. W. Norton & Company;
2013. p.24370.
4. Epstein M. The trauma of everyday life. New York: Penguin; 2013.
5. Wesselmann D. Healing trauma and creating secure attachments
through EDMR. In: Siegel DJ, Solomon M, editors. Healing
moments in psychotherapy. New York: W. W. Norton & Company;
2013. p.11528.
6. Garrison D, Lyness JM, Frank JB, Epstein RM. Qualitative analysis
of medical student impressions of a narrative exercise in the thirdyear psychiatry clerkship. Acad Med. 2011;86(1):859.
7. Rumi J. (Translated by Colman Barks). The guest house. The
essential rumi. San Francisco: Harper; 2004. p.9.
Patricia Lynn Dobkin PhD is a clinical psychologist specializing in
chronic illness and chronic pain. She is an associate professor in the
Department of Medicine at McGill University. As a certified mindfulness-based stress reduction (MBSR) instructor, she spearheaded the
mindfulness programs for patients, medical students, residents, physicians, and allied health-care professionals at McGill programs in
Whole Person Care. Dr. Dobkin collaborates closely with Drs. Hutchinson, Liben, and Smilovitch to ensure the quality and integrity of the
mindfulness courses and workshops offered at McGill University and
other venues (e.g. conference workshops, weekend training retreats).
Addendum: Monique gave birth to a healthy baby girl one year later.
19
20
find a place that we have never been to. The risk is that if we
teach what we think is mindfulness, but without understanding it from within, then we could be teaching the opposite of
what we think we are teaching.
We can all improve in our capacity to apply mindfulness
in our lives, but if a practitioner says they teach it but do not
practice it themselves then it is likely that they have not understood it. The more we understand it the more we will be
disposed to practice it.
We can apply mindfulness formally (e.g., mindfulness
meditation) and informally (e.g., being mindful in our dayto-day life). We may or may not practice 40min of mindfulness meditation every day, but at very least if we are making
sincere efforts to be mindful in our day-to-day life then we
are on the right path. Especially for those who are ambivalent to mindfulness, objectively exploring the impact of unmindfulness is just as useful.
This was the 2nd week of the 6-week mindfulness program
for the medical students. The previous week, the students
had been introduced to mindfulness meditation and were invited to punctuate their day with it for 5min twice a day
(full stops) and at other times for seconds to a minute or two
(commas). They were also invited to notice where their attention was as they went about their day-to-day life whether
studying, eating, speaking, playing sports, or doing anything
else. At the start of the class, we practiced a minute of mindfulness meditation to put a little space between their last
class and this one.
Good, I said, now let your eyes gently open. After a
couple of moments I asked, Now lets take the opportunity
to hear how you got on with the practices from the week; the
formal and informal practice of mindfulness. What have you
discovered?
You never know what will happen next and I have long
ago given up making assumptions or having expectations
about what will come forward from the group. Before long a
student, Peter, pipes up.
I didnt practice the meditation at all. I dont get the
point of it, Peter says in a half-confrontational way as if he
is testing how you are going to respond and whether there
is any reason to be spending curriculum time on something
soft like this.
It is very important, especially when all the students are
thrown into a mindfulness program as a core part of their
training, that they do not feel like they are having it forced on
them. Sensing the resistance in the voice, one also senses that
the resistance could be reinforced by opposing it. I internally
remind myself, as passionate as I might be about promoting
mindfulness, that this is an invitation to practice it, not an
obligation. In myself I notice a ripple of disappointment that
this is the first offering from the group and an oppositional
attitude to Peters input, which I let pass. I remind myself to
welcome whatever comes up in the moment.
C. Hassed
courage you and the whole class to just say it as it is and not
to just say what you think I want to hear. Now, would anyone
else like to share something from the week?
There are many participants in mindfulness programs who
practice very little mindfulness meditation particularly when
they did not choose to participate in the program to begin
with or are doing it because they were urged to by someone
else. If there is too much emphasis on having to practice the
meditation, and not enough emphasis on the role of mindfulness in daily life, then there is a possibility of alienating
many participants who might otherwise have gained a lot
from a mindfulness program.
Personal experience helps us to empathize with others
and relate to where they are on their own personal journey.
It helps us to be aware of what is going on within ourselves
in the process of teaching mindfulness. It is very easy, when
unmindful, to try and convince others or to oppose something that does not fit in with what we want or expect. It is
far better to inquire and help people to convince themselves
of what works or does not work. Opposition comes from our
own attachments and only creates a division between the
teacher and the student, patient, or client. Being open and
accepting does not mean never questioning or challenging,
but the attitude with which we question or challenge makes
all the difference. A large part of teaching mindfulness is the
modelling of it. Wherever possible we try to be an example
of mindfulness, and if we are inadvertently unmindful then
we can be a warning.
Our personal experiences are sometimes very useful from
a teaching perspective. A teacher of mindfulness instructs
much more by the way they are with the group (or individual) than by what they say. It is in the responses, attention,
openness, and interest that we demonstrate mindfulness in
action. Living mindfully reveals more than any amount of
theory could ever communicate.
21
ic. The questions arise in the moment directly from what the
person just said, whether that be in words or body language,
in response to the previous question. We do not quite know
where the conversation will lead but it takes attention and
mental flexibility to follow and not to force the conversation
where we think it should go. Although they could appear superficially similar, no two moments are the same, nor are two
conversations the same.
I have always found that questioning is far more useful
than trying to explain what mindfulness is about. A group
may have been given a mindfulness meditation practice to
practice, have been invited to be mindful in day-to-day life,
and have been given a mindfulness-based cognitive topic to
explore for the week (such as letting go, acceptance, or being
in the present moment), but it is what the individuals bring
back to the group the following week that really matters. Participants relate their experiences and then we see what the
experience teaches us. It does not matter whether the person
thinks it was a good or bad experience, whether they think
they are getting mindfulness right or wrong. The only thing
that matters is learning from that experience. Even our outwardly most negative experiences have the greatest potential
to teach us the most profound lessons if we are open to explore them mindfully. That provides the kind of alchemy that
turns lead into gold.
Sally was attending a mindfulness course for people with issues around anxiety. She was a capable, intelligent, and outgoing young woman. Her main problem was that for the last
few years she had experienced increasing levels of anxiety
and sometimes panic attacks came out of the blue, particularly in social situations. She was in a relationship with a
young man but he did not understand why she could not just
get over it. He was frustrated because these episodes prevented them from doing many things they would otherwise
do together. The pressure of trying to get over it as soon
as possible had led to Sally seeking out a range of therapies
but all to no avail. In fact, it made the problem worse. The
harder she tried, the worse the anxiety got. Sally felt increasingly bad about herself and was afraid that the relationship
might come to an end as a result. She came to a mindfulness
program. In the first couple of weeks, among other things,
we had learned a mindfulness meditation exercise and had
opened up an inquiry into the cognitive aspect of acceptance.
Well, how did we go last week?; What did we practice?;
What did we experience?; What did we discover? I inquired
of the group.
A few members of the group shared experiences and insights. Sally sat back and seemed to be listening but looked
as though she was shrinking back when further offerings
were invited from the group. Noticing this, I decided to
specifically invite Sally if there was anything she wanted to
share because this kind of body language generally means
that someone is sitting on something important, something
22
C. Hassed
23
Listening
For the abovementioned process to go well it all revolves
around listening, not to the clutter of ones own thoughts, but
to the person speaking. It is interesting to notice that we may
think we are listening to someone speaking but in actual fact
are hearing little of what they say because the attention is
on an internal dialogue. That internal dialogue may be about
C. Hassed
24
Impartiality to Results
One of the greatest barriers to teaching mindfulness is being
partial to results. If I, even inwardly, am OK when people
have pleasant experiences, but not OK with the opposite, then
I am modelling the opposite of mindful acceptance. I am not
adept at teaching the class about impartiality or acceptance
of lifes ups and downs, pleasures and pains, successes and
failures, if I am implicitly communicating the opposite. To
speak of acceptance when we are inwardly looking for one
kind of outcome and rejecting another is, at best, frustrating
and ineffectual and, at worst, demoralizing, hypocritical and
misleading.
Acceptance is what it says: acceptance. It is not nonacceptance with a veneer of acceptance. Our own attitude of
preferring one kind of experience for the group over another,
as well intentioned as it may seem, will reveal itself in the
sound of our voice, the openness and lightness with which
we respond, and the directness and interest with which we
engage in mindful inquiry. I try to remind myself to be as interested when someone says something like, It didnt work
for me, as when they say, It was wonderful.
References
1. Hassed RC. Know thyself: the stress release program. 1sted. Melbourne: Michelle Anderson; 2002.
2. Hassed C, de Lisle S, Sullivan G, Pier C. Enhancing the health of
medical students: outcomes of an integrated mindfulness and lifestyle program. Adv Health Sci Educ Theory Pract. 2009;14:38798.
doi:org/10.1007/s10459-008-9125-3.
3. Hassed C, Sierpina VS, Kreitzer MJ. The health enhancement program at Monash University medical school. Explore (NY). 2008
NovDec;4(6):3947. doi:10.1016/j.explore.2008.09.008.
Craig Hassedis a general practitioner and senior lecturer at the
Monash University Department of General Practice in Victoria, Australia. His teaching, research, and clinical interests include mindfulness,
mindbody medicine, health promotion, integrative medicine, and
medical ethics. He was the founding president of the Australian Teachers of Meditation Association and is a regular media commentator. He
has published seven books: New Frontiers in Medicine (Volumes 1
and 2); Know Thyself; The Essence of Health; a textbook coauthored
with Kerryn Phelps, General Practice: the Integrative Approach; with
Stephen McKenzie, Mindfulness for Life; and with Richard Chambers,
Mindful Learning.
25
26
before, I heard all about Sister Josepha and even had the
pleasure of meeting her one afternoon when I picked them
up. Of all things, I distinctly recall her clear voice and good
diction, perhaps projecting onto her my notions of the effects of a life-honing vocal skills, steeped in the history and
pomp of classical music, and the grandeur of the opera. I did
not know much then about opera, and still know very little,
only the familiar melodies that were part of my childhood. I
recall, however, in my brief conversation with Sister Josepha
learning of the folk roots of the opera, and how it was not a
reified art but part of the community aesthetic of the common people. And from that I could make sense of the connection my parents had with it. That the stories told the epic
tragedies depicted in the opera were somehow connected to
the broader human experience of suffering. It seemed to involve the placing of ones own personal dramas of birth, illness, aging, and death into the operatic storyline, connecting
these experiences with the universal human experience, and
in so doing healing through association, recognition, camaraderie, connection, and engaging the senses.
About 13 years later, I met Sister Josepha for the second
time. A lot had transpired in the intervening years, including
the death of my father about 7 years earlier from pancreatic
cancer. By this time, my increasingly busy medical practice
had already created within me the nascent seeds of burnout,
and I wondered how the coming years would unfold for me.
I explored ways to combat my emotional exhaustion through
physical activities, book groups, cultivating friendships,
while focusing on my home life with two of three children
already born. Reflecting on my fathers final 2 years, I was
struck by his relative health for over seventy-five percent
of the time he lived with his diagnosis. He had taken up a
sincere practice of mindfulness meditation, attending workshops, and retreats up until the last few months of his life.
Toward the end of his life, I also began to explore this myself
more deeply, and by the time I renewed my acquaintance
with Sister Josepha, I was facilitating groups of patients in
a meditation-based stress reduction activity called mindfulness-based stress reduction (MBSR). And that is exactly how
we met again.
Upon entering the waiting room in my office one Wednesday evening for the first gathering of a new MBSR class, I
gazed upon the 20 or so individuals sitting in the blue-cushioned chairs, nervously waiting for something to happen.
That is all except two women who appeared to be in their
mid-to-late sixties, whose eyes lit up as I went around the
room greeting participants before officially beginning class.
It was clear these two were confidant, curious, and engaged,
and at the time I could only assume they attended for reasons
that may be mysterious even to them. Although I introduced
myself, and repeated their names upon greeting, Sister Josepha and Norma, I did not at the time recall who she was, or
M. S. Krasner
that I had met her years previously. The class began with the
participants sharing what motivated them to take this program, and although I also do not recall the details, I know
that both Sister Josepha and Norma shared something about
the challenges of retiring. Both were college professors and
both were questioning how to find meaning and a sense of
engagement after their professional careers no longer defined their identities. I recall asking a question to them and
to the entire group about how do we truly know and define
ourselves, not through giving the group any answer to that
question, but inviting all of us, including myself, to consider
living with that question through the 8 weeks that we would
be spending together.
It was not until week three of the course that I realized
who Sister Josepha was, and as I came to that realization
I felt a longing for my father, knowing the connection she
had with him and with my mother. I approached her before
class and apologized for not remembering, and as I told her
this she lit up, beaming and smiling, acknowledging her own
recollection of my parents. I felt comforted by her compassion as I told her of my fathers death, and saw an authentic sadness in her as well. In that moment, I felt bonded to
her and Norma, who engaged in this conversation as well.
I realized that the two of them were best of friends. They
were colleagues and confidants, and in a very real way, life
partners. As I thought of this, I realized and contemplated
upon the many manifestations of love and relationship, and
felt opened up to seeing a broader expression of this than my
own narrow ideas of what relationship should look like. So
Norma, in this way, also became connected to my parents,
even though they had never met.
The following week before class, Sister Josepha had
something to show me. She took out a letter, typewritten by
my father in 1989, addressed to her. I trembled as I touched
the slightly faded paper that he had typed upon with the mechanical typewriter that he used in the home office where
I recall him spending long hours reading papers and planning classes and compiling data from his career in teaching
and qualitative research. As I read the letter, I laughed and
cried. It was a letter of persuasion, asking Sister Josepha
to consider making accommodations that would allow my
mother and father into the second Elder Hostel program on
Puccini. It seems that they were late enrolling, registration
was closed, and the program was full. In his very recognizable and undeniable style, with just the right show of respect
and ample use of his unique sense of humor and praise, while
also taking ownership of the responsibility for not registering on time, like a college student asking the professor for
special dispensation with good reason, he was able to convince Sister Josepha to let him and my mother into the program. Reading this letter so rich with his personality was like
having his voice speaking to me in that very moment. My
27
as melancholy. Outside of attending daily Mass and visiting the Mother House nearly every day, her social contacts
contracted.
Over the ensuing months and following year, she began
to find it difficult to remain living on her own in an apartment. Her memory began to slip, and she began to share a
concern that someone living in her apartment building had
been attempting to steal from her. Initially, her concerns
sounded plausible, and the thefts described involved documents that would allow this perpetrator access to personal
documents such as retirement account statements and securities she held. Over time, it became increasingly clear that her
concerns reflected a growing paranoia. She shared of how at
night, while she slept, the neighbor snuck into her apartment
and lifted documents, and as proof she described papers and
mundane items in the apartment slightly out of place.
Her growing anxiety and agitation over this led her to
move into an independent senior living facility, and prompted
me to further investigate her deepening cognitive and behavioral decline. It appears she has developed a vascular dementia which has been very challenging to treat. The medication
management has been complicated by her deep conviction
that any medication she is given will be contaminated by the
malevolent perpetrator who has the ability to gain access to
her current living facility. And despite moving into a caring
community that has been willing to assist her in locking up
her medications and personal documents for safekeeping, she
still believes that these are not safe and they are easily violated. Yet she has been making some progress. She has befriended one of the residents dwelling in the facility who looks
after her, regularly testing her reality and accompanying her
to medical appointments. She has restarted her medications,
both older ones for the management of her heart disease and
newer ones to assist in lessening her paranoid delusions. I am
finding she laughs and smiles more at appointments.
Although we do not agree on the veracity of her claims
of being poisoned and stolen from, she is willing to discuss
it with me. And she continues to light up when we speak of
Sister Josepha, sharing with me clear and untainted memories of their life together, in which I hear of events and experiences that are often new to me. Her memory also remains
clear on the class in which we first met over a decade ago,
and on the circumstances of my parents connection with
Sister Josepha. For me, Norma continues to be a connection
with a part of my life that at times seems to be fading away,
until I see her. And I hope for her that she finds comfort and
confidence in the medical care I continue to offer. But in
the end, it is more than simply medical care and connections
with the past. It is the continued unfolding of birth, aging, illness, and death that draw us together, within which the lines
between healer and patient blur slightly, at times merging
into simple human connection and kindness.
28
Michael S. Krasner, MD, FACP is a professor of clinical medicine
at the University of Rochester School of Medicine and Dentistry; he
practices primary care internal medicine in Rochester, New York, USA.
Dr. Krasner has been facilitating mindfulness-based interventions for
patients, medical students, and health professionals for more than 14
years, involving nearly 1800 participants, including more than 600
M. S. Krasner
health professionals. He has shared his work in peer-reviewed publications, scientific assemblies, workshops, visiting professorships, and
intensives throughout the world, focusing primarily on the roots of Hippocratic medicine through the cultivation of attention, awareness, and
reflection of the health professionalhealing relationship.
I first met Charlene while I was covering for her own psychiatrist. As I called her name in the waiting room, a tall thin
womanaround age 30, I estimatedseated in the corner of
the filled room lifted her gaze from her lap. Her eyeswide
as saucerscommunicated her pain and fear as they met
mine. Moving toward her, I held out my hand. Hi Charlene,
Im Catherine Phillips.
Early in my practice, I had pondered the ongoing question of how to introduce myself to my patients. I chose to
meet my patients not just as a physician to whom one turns
for relief from suffering but also as a fellow human being.
In each introduction, I intentionally dropped the use of my
title. By and large over the years, patients have chosen to call
me Dr. Phillips or have appreciatively nicknamed me their
own personal version of Dr. Phil. Aware of the issue of
potential boundary crossing, I have found I can always sensitively redirect my patient and clarify our roles if needed.
As I greeted her, Charlene closed her eyes. Placing her
hand on her left leg, she looked down and winced with pain
as she leveraged herself into a standing position using a cane
for support. She shifted her cane from her right hand to her
left, before reaching out to shake my hand. Hi Dr. Phillips,
she said; her hand was cold and dry. We walked slowly together down the hallway. Once in my office, her many sources of stress and suffering came pouring out. The pain in her
right leg, secondary to an injury in a motor vehicle accident
some years ago, overshadowed all else. She spoke of the unbearable physical pain that she endured night and day and
the significant limitations this placed on all areas of her life,
especially her interactions with her children. She spoke of
her anxiety and her fear related to the accident, including her
intense fear of driving, of riding as a passenger, and her fear
the pain would never end. She shared her emotional pain,
C.L.Phillips()
Department of Psychiatry, University of Alberta, The Mindfulness
Institute.ca, 14032 23 Avenue NW, Suite 282, Edmonton,
AB T6R 3L6, Canada
e-mail: drclp@shaw.ca
especially regarding how her symptoms affected her relationship with her family; she could no longer do activities
she had previously taken for granted such as playing with
her children, and she feared her husband might not tolerate
her emotional and physical limitations much longer. As her
distress escalated, the tone of her voice grew louder, more
forceful, and the rate of her speech accelerated. Her intermittent plea I need help Dr. Phillips! reverberated with a
sense of desperation. With wide watery eyes, she explained
that she had been diagnosed with a particularly severe and
nasty chronic pain disordera progressive condition which
might wax and wane in severity, and for which there was no
cure. She urgently wanted help and wanted to believe that
she could be helped, but she knew that I had no magic wand.
We had only an houra luxury, I thought, compared with
the likely time restrictions of her family doctor. Yet, an hour
barely gave us time to scratch the surface of the stressors in
her life and the dilemmas she faced. These poured out in a
disjointed torrent, allowing her perhaps some temporary relief
through venting, but leaving me feeling mildly overwhelmed
by the nature and severity of her stressors and suffering. I was
reminded of the comic strip in which a patient enters a psychiatrists office with a black cloud over her head, and when the
patient leaves it is the psychiatrist who now carries the cloud.
In addition to my awareness of both Charlenes sense of
helplessness and my own feeling of being overwhelmed by
the complexity of her stressors, I felt a sense of relief; in our
few sessions, I would listen empathically, review and adjust
her psychotropic medications if needed, and then her own psychiatrist would return, and Charlene would return to his care.
Several months later, however, I again found Charlene
booked in my schedule. I was again covering for my colleague, this time for a period of 6 weeks. When we had parted, Charlene had thanked me, told me I had a kind heart
and ended our appointment with a handshake and a God
bless you, Dr. Phillips. Beneath her suffering, I had had a
glimpse of a compassionate human being who cared deeply
about her children, her husband, and her connection with others. I had liked this woman. Yet, her presence on my schedule
29
30
triggered feelings of anxiety in me. Her neediness was tangible; I imagined that if she presented to others as she did to
me, their natural response might be to distance themselves
from her. She had made little progress under the care of her
previous health-care providers, who, like me, had probably
felt overwhelmed by her pressure of speech, tangentiality,
emotional liability, the magnitude of her losses and stressors
in all areas of her life, as well as her despair and desperation
to alleviate her palpable suffering. Given the degree of her
traumatization, my traditional tool kit of psychotherapeutic
interventions had significant limitations; although I wanted
to help, I doubted I had anything to offer. I also feared that if
she were to make a therapeutic connection with me over the
next 6 weeks, I might find myself feeling a sense of responsibility to continue working with her, in spite of just being the
covering physician. Yet, amidst my apprehension, I was filled
with compassion for this woman, for her caregivers, and for
myself. I paused; for a brief moment, I felt less helpless.
As human beings, we are united by many things, including by our own human suffering. As a psychiatrist and psychotherapist, I have chosen to work with this particular experience professionally as I help my patients explore the nature
of their suffering and how their own internal conditionings
can potentially contribute to this suffering. Over the years,
the fruits of my meditation practicebegun as a personal
practice over 30 years agohave directly and indirectly
found their way into my professional work. My perception
and understanding of the positive effects of my meditation
practice on my therapeutic skills have been affirmed by research findings over the past 15 years, which demonstrate
that the therapists mindfulness practice benefits therapeutic
outcomes [1, 2]. My practice of mindfulness inside and outside the therapy hour has enhanced my capacity for compassionate, nonjudgmental attunement to my own inner world,
to that of my patients and to our shared experience, as well
as my ability to stay present with the suffering of my patients
as we journey together in the safety of my office.
In my attunement to myself, I am acutely aware of my
own personal suffering and limitations, and the need to first
care for myself in order to be able to extend myself to others.
When Charlene appeared on my schedule, my life was already very full; I had a fairly heavy patient loadseveral of
whom had a combination of physical, mental health and pain
conditions. I considered, too, my desire to be more available emotionally to my own family. I did not wish to run
the risk of tipping this at times delicate balance. Would I be
able to walk the razor-fine edge with Charlene of being empathically present to her suffering while accepting my own
limitations and inability to offer her the cure for which she
yearned? Given that I was simply covering for my colleague,
these reflections and questions were perhaps premature, yet
I was very aware of them arising in reaction to seeing Charlenes name on my schedule.
C. L. Phillips
31
32
could not get better, not the insurance company, who was
convinced that she needed an intensive pain rehab program,
and not her primary care health team, who after this morning, now perceived her to be angry, hostile, and demanding.
How can a human being accurately convey the depths
of their suffering to others who have not suffered in such
a way? How can one truly understand anothers suffering
without having had (or daring to take) a glimpse into the
internal world of the other? What can a health-care provider
offer when faced with such suffering? These questions and
others passed through my awareness as I listened to Charlene and her physicians account of the incident that morning. Nothing I could recall being taught in medical school, in
the toolbox of various clinical tests, medications, or medical
procedures had prepared me to meet this magnitude of suffering.
In my experience, even good bedside manner frequently
falls short of what is called for in such situationsthe word
manner reflecting an outward presentation, and not necessarily the genuine internal intention, attitudes, or presence
of the clinician. To be truly supportive of another requires
empathy, which in part stems from an emotional understanding of anothers inner world and the nature of their suffering,
including knowledge of the person and the past experiences
that have shaped who they are. It also requires the capacity
and willingness to be present with anothers suffering as well
as with ones ownrather than turning away from feelings
of discomfort or helplessness. In spite of the good intentions
of the people by whom she was surrounded, Charlene did not
appear to feel understood or supported.
I knew both the on-call physician and her family doctor
well, having shared several mutual patients over the years;
I had great respect for them both. As we spoke, her family physician expressed understandable exasperation about
Charlenes behavior and demands that morning. Once in the
on-call doctors office, Charlenes distress over her accident
and injuries had apparently escalated in a crescendo. She had
insisted she needed home care as well as a motorized wheelchair in order to keep up with her children as she walked
them to the park. The on-call doctor had emphasized to her
that she needed to become more mobile, not relegate herself
to a wheelchair for the rest of her life.
This was, of course, true; she did need to stay mobile.
Her psychologist and I, however, were convinced that she
did not intend to become wheelchair-bound; she had told us
about her walks to the park and the supermarket, stopping to
rest every 100ft or so along the way. But we were not pain
specialists. We were not physiotherapists or occupational
therapists, or even her primary care providerswe were her
mental health consultants. Interestingly, Dr. Martinis and
my experience with Charlenes primary health-care team
had begun to mirror Charlenes experience. Just as Charlene
felt isolated and unheard by her primary care providers, Dr.
C. L. Phillips
meet our patient with what is called for in the therapy hour.
Thus, the foundation of therapythe clinicianpatient relationshipas well as the work required in the therapy may
be jeopardized: by the clinician who is partially unavailable
due to his or her inability to be present with what the patient
brings into the office, by the patients conscious or unconscious reaction to this, and by the interplay between these
dual internal reactions.
In my experience, a strong therapeutic alliance requires
the clinician to accompany the patient on her journey through
suffering with an empathic presence, and with an awareness
and openness to ones own helplessness and fears as well as
to those of the patient. The thirteenth-century scholar and
mystic Rumi describes this aspect of the healing process
in these words: Dont turn your head. Keep looking at the
bandaged place. Thats where the Light enters you [3]. In
therapy, as in life, attunement to ones own and anothers
suffering requires patience and compassion for oneself and
the other.
While exploring the challenges faced by Charlenes treatment team, Dr. Martini and I confronted our own experiences triggered by Charlene and were able to mobilize our
own strengths to work with these challenges. We were both
seasoned therapists who had worked with difficult patientspeople who have often experienced trauma either in
childhood or later in their lives. Such patients, like Charlene,
frequently have heightened reactivity as well as weakened
capacity to hold, contain and work with traumas and feelings by which they likely felt overwhelmed at the time of
the traumatic event, and which continue to overwhelm them.
As psychotherapists, Dr. Martini and I had spent thousands
of hours of practicing mindful attunementto all of our patients in the present moment, to our own internal world, and
to the interaction and felt sense between the two.
I consider the therapeutic work I do with patients to be
an informal mindfulness practice; much like formal mindfulness meditation, which is practiced in a time specifically set
aside for it each day, this work requires that I meet each moment in the therapy hour as best I can with sensitivity, attunement, and with my full presence (or, at least, as best I can
be present on any given day). To use an analogy sometimes
used in Mindfulness-Based Stress Reduction (MBSR) programs, I have learned to use my awareness like a flashlight,
at times shining the high beam on the patient, at times on
what is arising within me, and at times on the dynamic between us both, holding this awareness along with my knowledge and training.
Figure 6.1 illustrates the application of mindful awareness
in therapeutic communication. My patients verbalization
enhances my understanding of her patterns of thought, emotion, and interpersonal interaction. As I empathically attune
to her issues, dynamics and internal states, while serving the
33
Fig. 6.1 Mindful awareness in therapeutic communication: This diagram illustrates how sensitive attunement to ones patient, ones own
internal world, and the interpersonal dynamic can enhance the therapy process through fostering awareness and enhancing ones ability to communicate the patients repetitive conditionings patterns
of thoughts, feelings, attitudes, and behaviours. Such communication
has potential to assist patients in becoming unstuck from conditionings that do not serve them well, allowing them to live life with greater
awareness, creativity, and internal freedom.
34
within the hours she spent with Dr. Martini and me, small
changes began to emerge. Charlene became able to allow
space within her appointments in which to listen.
Very early on in working with her, I had introduced Charlene to a 3-min mindfulness exercise focusing on awareness
of breath. Even with my patient guidance, she had interrupted the exercise several times, giving the impression of
being disinterested and unable to concentrate for more than
a few seconds. I had not pursued the exercise. However, one
day as her volume and pressure of speech began to escalate,
I had the impulse to interject. As I frequently do with patients struggling with self-regulation, I suggested we pause
for a moment. What are you noticing inside yourself, right
now, Charlene? I asked. As youre talking, what are you
noticing in your body? She looked perplexed, and then her
left leg stopped tapping. She sighed, and sank visibly into
the chair. She was getting it. Yes, you were starting to get
worked up, I affirmed. What are you noticing about your
state of mind right now? Silence. What emotions are you
aware of? Charlenes tired, faded appearance dissipated, as
her eyes became unexpectedly animated. She sat up straight
and leaned forward; I am so angry, Dr. Phillips! For a moment, she looked like an apoplectic figure from a Dickens
novel, eyes ready to pop out of her head. Why did this happen, Dr. Phillips? Im a good person. I didnt do anything
to deserve this. It isnt fair. My family is suffering. I sat,
fully present, fully attuned, and taking in what she was sayingher helplessness, her disappointment, her physical and
emotional pain at her enormous losses, and her anger. There
were no consolations I could offer. I could only be as present as possible, there with her and for her. My face sombre, I nodded. I know. You are a good person, Charlene.
With this affirmation, Charlene jumped in again, her voice
becoming louder, faster. I intervened. Charlene, lets pause
again. What do you notice about your breath right now?
She abruptly halted, again looking puzzled, as if trying to
figure out what I was referring to. I was taken aback by her
response: Oh, the breath exercise you taught me. I didnt
forget it, Dr. Phillips. I sometimes do it. I was stunned; I
had no idea she had absorbed anything I had said that day,
some months earlier, when I had attempted to introduce her
to awareness of breath as a tool for self-regulation. Are you
willing to try it now? I asked. She nodded. Perhaps sit back
in your chair, and bring your awareness to your breath, just
as it is. Notice the quality of your breathwhether fast or
slow, narrow or broad, deep or shallow, following the breath
one moment at a time, one breath at a time. Lets follow just
one breathand another breathbringing awareness to
each moment of the breath. All the way in, and all the way
outand lets pause to tune in to whats going on in your
inner state. Tune in to the state of your body and notice
C. L. Phillips
35
References
1. Grepmair L, Mitterlehner F, Loew T, Bacheler E, Rother W, Nickel
M. Promoting mindfulness in psychotherapists in training influences the treatment results of their patients: a randomized, doubleblind, controlled study. Psychother Psychosom. 2007;76:3328.
2. Grepmair L, Mitterlehner F, Loew T, Nickel M. Promotion of
mindfulness in psychotherapists in training: preliminary study. Eur
Psychiatry. 2007;22:4859.
3. Rumi J, Barks, C. Delicious laughter: rambunctious teaching stories from the Mathnawi of Jelaluddin Rumi. Athens: Maypop;
1990. p.97.
Catherine L. Phillips MD, FRCP(C)is an Assistant Clinical
rofessor in the Department of Psychiatry at the University of Alberta,
P
where she is a psychotherapy supervisor and offers seminars and an
elective on mindfulness to psychiatry residents. Dr. Phillips has integrated mindfulness into psychiatric practice and psychodynamically
oriented psychotherapy for more than 25 years. A certified Mindfulness-Based Stress Reduction (MBSR) instructor, she has led the MBSR
program in Edmonton, Alberta, since 2006, and offers mindfulnessbased programs modeled on MBSR to health-care professionals and in
her role as psychiatric consultant to the Canadian Armed Forces
37
38
found health. A woman in her late 40s, she was calm and
seemed relatively at peace with what had happened. Her
hair was short and gray like many other cancer patients. In
good health, even a bit overweight, she was well enough to
start work and was happy about that. She was polite, wellspoken, and listened to my advice. I was excited and curious
about becoming her family doctor as I had never followed a
long-term cancer patient. I had an open mind and I wanted to
know her better. Without knowing it, I was experiencing one
of the attitudes of mindfulness: a beginners mind.
For a few years, I was happy to be an active support during the scary time when the possibility of a relapse loomed
large. At that time, I saw her every 6 months and then became
her husbands and two daughters family doctor as well. I
was there for one of her daughters through her pregnancies
and looked after the health of this growing family. I had the
joy of celebrating the end of her tamoxifen medication, an
important step that meant that she was slowly moving out
of the dangerous relapse zone. We had gradually developed
a mutual respect and appreciation. I was impressed by her
courage and positive attitude throughout that uncertain period and she appreciated my support and willingness to insure the wellness of her whole family. We had established a
positive therapeutic relationship.
Unfortunately, without warning, events took an unwelcomed turn. I discovered and had to announce that the cancer had returned. The dreaded moment every cancer survivor
wishes not to meet, the moment when they realize they will
have to fight again to remain a survivor, had arrived. But she
never had a chance to defeat this disease. Additional tests
revealed metastases, reducing the chances of another remission with current treatments. I had been there in times of
hope; then we had to face despair and the need to accept
what lay ahead.
I had not yet started practicing mindfulness mediation
when this happened but I was more experienced, could cope
better, and had the maturity to share this bad news in the best
way possible. Yet, I was feeling anxious and unsettled. How
would she react? How would I react if she was my mother, or
this was me? I wanted to be as empathetic as possible. I cannot remember if she came alone to that visit. This fact makes
me think that I was probably more preoccupied with my own
thoughts and feelings that I would have wanted to be.
I had discovered the metastases on a routine ultrasound
her surgeon requested every year. Without showing any
signs of anger, she remained calm and seemed sad. She
asked me what would happen next and I described the steps
ahead. There were a few moments of silence and I felt uneasy. Because I wanted to do and say the right things I filled
the silence with information, including the tests that needed
to be run, the next appointments she had to schedule, and the
leave of absence she needed to take from her work. I probably talked too much and did not give her enough time to
E. Baron
receive the bad news. I remember that she did not talk much
and as usual, she seemed to make an effort to listen carefully
to what I was saying and agreed with the plan. I offered my
support and tried to be empathic. She left in silence. I felt
somewhat satisfied about how the encounter had gone but I
did not really know how she was feeling. I wanted things to
be different for her.
After that day, I saw her less because she started a series
of treatments to contain the disease. Each time we met, similar to past visits, she remained calm, pleasant, and smiling.
At every appointment, I was supportive and answered her
questions and health concerns in an empathetic way.
Naturally, she expressed her fears about the future and her
difficulty accepting her fate, but afterward, she seemed resilient and able to enjoy the present moment. She was doing
everything in her power to control the disease and to appreciate her life.
But I knew her life was reaching its final stages and that
the aim of treatment needed to be oriented toward making
her final moments painless and hopefully, peaceful. In February of that year, I organized her transfer to a palliative care
home. Shortly thereafter, her husband called me and asked if
I would come and visit her in her own home, before she took
the last step in her journey. It was her wish to see me. Time
was against us.
It was a few years ago, nonetheless, the memory is so
clear in my mind that this could have happened yesterday.
I recall that day. That snow. Now, every time I see snow
falling in the same way, with big flurries looking like bunny
tails, it takes me back to that moment.
At that point, I had been practicing meditation for some
time and I wanted to use the tools I had acquired to fully
immerse myself in that meeting. I was a bit apprehensive,
but my mindfulness practice allowed me to move forward
toward her, toward death, with an open heart in a direction
that I would have avoided out of fear.
I cleared my schedule and made space for that moment
the next day. When I sat down in my office, I focused on my
breath and allowed my thoughts to float away like the flurries falling from the sky. Then I went on my way.
The practice of mindfulness has transformed my view of
death. I no longer feel the need to think of it as frequently,
and when I do, I no longer experience fear and anxiety. I see
with clarity the impermanence of all things, including life.
The practice of many of the attitudes of mindful meditation helped me in that process. Cultivating patience helped
me understand and accept that things have their own time for
unfolding. No need to force things, they will happen at their
own pace.
I also learned to trust myself more. I discovered that I am
my best guide. When I will be faced with my own death, I will
trust my own wisdom. The practice of non-striving, simply
being and not doing, strengthened my faith in my own wisdom.
39
Carmens Story
John H. Kearsley
41
42
present to myself and the room, I felt a sense of anticipation, almost excitement, at the prospect of meeting a totally
unknown person, and the prospect of making a difference
in whatever opportunities presented themselves. I enjoy the
not knowing about who the next person might be.
The door opened, and Carmen slipped through quickly
as if escaping from a threatening outside world. Katherine
promptly followed. Apart from a brief glance during introductions, Carmen avoided eye contact. She had a gentle
eastern European accent. Carmen looked at me fleetingly,
but then preferred to gaze at the grey linoleum on the consulting room floor. She quickly sat down, a little huddled on
the dark pink vinyl chair at the side of the imitation timber
desk where Katherine was about to commence taking Carmens history. Carmen was slender, attractive, and almost
elegant with wavy brown shoulder-length hair in large soft
curls and a prominent black choker around her neck. She
dressed well, but, she looked drawn; there were no smiles
nor was she wearing lipstick or makeup, and she appeared
hypervigilant and agitated. As she sat down, Carmen began
anxiously to massage her fingers in small, repetitive, writhing movements.
Katherine began the interview by staring awkwardly at
Carmen who said nothing, merely awaiting the first interchange of real words. Katherine half spoke, then seemed to
withdraw her words in mid-sentence. I am not sure what she
said, but Katherine seemed nervous and alone, not unlike an
actor on an empty stage. Well, then, Carmen, how are you?
Carmen averted her eyes to the grey linoleum floor again, I
am very depressed. She then began to weep. Carmen reached
for a small tissue from her sleeve to gently dry her nose and
eyelids, but the weeping did not cease. Great, I thought, a
perfect opportunity for Katherine to demonstrate how to deal
with an emotional patient. Katherine sat motionless.
Good, I reflected. I think that Katherine is letting Carmen compose herself before she proceeds.
But the crying continued. Katherine appeared frozen in
action; only a few days before, we had discussed in some
detail an approach to the patient who may become emotional
and teary in front of you. Yet, Katherine appeared catatonic;
her left forearm jerked forward only a few inches towards
Carmen, but then her arm froze, motionless. What to do?
Katherines eyes were wide open, her smile frozen, her lips
apart, her body leaning forward, but immobile. She looked
stunned as Carmens weeping turned to sobbing. Wrinkles,
lined with pain, appeared on Katherines forehead and
around her eyes. My fear was that Katherine would now become totally overwhelmed and might herself become tearful;
I needed a circuit breaker before the interaction imploded
totally.
I cannot recall planning exactly what I should do. Instinctively, however, I placed my two hands on the sides of my
chair and gently moved both myself and my chair forward,
J. H. Kearsley
8 Carmens Story
43
J. H. Kearsley
44
repose why Carmen thought she had developed breast cancer, and how the cancer diagnosis had been so severely influencing Carmens lifestyle since the diagnosis had been made
a week or two ago. Carmen indicated that she felt very guilty
about being the cause of her own breast cancer. I took hormone replacement therapy, doctor, for too long. I was only
supposed to take it for a few months, but I didnt understand
what the specialist said, and I took it for several years. Thats
why I think I have got the cancer. Its my fault.
At this point, Carmen began sobbing again. I held back
to see how Katherine might handle the situation, given that
she had developed an increasing degree of rapport with
Carmen. Katherine drew closer to Carmen, but then froze
again. I sensed that a new wave of brokenness had overcome
Carmen. What would Katherine do? To offer Carmen a hug
seemed appropriate. Sometimes, a hug is all that we may
have to offer.
I said to Katherine Katherine do you feel like giving Carmen a hugwould you please show me how you hug? I
had been taking careful note of both Carmens and Katherines emotions during the interview, and sensed that Carmen
needed further physical comfort, and that Katherine might
know what to do. But something was stopping her. I had no
doubt that Katherine was a tender young woman with lots
of empathy. But, how would she express her empathy? Fortunately, Katherine responded, albeit with a small reluctant
smile; Carmen was happy to be hugged. Katherines need for
empathic connection had been liberated at last.
While I recognised the reality of Carmens guilt, I also
recognized it was not my job to fix her guilt. When guilt
results in suffering, it is my view that no amount of cognitive-based reasoning with a patient will achieve anything to
relieve that suffering. There is little point in telling someone
not to feel guilty. It just does not work. A hug in silence
can often penetrate where words cannot go. As Katherine
bent forward, her hug appeared a little stiff and uncertain;
she was unsure how much hugging was appropriate. Momentarily, as she reached out to Carmen, her blouse rose up
slowly over her back to reveal unblemished and tanned flesh.
Katherine was vulnerable and exposed.
At the time of our parting, Carmen said farewell to Katherine by giving her a deep and sustaining hug. This hug was
different from the first hug Katherine had initiated; rather
than a slightly stiff embrace on Katherines part, Katherine
was much more natural in her response this second time. It
seemed to me that Katherine and Carmen had connected at
some deep level. They did not speak.
Carmen and I agreed that I would arrange her radiotherapy appointment promptly. Apart from some minor details
regarding the logistics of radiotherapy, I sensed that Carmen
did not need to know many technical details. All she needed
to know was that radiotherapy was highly likely to cure her,
that she would not be harmed and that she would be cared
Katherines Reflection
There really is not anything that can prepare you for the first
time that a patient is truly distressed and cries in front of you.
It was not that I had never been exposed to emotional,
distressed, or even crying patients, but they had never been
under my care. I had comforted friends before, so surely, I
thought, it would be the same? What I did not realize was
just how true this really was.
Carmens answer to my simple How are you? was not
at all what I expected. While I had felt her anxiousness initially, I was not prepared for the bluntness of her honesty in
replying, Im very depressed. When I asked if she wanted
to explain it further, the way she began to cry knocked me
over. I just felt so unprepared and overwhelmed by her distress. I could feel my mind going blank.
Thinking back to it, I realize now that I had been unsure
as to how I should act professionally. While professionalism
is a very important aspect of being a doctor, I cannot help
thinking, why was I so conscious of this? And did I fixate
on this rather than just act as a human being? At the time, I
would instinctively feel my hand move out to touch her, but
I would catch myself. I felt too unsure. I did not know how
to rub her shoulder, or how to give her knee a squeeze. I did
not know how to be appropriate in the situation.
This need to be appropriate is something that I feel can
create a challenge for many students, such as me. I feel that
we are often caught in this pattern of erring on the side of
caution, and not allowing ourselves to be truly compassionate humans. By holding back, we lose the ability to fully empathize. How can we offer our patients care, and true caring,
to the best of our ability, if we hold ourselves back?
One of the things I felt I really learned from this experience was that it is okay to sit close to a patient. It is okay to
give their shoulders a squeeze, or even a hug, just as you
would a friend. Professor Kearsley encouraged me to give
8 Carmens Story
45
Callums Reflection
My name is Callum Barnes and I am a medical student with
the University of New South Wales. On Thursday, 7 November 2013, another student and I were fortunate enough to be
scheduled to a radiation oncology clinic with Professor J H
Kearsley.
Before we saw our first patient, Professor Kearsley sat
us down and spoke to us about what he would like us to do.
We reviewed the patients history and pathology and spoke
about her prognosis and the treatment options available to
her. The patient, Ms. Carmen S, was a woman in her mid-50s
of Romanian descent. She had been diagnosed with breast
cancer following a screening mammogram and which had
been completely excised during a lumpectomy procedure. I
do not recall the grade/stage of her tumor, but I understand
it was minimally invasive with no nodal spread and that we
could be relatively assured that her prognosis was good.
Unfortunately, as we found out, she had not been told such
information. Professor Kearsley and I stayed in his room,
while my colleague went to the waiting room to find Carmen
to bring her in. When she entered the room, we could see that
this woman was suffering, both emotionally and physically.
My fellow student began the consultation by asking
Carmen how she had been doing since her procedure (the
lumpectomy), and it transpired that things had not been
going very well. The patient noted that she felt depressed
and found no pleasure in things she had previously enjoyed.
She had also stopped eating well and exercising regularly.
As we delved deeper into these emotions, Carmen began to
break down into tears.
I cannot speak for my colleague, but this was definitely
the first time I had been so exposed to the internal torment
of another person (whom I did not previously know), and as
such I was taken a little aback. I believe she was able to open
up to us so readily because of the caring atmosphere of the
room and the nature of the consultation.
Fortunately for Carmen, Professor Kearsley was no
stranger to seeing this side of peopleand as such he could
read the situation perfectly, knowing exactly how to react.
Professor Kearsley had been sitting approximately 1.5m
46
Carmens Reflection
When I came to see you, I had so many mixed emotions. All
the negative thoughts I could think of all came pounding into
my mind.
First, I would like to say that I am a believer of the saying
you are what you eat. For years I have been following a
healthy diet. I would stay away from unhealthy foods which
might give toxicity into my body, which could then eventually lead to some diseases.
J. H. Kearsley
8 Carmens Story
Epilogue
Michelangelo, it is said, carved in order to liberate the person imprisoned within his block of marble; I saw the angel
in the marble, he wrote, and carved until I set him free
[11]. Several of his slaves remain unfinished sculptures
on purpose. Maybe what we are doing in the field of whole
person care is to replicate the work of Michelangelo with
human subjects. People find themselves again; and, as we
chip away, perhaps we may even see ourselves in a new
light; complete, though unfinished; whole, though imperfect.
Acknowledgments I am indebted to Ms. Carmen Simon for her resilience in allowing herself to be the subject of this story. I also acknowledge the bravery of Ms. Katherine Nguyen and Mr. Callum Barnes for
making themselves vulnerable enough to contribute to Carmens story.
I thank Ms. Sue OReilly for helpful editorial comments, and Judy
Cush for her secretarial expertise.
References
1. Hojat M, Vergare M, Maxwell K, etal. The devil is in the third year:
a longitudinal study of erosion of empathy in medical school. Acad
Med. 2009;84(9):118291.
2. Coulehan J. Todays professionalism: engaging the mind but not
the heart. Acad Med. 2005;80(10):8928.
47
3. Kearsley J, Lobb EA. It Is not a disease we treat, but a person:
reflections of medical students from their first rotation to an oncology and palliative care unit. Pall Care. 2013;29(4):2315.
4. The Holy Bible, Psalm 31. New Testament Version. International
Bible Society: East Brunswick; 1978.
5. Hamilton J. Dr. Balfour Mount and the cruel irony of our care for
the dying. Can Med Assoc J. 1995;153(3):3346.
6. Buckman RA. Breaking bad news: the S-P-I-K-E-S strategy.
Comm Oncol. 2005;(2):13842.
7. Buber M. I and thou. New York: Simon & Schuster; 1996.
8. Rohr R. The naked now. New York: Crossroad Publishing Company; 2009.
9. Kearsley JH. An exquisite presence (after Buber). Pall Supp Care.
2012;10:307.
10. Cassell EJ. The nature of suffering and the goals of medicine. 2nd
ed. New York: Oxford University Press; 2004.
11. Kearsley JH. Rembrandt, Michelangelo, and stories of healing. J
Pain Symptom Manag. 2011;42(5):7837.
John H. Kearsley MD, PhD is a professor of medicine at the University of NSW, Sydney, Australia, and director of the Department of
Radiation Oncology at St. George Hospital, Kogarah, NSW. He is an
accredited physician in medical oncology, and has a doctorate degree
in pathology. His major interests in oncology include psycho-spiritual
aspects of patient care and medical student teaching. He is the founder
of the Prostate Cancer Institute at St. George Hospital, and Whole Person Care Australia.
Lisa sat on the examination table with her head hanging low.
She did not look up when I entered the room. This was her
fourth visit in the childhood obesity clinic; third visit with
me and second visit with our licensed clinical social worker,
Meryl. At first glance, Lisa looked like any other sullen teenager that had been dragged to the doctors office by a parent.
And yet after spending just a little time with her at that first
visit 3 months ago, I had a feeling that there was a story she
wanted to tell.
At the age of 15, Lisa was still wetting the bed. She was
referred to our program by the pediatric urology team to address her weight and associated comorbidities. I met with her
alone during our first visit to learn more about her daily habits. She was not hungry in the morning and skipped breakfast
most days. She usually skipped lunch too; she did not like
the food. She had a long history of disrupted sleep, often falling asleep early in the evening after school and waking up in
the middle of the night. She is not sure why it is so hard to
fall asleep and stay asleep. She did not want to talk about her
bedwetting or stool accidents. I do not think she made eye
contact with me once during the 30min we spent together.
A high school sophomore, Lisa seemed to be somewhat
isolated reporting no real friends or social activities. She
walks the school track during lunch so she will not have to be
with the other teens in the cafeteria. This is in stark contrast to
her very outgoing and gregarious younger sister. She mostly
keeps to herself, even at home, eating dinner alone in her
room. She reports a lot of tension between her and her mother,
and she is not very fond of her stepfather. She longs to spend
more time with her father who recently relocated to the area.
Lisa was numb. Her affect was flat and everything about
her seemed to scream sadness. I wondered what her life was
like. I imagined how she may have used food to ease the discomfort and pain she felt inside. How the weight may have
M.L.Bailey()
Department of Pediatrics, Duke Childrens Healthy Lifestyles,
Duke University Medical Center, PO Box 3675, Durham,
NC 27707, USA
e-mail: michelle@drmichellebailey.com; Michelle.Bailey@duke.edu
49
M. L. Bailey
50
Practicing Presence
I was first introduced to mindfulness in 2005 during my integrative medicine fellowship. I was intrigued learning about
the connection between mind and body and how it could help
reduce stress. I had no idea how disconnected I was from my
body. When teaching medical students and residents about
mindfulness, I relay a story from my primary care practice
that illustrates this point.
Johnny came into the office to see me for his 3-year wellchild check. He was a very charming boy who enjoyed his
visits to the doctor. I appreciated his inquisitiveness and was
happy to see his name on my schedule. We were close to
wrapping up the visit and I was providing some anticipatory
51
my daily practice so I could return to this place of calm. Initially, I approached my new mindfulness practice as an intellectual exercise. My goal was to become more aware of both
my internal and external environment at work and at home.
I started to identify habit patterns I had been unaware
of. For example, my body held onto stress in my neck and
shoulder areas. I soon realized that my shoulders would rise
in response to stress, like a turtle retreating into its shell.
This became a signal to me; when I noticed my shoulders
up around my ears, I paused to pay attention to thoughts and
feelings that may be contributing to stress. Asking questions
with an attitude of curiosity allows you to gently peel back
the layers of busyness to clearly see what is inside.
We deal with uncertainty in medicine all the time. While
it might be easier to live in a world that is black and white,
the reality is that much of what we do falls in a gray zone.
There are times when we have a well-defined path to follow.
At other times, we rely on our experience to guide situations
where the way is less clear. This is the real art in medicine. In
the encounter with Lisa and her mother, there were a variety
of factors that created great uncertainty from the mothers
response to information disclosed... to the patients trust of
the health-care team.
In cases such as these, it is important to be aware of the
moment-to-moment unfolding so that an informed response
can be chosen, rather than unknowingly reacting to difficult
thoughts and emotions. As I observed Lisa in the consultation room, I could see and appreciate the tough situation she
found herself in. Putting myself in her shoes allowed me to
imagine the flood of emotions she may be feeling. Without
that awareness, I may have missed an opportunity to validate
her experience and acknowledge the bravery of her act in
telling her truth. It was due to this cultivation of awareness
that I was also able to sense the confusion, disbelief, and
utter helplessness experienced by our nurse practitioner student. This led to an invitation to talk about a medical encounter that she is not likely to forget during her career.
M. L. Bailey
52
Holding Space
The skills described above are very useful in the clinic setting. When I work with medical students, I often emphasize
the importance of not making assumptions. This is hard to
do at times, however, and I have seen it backfire when we
assume a patient will not have a negative reaction to news
shared and then they do. You never know when intense emotions may appear in the room. It can really catch you off
guard.
There is a recent situation that illustrates this point and
stands out in my mind. My last patient of the day was a Hispanic family with two school age children. The children were
well known in our primary care clinic located downstairs;
however, this was my first meeting with them. Mom appeared
to be very distant answering even open-ended questions with
short one- or two-word answers. I was working with one of
our very skilled Spanish interpreters, Genris aka Henry who
knew the family well. He had warned me that this was a difficult mom who did not seem to understand the importance
of making changes to improve the health of her kids.
53
Mindfulness in Action
People have asked me how long I practice mindfulness each
day. This is a hard question to answer because the practice
does not end when I leave the mat. The longer I practice the
easier it is for me to see how my informal practice is woven
throughout my day. There are many ways to practice mindfulness in the midst of the day. One of the most useful has
been in becoming aware of when I am not operating at my
best and need to make changes. I call this course correction.
This becomes most difficult for me when my energy is low
(i.e., I am tired) and/or when I am stressed. The story below
is a good example of how course correction can benefit both
patients and providers.
I was nearing the end of a very busy day and was eagerly awaiting the clock to strike five. I had one more patient
to see. My 4:00 p.m. overbook was an 8-year-old Hispanic
male scheduled for follow-up. In reviewing his record, I was
struck by the long list of comorbidities for such a young
child. I had been working with the pediatric weight management center for 5 years and seen many kids and teens with
severe obesitybut he was so young. I typed a quick summary into my template note to help guide the visitbody
54
M. L. Bailey
With this question, I was hoping to help her see that there
are many different ways to be physically active. Next, we
would address the myth that exercise is not good for kids
with asthma.
Umm There was silence. After some time, I asked
her mother if she could think of any ways that Natasha could
exercise indoors. Moms response was a bit surprising to me.
She rattled off a long list of why Natasha and her younger
brother could not exercise inside. The bottom line for many
of the excuses given was a fear of the kids breaking valuables inside the house. She also mentioned that they could
not afford a gym membership at the fitness club. Mom had
already investigated that option last month; it was too expensive. There was an increasing frustration in her voice as she
continued to talk.
I paused for a moment to decide where the conversation
should go from here. There was certainly a lot of resistance
coming up. Both mom and Natasha wanted to see her move
her body more to be healthier and yet they kept running up
against barriers. This is hard for them. They want it to be
different and there are so many variables that they feel are
working against them. What a difficult place to be, I thought.
Like being trapped between the proverbial rock and a hard
place.
I spent some time summarizing what I had heard both of
them say. Natasha was really motivated to find fun ways to
move her body. Mom was ready to support Natasha in being
more active. Neither of them could think of how to make it
happen without risking an asthma flare or spending a lot of
money. I applauded mom for researching community options
for indoor exercise. Her action demonstrated that this is important to her. She smiled.
Is this a good time for me to suggest some strategies that
have worked for other families in a similar situation?
They both nodded.
Ive found that yoga has been a positive solution for
many families. I explained the concept of the mindbody
connection and how yoga was an effective way to help girls
learn to be more aware of their bodies. Body awareness was
a great way to check in with the body to pick up on hunger
cues and satiety cues, teaching kids to eat guided by internal signals rather than external factors (i.e., the clean plate
club). As I went on to describe the benefits of yoga, I sensed
a problem. Moms smile was gone and she had taken on a
completely defensive posture. She was sitting up straight
with her back pressed so hard against the chair, I feared it
might topple over. Her arms were folded tightly high across
her chest and her legs were now crossed.
What had just happened? I was assaulted with a series
of thoughts thrown at me in rapid fire succession. Did I say
or do something wrong? Did I miss something that had occurred between her and her daughter? Was there a secret I
55
56
M. L. Bailey
I can show up for my life. The benefits of mindfulness practice are too numerous to list here. I hope the reflections
above have helped to give you a glimmer of what is possible
with a commitment to a daily practice. Here are my parting
thoughts on the top points to take away:
Learn how to be with uncertainty, yours and your patients.
It will pay off big time.
Be curious about the unfolding; you never know where it
may lead.
Do not be afraid to open your mind and your heart. There
are unexpected gifts waiting for you.
Do not beat up on yourself when you fall short. You are
human. Remember your patients are too.
Extend kindness whenever and wherever you can. A
caring word, a generous thought, a simple smileyou
never know whose day you will change. This is an act of
strength, demonstrate it every day and encourage those
around you to do the same.
My personal mindfulness practice has helped me to stay in
medicine. It has highlighted the importance of self-care and
compassion in everyday life, both at work and at home. It has
led me to show up and be more present for my patients, my
loved ones, and myself. I am now experiencing the moments
of my life and I get to share moments with those in the world
around me. We are all on a journey towards remembering our
wholeness. We are not broken, nor are our patients. We simply forget. Mindful moments help us to return to ourselves
and feel whole again. With mindfulness, we are human beings rather than human doings. And when we focus on the
present moment, our being can inform our doing. Here is to
being mindful.
Acknowledgment The author would like to kindly acknowledge the
following individuals and groups for their generosity of time, wisdom,
spirit and funding that informed the development of this chapter: The
Arthur-Vining-Davis Foundation, Jeffrey Brantley, MD, the Duke Childrens Healthy Lifestyles team, Duke Integrative Medicine faculty and
staff, Meryl Kanfer, LCSW, Karen Kingsolver, PhD, John and Christy
Mack, Javier Rodriguez, Genris Rumaldo, Silvia Valencia, the University of Arizona Fellowship in Integrative Medicine Program with special thanks to Tieraona Low Dog, MD and Victoria Maizes, MD, and
the patients and families that have allowed me to participate in their
care and taught me many valuable lessons over the years.
Michelle L. Bailey MDis a pediatrician and educator in the Duke
Childrens Healthy Lifestyles Program and Duke University School of
Medicine Durham, North Carolina, USA. She serves on the Executive
Committee for the American Academy of Pediatrics Section on Integrative Medicine.
10
Sonia Osorio
57
S. Osorio
58
Falling Away
I think my mind is falling in, he says to me.
Please hold me close,
Before I fall,
So I can feel before I fall
I hold him close,
Beside my arm
His tears so warm,
Upon my arm
His hands so withered, dry and cold
He seems so tired, lost and old
I do not know where he came from or where he went. Paranoid schizophrenia was the diagnosis given, which he despised. I do not know what he suffered from, but he did suf-
Returning Home
She enters the clinic for the first time with a blast of cold
air and activity. She hurriedly begins taking off her coat and
clothes that buffer her against the subzero Canadian climate.
As she removes multiple layers, she is apologizing for her
lateness. She speaks with a thick accent; her voice is hurried
and tremulous. It is so cold and windy, she had to fight hard
against the elements today. She was rushing to get here; she
had to take her granddaughter to school, she knew she would
be late. She hopes it does not disrupt things for any other
patients; she can take less time, if so, but she is glad that she
made it here.
She is a small thin woman, her hair finely cropped and
gray. The tendons in her neck are taut as she speaks. As she
slips her arms out of one last layer of clothing, I hear a sound,
as if small change has fallen from her pockets. I gaze down at
the floor and notice two rings lying by my feet.
Ive lost so much weight, I cant keep these on my fingers anymore, she says, as I bend down to pick up the jewelry and hand it back to her. She slips the rings carefully
back onto her frail fingers, hands slightly shaking, and veins
prominent through fragile skin. The rings are unusual in their
design; they appear crafted during another era, in another
place.
Cancer. Surgery. Multiple metastases. Chemotherapy,
scheduled again. I jot down the notes as she tells me her
medical history. Then, a single phrase moves us into another
history, her life before the diagnosis and treatment, In my
country, we call cancer the disease of sadness, she says.
Please, tell me more about your sadness, I request.
She pauses, looks down at her hands, and touches her
rings, so loose now on her fingersreminders of another
time, another place. Her answer, twirled in the memories of
her rings, surprises me:
My daughter is my sadness. She was my reason for living and
now I cant understand who she has becomeits like she
doesnt love herself or her own child. It hurts me so much to see
that. Its like Ive accumulated all that in me over these years.
I had to leave my country to come care for my granddaughter
after she was born. The little girl needed me; her mother couldnt
cope; I knew that. And, now, she only needs me to care for her
daughter; I know that, too. She doesnt need me. The little girl is
my life now, like my daughter was. I know I will not live much
59
Meeting Experience
I have almost 20 years experience in somatic approaches to
bodywork, and practice massage therapy and homeopathy.
I also teach and mentor yoga and meditation practitioners.
My work, really, is the container for an ongoing practice:
meeting people in the experience of their struggle, pain, discomfort, confusionwhat one would call suffering. And, I
would include that place of meeting, to be one within myself
as well. As I meet that experience in myself, I can greet those
who come to see me where they are, and as they are.
How to return to what is happening in the momentand
then expand out into an exploration from thereis an ongoing challenge, since the tendency is to want to give meaning or explanation to our pain or struggle, which imperceptibly moves us away from experiencing it fully.
How often do we speak of the body versus feeling into
its experience? This is the essence of disease or unease, that
separation from the wholeness of experience. I am ever curious about what takes someone away from what is happening
in the moment, in their bodies, because that is sometimes
the very thing that can take us back to wholeness and health,
going right back through the same door that let us walk away.
So, the first place I try to return to is always the body: what
is going on in the clients body and in mine, in this moment?
That is all we have to work with. It may be held in an idea or
story, it may be held in a place of tension or pain, but within
those places and those stories, there is an experience, felt and
expressed through the body.
Through my practice and my work I endeavor to continually be with experience as it arises, internally and externally,
and be responsive to that. This, to me, has become the definition of compassion: meeting experience as it arises, deeply
grounded in a respect for our capabilities and each persons
capacity, including our own, in that moment. This is more
than mindfulnessit is, as Buddhist teacher and writer
60
S. Osorio
11
Andrea N. Frolic
Cast of Characters
Andrea: Forty-something ethicist, harried, works in a large
childrens hospital
Lucy: Thirty-something social worker in the Neonatal Intensive Care Unit (NICU)
Joyce: Forty-something ethics consultant trainee and
nurse, works with Andrea
Emma: Thirty-something professional, exhausted but
well put together, mother of twins, Abigail and Rachel
Scott: Forty-something professional, stoic, father of Abigail and Rachel
Rachel: Four-month-old baby
Setting: Andreas office and the quiet room of the NICU
in a large childrens hospital
Act I
(Andreas office. A cramped space with a small desk piled
with stacks of paper, and a little table and chairs. The office
has a subterranean feel. The concrete walls are painted an
industrial off-white, covered over in lively childrens drawings addressed To Mommy with love. Andrea sits typing
on a computer.)
(Knock sounds at the door.)
ANDREA: Come in! (door opens) Lucy! Come in and
have a seat. (Lucy enters and sits the small table.) How are
the babes up in the NICU? I havent seen you in ages.
LUCY: Thanks. Well, its been pretty quiet lately in Neo,
but I have a case now Id like your help with. Do you have
time to chat now, or should I make an appointment?
A.N.Frolic()
Office of Clinical & Organizational Ethics, Hamilton Health Sciences,
McMaster University Medical Center, 1F9-1200 Main Street West,
Hamilton, ON L8N 3Z5, Canada
e-mail: frolic@hhsc.ca
ANDREA: No, no, youre here now, lets talk. Just let me
send this message before I lose my train of thought. (Turns
back to the computer, reads, types another sentence, hits
Send with a flourish and turns back to Lucy.) Okay, Im all
yours, whats going on?
LUCY: We have a baby on the unit. Abigail. She was born
prematurely, about 27 weeks. Shes been here three months
or so. She has a twin sister Rachel who was also in the NICU.
Rachel did well and was discharged home four weeks ago.
Mom and dad are recently married. A lovely couple. Very
attentive, very articulate. But they are struggling right now.
ANDREA: Why? Hows Abigail doing? (pulls a notebook from her desk drawer, starts taking notes)
LUCY: Not so well. It was a complicated delivery and the
doctors suspect she suffered a hypoxic brain injury. She was
resuscitated at birth and placed on a ventilator. Shes off the
vent now but she continues to have these episodes where her
oxygen levels suddenly plummet. She needs deep suctioning
and a lot of stimulation to bring her levels back up. Sometimes she has 10 or more episodes like this a day. She had a
G-tube placed for feeding. They hoped it would decrease her
reflux and stabilize things, but these I dont know what
youd call them these mini-arrests have continued. The
physicians are beginning to suspect they are somehow related to her brain injury, which is a bad sign.
ANDREA: So whats her overall prognosis?
LUCY: Well, thats the catch. Her brain scans are inconclusive. I cant explain everything the neurologist said
in the last family meeting, but basically the scans show an
unusual pattern of injury. They know there will be some cognitive disability and cerebral palsy, but you know neurologists. (Lucy shrugs) A brain scan cant predict functional
outcomes. Which is true, but unhelpful. Theyve consulted
with other specialists around the globe. But at this point there
is no definitive prognosis. All the doctors can agree on is that
her funny brain scan and these episodes indicate shes likely
to die soon, probably of respiratory arrest or infection. But
whether thats this week or next month or years from now,
they cant be sure.
61
A. N. Frolic
62
Act II
(SETTING: Same office. Andrea is again sitting at her computer, typing. Stuck to the bottom of her computer monitor
is a small card that reads Right Speech. A knock sounds at
the door. Andrea gets up and opens the door.)
ANDREA: Oh, hi Joyce. Is it 1:30 already? Where has the
day gone? How was your shift in the ICU today?
JOYCE: Oh the unit is crazy. But not as crazy as the parking lot here. My God, I had to drive around for 20min.
ANDREA: Ive had a hectic day myself. Ive been in
meetings since 8 AM. And you know what meetings mean
more work! But of course I cant get any work done because Im in meetings. (shakes her head) What do you say
we take a minute to settle ourselves down and then well talk
about our approach to this consult?
JOYCE: Sure, Id love that.
(Andrea takes out her cellphone and fiddles with the buttons.)
ANDREA: There, Ive set the timer for 3min. So lets
just close our eyes for a moment. (Andrea and Joyce both
close their eyes.) Letting our bodies and minds arrive here
and now, in this room together. Letting go of whatever weve
done or not done this morning. Feeling the chairs holding us.
The spine rising up like the trunk of a tall tree. The top of the
head touching the sky, the feet resting on the floor. Focusing
attention on the breath. (pause) Noticing the refreshment and
release that comes with each in-breath and each out-breath.
(Andrea pauses for a moment. The two women remain still
and silent.) And as this quiet time draws to a close, setting an
intention for our meeting with our clients today. (A few sec-
Act III
(SETTING: The NICU quiet room. The walls are painted
light green, decorated with pictures of flowers. The furniture
is industrial-cozy; two vinyl couches face one another, separated by a plain wood coffee table. Three chairs complete
the circle. Emma is sitting on one of the couches, nursing
Rachel; Scott is sitting beside her. They are both silent and
relaxed, totally engrossed in watching the baby suckle. The
door opens abruptly.)
63
64
at them and then theyre whisked away. And the next time
we see them theyre in these plastic boxes with tubes everywhere and people are whispering and watching the monitors
and looking worried.
(Emma has finished nursing. She passes Rachel to Scott
while she adjusts her clothing. As he speaks he gazes at Rachel.)
So there we are, trying to wrap our heads around the fact
that these two little red critters are our children, and trying
to figure out how to be parents to them when we cant even
hold them. Rachel, she came out vigorous and we could see
she was getting bigger and stronger every day, like normal
babies do. But with Abigail nothing seems normal. Every
day theres another test: swallowing assessment, MRI,
bloodwork, head ultrasound, echo. It goes on and on. And
after every test theres another meeting with more dire predictions: brain damage, developmental delay, blindness,
hearing loss, pneumonia. They still dont know what is going
on with her breathing. When her rates drop its sometimes
hard to get her stabilized again. And on bad days shell have
10 or 15 episodes. So everyday we wake up wondering, is
this the day our daughter is going to die? I never imagined
living like this. (pauses)
And every week theres a new doctor who thinks up a
new plan. Lets try her on another medication. Lets try this
G-tube. Lets send her scan to Harvard to get another opinion. And we get this little buzz, like, oh this will fix things.
But then we come back to the reality that her brain is really
messed up. It isnt like a broken leg, it cant be fixed. No
matter what they do she wont live very long. So then wed
wonder, what are we doing all this for? Its enough to drive
you nuts.
EMMA: (nodding) Totally. So on bad days Ill be planning Abigails funeral, and at the same time Ill be taking
care of this little one (caressing Rachel) who is growing
and thriving. Now shes even smiling at us. But most of our
time is spent thinking and talking about Abigail. Rachel here
hardly gets a second thought. I practically live at the hospital
so she doesnt get to be outside or have any kind of normal
life. I feel terrible about that.
ANDREA: The good thing about newborns, well, healthy
newborns, is that their needs are so limited. If theyre fed
and dry and attached to mommy and daddy, thats pretty
much the definition of the good life. (smiling at Rachel) She
doesnt look like shes suffering. She seems happy just being
close to you guys. (pauses) I cant imagine how torn you
must feel, celebrating Rachels milestones and bringing her
home and setting up house with her. But then having to deal
with this situation with Abigail. Becoming a parent for the
first time is hard enough. Becoming the parents of twins is
doubly hard. But here you are, youve had the joy of birth
and the anticipation of death all mixed up together. Feeling
nutty seems like a very sane response to me. (pauses) So
A. N. Frolic
given all that youve told me, what are you hoping to get
from our conversation? How can I help?
EMMA: Well, Lucy said youre someone parents sometimes talk to when theyre feeling stuck or conflicted. Scott
and I, we havent always agreed on what should happen with
Abigail. (Pauses, looking at Scott; he raises his eyebrows,
but doesnt say anything.)
ANDREA: Youve had a lot of decisions to make, under
huge pressure. It isnt uncommon for parents to disagree
sometimes about the direction of care for their child. Can
you tell me a bit about where you feel stuck now?
EMMA: (takes a deep breath.) I think my biggest concern
is protecting Abigail. We get that she isnt going to live very
long. And until recently she wasnt very responsive, so it
seemed like her whole life was just getting poked and prodded. When her breathing stops she starts suffocating. Its just
just awful to watch. And I worry that she may be in pain
other times too and we just cant see it. I dont want her life
to be about pain. But it seems like that could be all she ever
feels. (becomes teary) You know, if she cant do any normal baby things, and if shes going to die anyway in a few
weeks or months, then what are we doing? (Pauses, wiping
her eyes.) I guess I feel like I havent done a very good job
keeping her safe. I couldnt keep her safe inside of me, and
I cant keep her safe outside either. I just want her to have
some peace. (Breaks off, Scott takes her hand.)
SCOTT: And I guess for me, I dont want her to suffer either. But I am less clear about stopping everything. I honestly
cant understand whats going on half the time. Ive heard so
many conflicting stories. Shes going to die. Shes doing
better today. You can take her home soon. Shes had a
setback. I have no idea whats around the next bend. And
because I dont know what her future holds, its hard for me
to say, Okay, enough is enough, lets stop now. I just cant
do it yet. I want to get her home to have some kind of normal
life with us and her sister and her grandparents. I dont want
this place to be all she ever sees of life. But then I wonder
if Im holding onto her for selfish reasons, because Im not
ready. (pauses)
Emma told me to talk it over with her, so I did. A couple
of nights ago I sat with Abigail. And I told her everything
that was going on, everything the doctors had told us. About
the little stars that light up on her brain scan, and why she
needs the feeding tube. And I told her about how her mom
and sister are here all the time watching out for her, and how
hard the nurses are working to keep her safe. (voice breaks,
continues in a whisper). And I told her that even though we
love her, we will be okay if she needs to go, if its too much
for her. But I told her we want her to stay, for a little while
longer, if she can, so she can sleep in the room weve prepared for her at home. (pauses, wipes his eyes briskly) Whatever. I dont even know if she can hear me, but I felt like I
had to explain it to her, why were putting her through this.
65
66
This week shes getting better, next week its hopeless. The
flavor changes with each new data point, and her response to
each treatment they try.
The up side of this whole process is that you have access to the collective wisdom of many physicians, who have
treated thousands of patients. Theyve even reached out to
colleagues at other hospitals. While this only adds to the
murkiness now, when things do become clearer and decisions have to be made, you can feel confident that their predictions are as accurate as humanly possible.
SCOTT: (frustrated) Yeah, I get this. I get their need to
turn over every stone. I am grateful, I am. Dont get me
wrong. But in the meantime were sitting at her bedside
watching her writhe in agony.
We are her parents. We are her voice. We are the ones who
have to think about her future. About all of our futures (gesturing to Rachel). How are we supposed to make plans when
they cant make up their minds? I keep wondering, should
I be at home renovating the house because someday she is
going to need a wheelchair ramp to get in the front door? Or
should we be at the funeral home picking out a coffin? I get
that the doctors are stuck. But what about us? Were in this
state of, I dunno, suspended animation. This cant go on.
ANDREA: (leaning forward) Its maddening. I get that.
(pauses) Actually, I dont get it at all. But I can hear the frustration in your words and I can imagine being in your position. You are in this betwixt and between space. You dont
know whether to you should be planning a life with her or
without her. (pauses) I know this is going to sound stupid,
but Ill say it anyway. This is really hard because it is really
hard.
SCOTT: Im sorry, but what is that supposed to mean?
ANDREA: Often in times of stress, people retreat from
reality. They hang on to false hope or they deny anything is
wrong or they imagine the worst case scenario is about to
come true. But the two of you (pausing, looking both of them
in the eyes) you are both deeply in touch with the real ambiguity of this situation. Abigail may die tomorrow if her brain
is so damaged that it tells her lungs to stop working. Or her
brain may keep telling her lungs to breathe, but a year from
now she may get an overwhelming infection and die. You
know the book of her life will be slim, but the last chapter of
her story hasnt been written. Nobody knows when or how it
will end. You grasp this uncertainty, which in some ways is
harder than a clear death sentence.
SCOTT: I dont see how that is any help.
ANDREA: Well, it isnt frankly. But longing for certainty
when there isnt any seems to be causing you and Emma a
great deal of distress. It looks like Abigail is in charge here.
She has to declare herself. We wont know her future until it
unfolds. She has to show us what shes capable of, and that
will take time. This requires almost superhuman patience on
your part. (leaning back into her chair) I guess Im wonder-
A. N. Frolic
67
home, even if the child dies more quickly than she would in
hospital. Every familys story is different. But it might be
useful to think about this question: if you were to create a
story for Abigail based on her circumstances and your values, what would it look like? (Scott shifts in his chair)
EMMA: Its hard to imagine her whole life story because
the day-to-day feels so overwhelming. But it might be worth
talking about.
ANDREA: Yeah, it is overwhelming. Try it out and see
what bubbles up. You might even put pen to paper and write
out her life story, as you imagine it, just to see what emerges.
(scanning over her notes) Okay, so weve talked about how
medical decision-making works. Weve talked about best interests and the idea of the harm-benefit ratio. Weve talked
about your values and weve talked about creating a story for
Abigail. There is one more thing Id like to leave you with.
(takes a breath)
Id like to give you some ideas for living day-to-day in
this state of uncertainty. We are so accustomed to thinking
about the future and making plans. But with Abigail you
cant make plans because her future is too murky. Some of
the best specialists in the world have looked at her case and
even they cant figure it out. So given that perpetual uncertainty is your new normal, how can you keep it from driving
you mad?
Perhaps one way to cope is to set small goals or intentions
every day. Instead of focusing on the big ticket items, like
should I renovate the house or choose a coffin, focus on the
little actions you can take to connect with her. Like, I dunno
(gesturing with her hands) today Im going to tell Abigail the
story of her crazy uncle Harrys stint as a circus performer.
Or, today I am going to sing the entire score of the Sound of
Music to Abigail. Or today I am going to give her a massage.
Try to notice and celebrate the small joys, in the midst of
all the chaos. Accomplishing little acts of connection, even if
the big questions remain unanswered, is one way to reclaim
your sense of purpose. And over time, these little acts will
make you feel like good parents to Abigail, however long
you have together. They may even become the threads you
weave together to tell her story. The story of your family.
(Rachel stretches and stirs, giving a short cry.)
Oh dear, I think it is time for another feeding. Perhaps
thats our cue to finish for now. Has any of this been helpful
to you?
EMMA: I think so. Its been helpful to talk about our values and her story. Ill keep thinking about that.
SCOTT: (handing Rachel over to Emma) Not really, honestly. It feels as confused as ever.
ANDREA: (sitting back, smiling) I appreciate your honesty. Confusion seems like a very reasonable response to
your situation. I wish I could wish away your burden. (closing her notebook) I have enjoyed meeting you, and meeting
Abigail and Rachel. They are both so beautiful, and they are
A. N. Frolic
68
Third, reading a play is like working out a puzzle. In expository prose, the author can tell the reader what is going
on, and can describe the characters inner thoughts, desires,
and schemes. But the reader of a play must piece these together for herself, using only the words spoken and actions
described. A play shows, it does not tell. In these scenes, I
have attempted to show how mindfulness infuses my practice as an ethicist.
Epilogue
Three Minute Breathing Space At least once each workday, I set aside a few minutes for formal meditation practice.
By simply stopping and bringing awareness to my breath and
my body, I am better able to transition from one mode or
activity to another.
Setting an Intention I keep a stack of intention cards in my
office [1]. I pick one from the deck every morning upon my
arrival. Sometimes the intentionsuch as honesty, responsibility, or compassionfits the flow and challenges of my
day intuitively. Other times, it feels like a struggle to understand how the quality relates to my current circumstances.
Throughout my workday, I try to reflect on how I can bring
the days intention to whatever activity I am engaged with.
Mindful Listening I try to begin conversations with clients
by inviting them to tell me their story, and then shutting up.
This second step is the most difficult and the most important. In the hospital environment, patients and families are
constantly interrupted by pagers beeping, by impatient learners wanting just the facts, by harried clinicians awareness
of the multitude of other patients waiting to see them. Mindful listening requires self-regulation to curb the temptation
to interrupt or to preempt the punch line of the clients story.
When I am mindfully listening, I wait for the client to stop
speaking; sometimes I wait through long pauses to see if
more of their story will emerge. Through this practice, I learn
what is most important to the client, rather than what I think
is important. It is astonishing how little time this actually
takes and how much wisdom clients uncover for themselves.
Throughout my clinical encounters, I also try to check-in
with my own emotions, thoughts, and bodily sensations. For
example, when clients resist my suggestions, I sometimes
notice defensiveness or fear arising as a knot in my belly.
Naming this feeling, I can take a deep breath to loosen the
69
References
1. Murdoch A, Oldershaw DL. 16 Guidelines for life: the basics. London: Essential Education; 2009.
2. Hanh TN. Happiness: essential mindfulness practices. Berkeley: Parallax; 2009.
3. Dass R, Gorman P. How can I help? Stories and reflections on service. New York: Knopf; 1985.
12
Linda E. Carlson
I met Stephen during my residency year before the completion of my PhD in clinical psychology in 1997. Stephen had
recently received a diagnosis of stage 4 non-Hodgkins lymphoma. I had some training in health psychology, but it was
my first introduction to working with cancer patients. I was
seeing people preparing to undergo high-dose chemotherapy
and stem-cell transplantation in the bone marrow transplant
unit, and was learning a lot about the cancer experience and
what it entailed both medically and psychologically. My job
was to help people cope through this grueling procedure
by applying principles of counseling and clinical psychology, providing support to patients and families in ways that
fit with their resources, personalities, and values. We were
learning to treat specific psychological reactions including
anxiety and depression, as well as and symptoms, such as
sleep disturbance, pain and fatigue, and existential concerns
around death and dying.
Stephen was to be one person I saw through his entire
intense medical journey, and well beyond, for over 10 years.
We became very close, with the kind of familiarity and deep
implicit knowing of one another that eventually results in
understanding without the requirement of much speech. The
relationship provided him comfort, familiarity, and a feeling of being seen, understood, and accepted. He also learned
concrete tools for coping and integrating mindfulness practice into his everyday life. But how did we get there? There
were considerable challenges to overcome, medically, and
psychologically. I will first tell you about his medical treatments, my role at that time, and how we integrated mindfulness into our relationships and into his process of healing
and recovery.
L.E.Carlson()
Department of Psychosocial Oncology, Tom Baker Cancer Centre,
1331 29St NW, Calgary, AB T2N 4N2, Canada
e-mail: lcarlso@ucalgary.ca
Department of Oncology, Faculty of Medicine, University of Calgary,
Calgary, AB, Canada
Autologous stem-cell transplantation (ASCT) is a procedure whereby people with systemic cancers, usually lymphomas, are subjected to extremely high-dose chemotherapy
which depletes the immune system. Before the chemotherapy, the patients own stem cells are harvested, cleaned, frozen, and stored for later reinfusion. This can only be done in
cases where the cells themselves are thought to be relatively
cancer free. In the case of most leukemias, donor marrow or
peripheral stem cells are harvested and those are later reinfused, rather than the patients own blood cells, which are
tainted with cancer.
Regardless of whether the procedure involves later infusion of the patients own cells or donor cells, after the harvest
they are subjected to high-dose chemotherapy, much higher
dosages than could normally be safely administered due to
immune depletion. Then after the chemotherapy, the clean
cells are reinfused into the patient with the hope that they will
safely engraft and reestablish a healthy immune system. This
process involves sometimes lengthy inpatient stays while the
person is immunosuppressed and the process of rebuilding
the cells is occurring. At the same time, terrible side effects
of the chemotherapy are common, including painful mouth
sores, diarrhea, hair loss, neuropathy, and overall extreme
fatigue and nausea.
Stephen was not well suited for this kind of treatment.
The cancer experience in general is fraught with uncertainty
and loss of control. No one can tell you what your chances of
survival are, or how your disease may progress. Death may
be imminent. Oncologists cannot even tell you exactly what
treatments you may need, or even, in some cases, definitively what the diagnosis is. They cannot tell you if or when it
might recur. Stephen was 36 years old, and was physically fit
and active. He was married but he and his wife had chosen
not to have children; they had a full life with a small but active social circle, family ties, and travel. He was well read,
intelligent, and a good conversationalist with a passion for
politics and music, but he had his own mental health problems that predated the cancer.
71
72
He grew up in a family with a history of depression, anxiety, alcoholism, and abuse, and had a long personal history
of anxiety and depression himself. He has been diagnosed
with obsessivecompulsive disorder (OCD), generalized
anxiety disorder (GAD), and had also suffered from major
depressive disorder (MDD) intermittently. While his anxiety symptoms had been quite constant throughout his life,
depressive symptoms waxed and waned. Despite these challenges, he was resilient. He trained in technical school and,
while he had periods of anxiety and self-doubt, became a
licensed tradesman. After a few years in the field, however,
the stress of trying to work in a job that required precision
and focus, where the consequences of slipping up could be
fatal to himself or others, had taken a toll. Escalating OCD
symptoms had led to leaving his job and taking disability a
year or so prior to his illness, as he was unable to function.
He doubted his own minds ability to complete the required
tasks, was constantly second guessing himself and checking
his work obsessively. This resulted in a high level of mental
fatigue and depression which culminated in a suicide attempt
and brief stay in a psychiatric unit within the 2 years previous
to his cancer diagnosis. He had been treated with medication and supportive counseling and been recovering from this
traumatic experience when he began experiencing symptoms
of lymphoma. Stephen did not do well with uncertainty, and
his obsessive personality style and chronic anxiety escalated
once again as he entered the cancer treatment system.
I am not sure what my supervisor was thinking in assigning me this case. I had no idea how to help him through this
experience, and certainly could not imagine trying to treat
all his other psychiatric problems during the storm of cancer
therapy. I got to know him and his wife gradually, through
the first intake interview where I learned a little about his
background, and more and more each time I visited his bedside during treatment. I was impressed by their bond, and
her commitment to stick by his side through thick and thin.
She was there most days and maintained an upbeat persona.
They talked about everything and were very open with one
another. They had already been through a lot, but she was
his rock. She was stable, good-natured and while she shared
some of his more minor obsessive personality traits, did not
suffer any serious psychopathology. She worked full-time in
a stable job, had many friends, maintained an exercise routine, and received a lot of support at the workplace. Stephen
was fortunate to have such a caregiver and partner in his life.
I wondered, as Stephen got sicker and sicker, whether I was
doing any good. I felt helpless and overwhelmed by his problems; and his prognosis was poor. All I could do was sit by
his bedside, sometimes I would help him relax by instructing
him in the use of deep breathing techniques. I talked with
his wife when he was sleeping or in too much pain; she was
practical and worked hard to hold herself together. She kept
busy with managing his needs.
L. E. Carlson
It was hard for him to apply these ideas in the midst of the
whirlwind of treatments, tests, fear, and misery. I think he
shifted a little, but OCD is a powerful master. Stephens obsessions were largely mental, games he played in his head,
questioning even the processes of his own mind: was what
he perceived reality, or a trick his mind was playing? It was
hard to get him out of his head and into his body, which is
what we often do in mindfulness training; his body was not a
refuge either during those times due to unrelenting pain and
discomfort. So mostly I just listened, remained calm, and
tried to understand, breathed with him.
Miraculously, the second round of high-dose chemotherapy worked, and the transplant was deemed successful;
Stephens immune system began to rebuild itself. There were
many serious medical problems encountered and overcome
during this second ASCT, but eventually, Stephens immune
system and overall health began to rebound. Stephen was
then reassigned to radiation oncology for 40 more radiation
treatments to his torso. Now he also had to rebuild himself
in so many other ways. As is often the case, the terror and
despair really hit him after the treatments were completed;
then the fear of recurrence loomed large. Ultimately, Stephen
was informed that his remission would likely be brief, between 2 and 6 months. This was a very real threat; it had
come back quickly and aggressively before, and the initial
onset was also a swift blow. It was at this point he began attending our 8-week Mindfulness Cancer Recovery Program.
We had been offering it only a year or so at that time, and
were still refining the content, but it was an adaptation of
Kabat-Zinns mindfulness-Based stress reduction, with more
of a focus on cancer and the uncertainty it brings. Stephen
attended the program and practiced the meditation and yoga
exercises we prescribe faithfullyhis obsessiveness and
conscientiousness made him a good student. He attended all
the classes, participated, shared his experience, and did his
homework (45min of practice a day). But he struggled with
his mind still. Some question the utility of meditation for
people with mental obsessions; would this just become the
next obsession? Was self-reflection in the form of mindfully
watching the mind advisable for someone already obsessed
with an unreliable mind? I tried to assist Stephen, to move
his focus into the bodythis was a bit difficult too, though,
as he could become obsessed with analyzing minor sensations from his chest, where the tumors had been. Were they
growing back? What did that little tug mean?
We persisted nonetheless. I thought it would be useful for
him to become familiar with what it felt like in the body to be
anxious, versus tired, versus depressed, or actually physically sick. Through this work, he did learn to distinguish anxiety
in his body from physical symptoms, which he had been confusing. The typical pattern went like this, I feel something
funny in my chest, could this be the cancer coming back? Oh
my God, if its back Ill be dead, there is no more treatment
73
for me. What will happen to my wife? How will I die? Will
I suffer? How long is this going to take? I dont want to die!
Im terrified! Like a merry-go-round from Hell, on and on it
would go. Of course then the symptoms would escalate with
the fearIt is cancer! Im sure of it! Why else would I feel
this way? He would poke and prod his body constantly and
further exacerbate symptoms.
We persisted with individual sessions after the group
program, and practiced mindfully observing, identifying,
and responding to stress-related symptoms, rather than automatically assuming that he was on the path to his inevitable
death. Stephen was able to arrest the process over time. He
did a really good job of thishe surprised me somewhat. We
instituted a rule: If you feel what you think might be a symptom, note it, then immediately let it go, do your meditation or
breathing exercises, leave it for a week, and if it is still there
in a week, call the doctor. The symptoms almost always went
away. This practice reinforced the idea that stress can manifest as physical symptoms that mimic his cancer symptoms.
This practice was immensely helpful and he has continued to
apply it for years.
I would like to report that my work with Stephen was a
miraculous success story. However, despite some progress,
he was still symptomatic 10 years later. I think given his history it would be miraculous was he not, but he has certainly
made gains. A year or so after treatment we discovered something else; every year on the anniversary of his diagnosis, he
became depressed and anxious. He had vivid nightmares of
the hospital room he spent so much time in; the doctor telling him he was not doing well and his time might be limited. I diagnosed him with post-traumatic stress disorder
(PTSD). He had all the symptoms. Now what would we do?
I favor exposure therapy for PTSD, and in fact, mindfulness
training is just that: gradual controlled exposure to the full
range of content of the mind. This included flashbacks and
memories of the trauma of his diagnosis and treatment. We
reviewed it again and again; how one day he felt a lump in
his chest, he fainted due to a syncopal episode, and eventually was taken to the Emergency Room; the swift diagnosis,
the brutal treatments; seeing his roommates at the hospital
deteriorate until eventually two of them died. We went over
it again and again, hoping the memories would fade in their
potency. Over time eventually they did, but even as our sessions became less frequent, every year at the anniversary I
would get a call from him for a few sessions. He would tell
the whole story to me yet again. I knew it so well I could tell
it myself, but nonetheless I would try to apply beginners
mind and listen as if for the first timeI would even add in
bits if he missed them.
We actually came to laugh about Stephens storieswe
called them his bird songs. I had read somewhere that once
male birds of a certain species start their call; they cannot
stop until it is done. There is no interrupting. Stephen had a
74
L. E. Carlson
13
Kathy DeKoven
K.DeKoven()
Department of Anesthesiology and Pain Clinic, Centre Hospitalier
Universitaire Sainte-Justine, Universit de Montral, 3175 Chemin de
la Cte-Sainte-Catherine, Montreal, QC H3T 1C5, Canada
e-mail: kathryn.dekoven.hsj@ssss.gouv.qc.ca
75
76
K. DeKoven
77
have to remove her uterus. This is the first time that I see Madame N cry. It is almost a relief to see her expressing some
of her suffering. Until now, she has managed to remain so
cheerful, pleasant, and stoic in the face of such difficulties. I
really wish her partner could be here. I feel so alone with her.
I am conscious that I am projecting my own fears and past
traumas onto my patient: my D+Cs, a debilitating bike accident shortly after a romantic break-up, my ultimate fear of
suffering alone, and my neediness. I am more afraid of aging
alone than I am of dying. I have a flashback to 6 years ago,
when I took a month leave from my regular life to take a
meditation course in a Tibetan Buddhist monastery in Nepal.
I was sweeping the floor with my androgynous roommate,
a woman who had been plagued by spaghetti-like intestinal
worms during our time together at Kopan. Chatting with my
roommate, I had the realization that my only hope of happiness was if I let go of my desperation to have children. I
believe that this new mental stance contributed to my husband finally agreeing to have a family with me. This was a
great victory for me which temporarily appeased my fear of
dying alone.
In the recovery room, shortly after the discussion of a
possible hysterectomy versus other options, Madame N becomes cool, sweaty, even paler and her heart rate drops to
45bpm. I switch gears into emergency mode, quick decisions followed by actions. It is a familiar mode for me: crisp,
clear, rational, vigilant, goal-directed, emotions on hold.
When the emotions break through, it becomes much harder
for me to think clearly and perform efficiently. The hardest
times I have had trying to keep my cool at work have been
anesthetizing sick little babies, while my little baby was at
home. The fragility of the tiny patients combined with their
resemblance to my own precious brood posed a challenge for
me upon my return from maternity leave.
The gynecologist makes a definitive decision Madame
N, we will remove your uterus. There is no more time to
waste. The patient accepts, and we rush her to the operating room for her third anesthetic that night. Take 3. I hold
her same hand. It is cold, pale and damp, but still very alive.
The resident puts her to sleep. She is stable throughout the
operation, although she requires numerous blood products. If
we had waited any longer, it may have become more difficult
to resuscitate her safely. I am relieved that she is safe, but I
feel melancholy related to her losing her uterus. Presumably,
this represents the loss of hopes and dreams for her and her
family. I know that my children are my crown jewels. There
is nothing more precious to me than my family, and I can
only hope that others who wish to can experience the same
joy (and chaos).
This operation represents the loss of an unknown seed, an
unknown potential, an unknown love. During the procedure,
I am surprised by the appearance of her uterus. From the
outside, it looks so innocuouspink, shiny, little and firm. It
78
K. DeKoven
14
Ricardo J. M. Lucena
It is only with the heart that one can see rightly; what is essential isinvisible to the eye
Antoine de Saint-Exupry
Introduction
In this chapter, I describe a case of a patient with comorbid
alcohol use disorder and paranoid personality disorder. The
patient agreed with the description of his case in this chapter under the condition of maintaining his identity and the
identity of his family members anonymous. The case will
be described according to its 4-year follow-up in my private
practice as a psychiatrist in the Northeast of Brazil. I used
mindfulness as part of dialectical behavior therapy (DBT),
which was originally designed to treat individuals with borderline personality disorder by a psychologist, Dr. Marsha
Linehan [1]. It stems from cognitive behavior therapy and
differs from it in its emphasis on validation which consists of
helping the patient accept uncomfortable thoughts, feelings,
and behaviors rather than struggling with them. The term dialectics refers to the balance between acceptance and change
[2]. The therapist leads the patient in the process of change
from the old behavior (e.g., drinking) to the new behavior
(e.g., abstinence) by helping the patient develop a set of coping skills involving mindfulness, distress tolerance, emotion
regulation, and interpersonal effectiveness.
Before moving forward, let me write a few words on the
title of this chapter. It refers to a well-known book on addiction In the Realm of Hungry Ghosts: Close Encounters with
Addiction [3]. Hungry ghost is a Western translation of a
concept in Chinese Buddhism representing beings who are
driven by intense emotional needs. These beings are ghosts
only in the sense of not being fully alive; not fully capable
R. J. M.Lucena()
Department of Internal Medicine, Centre of Medical Sciences,
Universidade Federal da Paraba, Rua Monteiro Lobato,
691/APT 1101, CEP58039-170 Tamba, Joao Pessoa-PB
CEP58039-170, Brazil
e-mail: lucenar@uol.com.br
79
80
R. J. M. Lucena
am doing here. I have no problem. My parents are the problem. They should be here. Not me.
I thanked him for coming and suggested that we talk for
a while. He was clearly annoyed to be there. He took a seat
and continued, My parents humiliate me as much as they
can to the point of sending me to another shrink. You cannot do anything for me. They say I drink too much. I see no
problem with that. You should treat them so they respect me.
Besides, I do not trust anybody. Do not even try to fill me up
with meds. I will take none.
Applying one basic principle of motivational interviewing [5], to roll with resistance, I told Emilio the following:
I can imagine how difficult it is for you to be here, and I do
not want to make it worse. I am not here to judge you or to
prescribe medication for you at this moment. I am here to
listen to you. I met your parents last week, and they talked to
me about you. Now I would like to hear you.
Emilio, with an attitude of surprise and suspicion, agreed
on talking: Fair enough, Doc. I do not know what kind of
arrangement you have with my parents, but I will let you
know my side of the story, although they might have bought
you. I interrupted him by saying Emilio, please, let me be
clear: they did not buy me. They paid for an appointment
with me. Can you see the difference? In fact, they paid for
two appointments: one for them, one for you. So take advantage of your time here and tell me your story.
Emilio started by saying, My parents always devalued
and criticized me. I never did anything right. They compared
me with other kids, my cousins, for example, who were always better than me. My parents never missed the chance to
put me down, especially when other people were around to
witness. I felt humiliated all the time. I wanted them to spank
me instead of humiliating me.
For the first time in the appointment, at a glance, Emilio
showed his broken heartbehind layers and layers of anger
and suspicion. He continued, My parents criticize me for
drinking, but drinking brought me this far. I could not be
here today if I did not drink. I started drinking when I was
15 years old, and I remember why. I was eager to park my
fathers car in the garage. He let me do it while he observed
me. I was almost done when I lost control of the car and hit
the gate and smashed one side of the car. Right away, my father screamed at me at the top of his lungs. You idiot, you
jackass! Do you see what you did? Get out of my sight! My
grandfather, my uncles, my cousins, the maids of my house,
they all saw what happened. I was so ashamed that I did not
know where to put my face. Everybody was laughing at me.
He continued, I left my house and went to the beach with
some kids from our neighbourhood. It was carnival time with
lots of people drinking. The kids and I started drinking, and I
drank until I could barely walk. I just heard my father telling
my grandfather, There he isas drunk as it gets! Lets go
home, you ass! You are embarrassing our family in front of
81
82
R. J. M. Lucena
ated in administration from a local university, and was enrolled in an MBA program funded by the company. She was
a very smart and ambitious young woman. In one of the several appointments, when she accompanied Emilio, she said,
I want to be in charge of my office when I finish my MBA.
And I want Emilio on my side. He will change for the better.
He just needs to control the amount of liquor he drinks.
By then, Emilio had evolved in his understanding of the
problem of drinking and considered changing his drinking
pattern. I explained to both of them the basic concept of addiction as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful
consequences [7] in which one loses control of the substance
use. Due to this feature of loss of control over the substance
use and potential relapses, a person addicted to a substance
cannot be continuously exposed to it. Substance abstinence
is the most viable alternative to interrupt the out-of-control
pattern of substance use and to prevent relapse. Rebeca believed Emilio could control his drinking to moderation, but I
explained this is not an alternative in the context of our treatment, where abstinence is an ultimate goal to be achieved.
A couple of months went by, and Emilio came to the session announcing that Rebeca was pregnant, and they were
going to get married. He added, My parents are not happy
with the news. The first question they asked was where I was
going to live with her. I answered right away: Not under your
roof! I am going to live with Rebeca at her mothers house
where I am treated like a king.
A few weeks from that announcement, Emilio and Rebeca
got married. Emilio stopped going to rodeos and seeing his
drinking buddies. He just went to bars with Rebeca. Emilio
claimed that he was drinking much less and just with Rebeca. However, the honeymoon period did not last long. When
Emilio heard a rodeo song or met an old drinking buddy by
chance, he could not resist. A deep urge to drink kidnapped
him from Rebeca, and he went out to drink. That is when
Rebeca would look for Emilio in bars and bring him back
home, very angry at him. This pattern of behavior became
more frequent after their daughter Stella was born.
The stress of having a newborn in the house was too much
for Emilio. He was coming to my office twice a week and
was exposed to DBT, beginning with distress tolerance strategies. For the first time, he accepted to take a medication
(Naltrexone) to help him cope with cravings. This was in
the second year of treatment. Emilio was very much aware
of how primitive it was to use alcohol to deal with distress,
every time he had a fight with his parents or more recently
with Rebeca. However, he was still learning the alternatives
to drinking every time he was angry, frustrated, feeling humiliated, and so on. He continued to drink at home with Rebeca, who did not see a problem in social drinking. However,
frequently when Emilio drank, the result was a fight with
Rebeca.
83
Closing Thoughts
At the beginning, I was taken by the parents negative attitude towards Emilio. They could only see the negative facts
about him. Later on, I could see in Rebeca, his wife, a similar
attitude. In their view, Emilio was to blame and should be
punished. He was given every chance to be a better person.
But he spoiled each opportunity. I saw first his parents and
then his wife express many complaints about Emilio and
very little compassion and understanding of his psychopathology, in spite of my efforts to inform them accordingly. I
also understood that Emilios disruptive behavior had deeply
R. J. M. Lucena
84
wounded his parents and wife over the years, and to make
the situation even more complex, Emilio had little insight
into the harm he was causing himself and his family. Emilio
blamed his family for his misfortune. As described in Virginia Satirs [8] styles of communication, the person blames,
judges, accuses, dictates, and oppresses the other, making it
difficult to see each other with empathetic eyes and to discover a compromise.
In this scenario of blaming from both sides, I played the
role of a mediator. On one hand, I explained to Emilio that
his family was there for him and helped him express that
understanding to his parents and wife. On the other hand, I
explained to his family Emilios limitations and long-term
progress. For all of them I constantly had to renew their
confidence that improvement was possible. In reinforcing
confidence, being in the moment for all of them helped tremendously to overcome the interference of rumination of a
past filled with pain and frustration. As a result, Emilio could
achieve some change in his maladaptive patterns and to a
certain extent change in his familys dynamics. Compassion,
understanding, and perseverance were the main ingredients
of the work in this case.
References
1. Linehan M.M. Skills training manual for treating borderline personality disorder. New York: Guilford Press; 1993.
2. National Alliance on Mental Illness. Dialectical behavior therapy.
http://www.nami.org/Content/NavigationMenu/Inform_Yourself/
About_Mental_Illness/About_Treatments_and_Supports/Dialectical_Behavior_Therapy_%28DBT%29.htm. Accessed: 28 May 2014.
3. Mate G. In the realm of hungry ghosts: close encounters with addiction. 7th ed. Toronto: Knopf; 2008.
Hungry ghost [internet]; 2014. http://en.wikipedia.org/wiki/Hun4.
gry_ghost. Accessed: 29 May 2014.
5. Miller WR, Rollnick S. Motivational interviewing: helping people
change. 3rd. ed. New York: Guilford; 2013.
6. Saint Exupry A. The little prince [internet]. http://srogers.com/
books/little_prince/ch21.asp. Accessed: 28 May 2014.
7. National Institute on Drug Abuse. Science of addiction. http://www.
drugabuse.gov/publications/science-addiction. Accessed: 28 May
2014.
8. Satir V. People making. Palo Alto: Science and Behavior Books;
1972.
Ricardo J. M. Lucena, MD, PhD, is a psychiatrist and an associate
professor in the Department of Internal Medicine, Centre of Medical
Sciences at the Universida de Federal da Paraba, in Brazil. He maintains a private practice and specializes in addiction and personality disorders. He offers dialectical behavior therapy to his patients.
15
Christian Boukaram
85
86
C. Boukaram
87
C. Boukaram
88
References
1. Servan-Schreiber D. Anticancer, a new way of life. Paris: ditions
Robert Laffont; 2007.
2. Boukaram C. Le pouvoir anticancer des motions. Montral: ditions de lhomme; 2011.
3. Dobkin P, Hutchinson T. Primary prevention for future doctors: promoting well-being in trainees, Med Educ. 2010;44:2246.
Christian Boukaram, MD, is the chief of Radiosurgery at Maisonneuve-Rosemont Hospital in Montreal, Canada. He is a professor at
the Universit de Montral and an associate researcher and radiation
oncologist at Maisonneuve-Rosemont Hospital. He presently serves as
a co-chair of the Education Committee for the Society for Integrative
Oncology. He is the author of a book, Le pouvoir anticancer des motions, focussing on mindfulness and mindbody therapies in oncology.
One of his missions is to promote whole person care by bridging the
language barrier in the French-speaking health world and opening up
the opportunity for collaboration.
16
Ted Bober
Introduction
A short drive away from my urban home is the Bruce Trail,
an 800-km hiking trail, stretching along the Niagara Escarpment in Ontario. Over millions of years, this landscape was
shaped by the flow of water and the movement of glaciers.
A landscape first travelled by humans over 12,000 years
ago. Nowadays, my hiking pal Dawson, the family golden
retriever, and I walk the trail through Carolinian and boreal
forests among dozens of species of trees, sugar maples, red
oaks, balsam firs, white spruces and 700-year-old cedar trees
growing from limestone cliffs. We may pass one of the 60
waterfalls and the remarkable diversity of nearly 500 species
of birds, mammals, reptiles, fish and amphibians. Among
them are screech owls, trumpeter swans, the warblers, great
blue herons, the lesser scaup, the Jefferson salamanders, red
foxes, white-tailed deer, striped skunks and spotted turtles.
Rare orchids are among the 1500 plants coming and going
over the seasons. Some of the plants and animals are abundant and others at risk of extinction.
T.Bober()
Physician Health Program, Ontario Medical Association, 150 Bloor St
W., Suite 900, Toronto, ON M5S 3C1, Canada
e-mail: ted.bober@oma.org
89
90
the right versus the wrong way and more so about right as
an appropriate, skilful or wise practice for living and working [3].
In this chapter, the focus is on two practices, namely skilful intention and skilful speech using narrative examples
drawn from personal and professional experiences and applied practical research. There are several ways to read this
narrative: quickly scanning for themes, slowly savouring
ideas, attending to ones thoughts and reactions, including
ones physical sensations or thoughts of the material being
interesting, boring, pleasant, instructive, uncomfortable or
familiar. My invitation to you (the reader) is to consider the
chapter as an opportunity for personal reflection, a kind of
personal workshop to read, reflect and engage with the information and questions.
Skilful Intention
My older brother had many wonderful qualities including
natural athleticism, strength and speed. As a handsome,
gentle man he enjoyed sketching and history, particularly
Egyptology. He drew Nefertiti and Tutankhamen and told
me about times and places I had never heard of as a teenager. Tutankhamen or more commonly King Tut, became a
pharaoh at the age of nine suggesting that anything is possible. Understandably, I admired my brother or at least until he
began making the rounds of emergency and inpatient admissions. As a young adult, he was diagnosed with schizophrenia. I struggled to feel and understand my own emotions.
In retrospect, the loss of the brother I thought I knew was
heartbreaking. The heartbreak deepened as my brother tried
to come to terms with the effect of this illness on his life,
including how otherspolice officers, nurses, doctors, community workers and I were generally kind and compassionate, but sometimes careless, and on occasion callous.
Around the time of his first bouts with illness, slowly and
subtly, I shifted from admiring, wanting to emulate my brother, to distancing myself from him. Stigma crept its way into
my life and bundled itself up with my sense of loss, fear and
anger. I recall sitting on a bench in a leafy peaceful neighbourhood in Torontos west end. On that day, my brother was
beleaguered and looked unwell. For the first time I noticed
how some people, as they walked near us, averted their gaze
while others made a conspicuous directional change away
from us. I do not know what they were thinking or feeling
but it struck me I had been doing much of this myself, making a significant emotional and behavioural change in direction, moving away from caring to disconnection and distance
without being fully aware of this shift. Over time, l learned
something about myself, even if there are limits to reducing
suffering in the moment, compassion is a basic necessity for
others and oneself. Moreover, mindfulness is helpful particu-
T. Bober
91
Skilful Speech
There is evidence of the development of modern language
and speech extending back thousands of years. Today there
are more than 7000 languages and typically men and women
speak an average of 16,000 words per day, at least in North
America. We have survived in part because we have developed the remarkable ability to effectively coordinate our
thinking, emotions and speaking and this coordination can
be difficult at times.
Are we that easily thrown off our well-intended, skilful
communication skills? For the past 10 years, I have asked
residents attending workshops on physician wellness, resiliency and excellence if they have ever been irritated or annoyed after reading an email or text or regretted what they
have said moments after speaking. Virtually everyone raises
their hand indicating yes. Imagine that, we see a lit flat
screen with some black lines and within seconds, we can feel
irritated, angry or hurt. Words can be hurtful and it is useful
to be aware of the speed of our emotions and reactivity as
well as the accuracy of our interpretations. In this section,
the discussion of skilful speech includes the many ways we
communicate such as, text messages, images and non-verbal
behaviour. This section also considers how we speak to ourselves and how we listen as integral parts of skilful speech.
92
Watzlawick etal. stated that people cannot not communicate [14]. Words and mostly our non-verbal behaviours
communicate a message and meaning. We can express care
and compassion for others as we share information and
make collaborative decisions. We may communicate about
our needs, status, power and control in our relationships. We
may talk lightly about the weather or just shoot the breeze or
gossip or be hostile and divisive.
Salzberg insightfully observed, There are three aspects
to every action or speech. There is the intention behind it,
there is the skilfulness of the action, and there is the immediate response to the action. We tend to ground our identities
only in the third aspect, and to ignore the first two. Yet the
first two are by far the most important. Plus there is also a
long term response to a communication that we also usually fail to take into account [15]. Compassionate patientcentered communication as a form of skilful speech takes all
this into account. A substantial amount of evidence demonstrates that patient-centred communication has a positive impact on important outcomes, including patient satisfaction,
adherence to recommended treatment, and self-management
of chronic disease [16].
In a medical inpatient unit, I, in my role as a social worker, worked with a robust interdisciplinary team to assess,
make recommendations and arrange follow-up services in
the community. As a team, we took pride in patient-centred
care and communication, which was often challenged by the
shorter lengths of inpatient stays and stretched hospital and
community resources. I often felt the pressure of the need
for the inpatient bed by the ER staff and patients waiting in
hallways of the emergency department, as well as knowing
the community services were limited for many discharged
patientsa reality reflected in the look in the eyes of caring,
though overburdened family members.
One of my best teachers in patient-centred communication was a woman who spoke English, quietly and with a
strong Portuguese accent. She, along with her thorough
cleaning skills, was valued as a vital part of hospital infection
control. As she worked her way around a patients room, she
often paused at the bedside, made eye contact, said hello and
asked how the person was feeling. For some patients who
were quite unwell, she leaned in as she listened. She completed her full workload in a timely manner. This woman,
whose name I cannot recall, taught me about the importance
of the pacing and connection in a conversation: brief pause,
relaxing into listening, showing openness to whatever answer came and acknowledging what she heard. All of this
took less than a moment; on some hurried days, that moment
may have been the most validating and therapeutic encounter
the patient experienced in the unit.
Years later, I began to learn about Insight Dialogue, which
furthered my own communication skills. The first three steps
T. Bober
Concluding Thoughts
Late one winter day, the thawing and freezing of the snow
and ice created interesting markings along the Bruce Trail.
Dawson scampered with ease. Being a human with only two
legs, I walked more slowly than usual, particularly on the
steeper sections. Just as I reached the end of the trail and
was about to head back to my car, my footing gave way. My
legs shot straight out, for a moment both feet were pointed
in unison as if I was trying to collect scoring points on the
fall. I had experienced an unexpected, unwanted directional
change as I flew up off the path. A second later, I hit the
ground with a thud, slid downhill and then sensed an ache
in my right side. I took a breath and all seemed intact. The
trail was well marked, I had taken it many a time and I was
dressed comfortably in layers of cotton, wind and water resistant clothing. My intention to be present, safe, at ease and
happy was interrupted when I picked up the pace and let my
mindfulness fall by the wayside during that final stretch of
the hike.
It called for short measured steps, feeling ones footing
underneath; yet, I sped up precisely when I needed to slow
down. The eightfold practices can guide us in taking mindful
and skilful steps. With clear intentions and skilful speech, we
will go a long way for ourselves and those we care for when
unwanted change or interruptions in life or health arise. For a
moment I was annoyed with myself, I paused, and then with
a slight smile, Dawson and I headed home.
References
1. The Niagara Escarpment. Available from: http://brucetrail.org/
pages/show/the-niagara-escarpment. Accessed: 21 March 2014.
2. Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman
B, Mooney CJ, Quill TE. Association of an educational program
in mindful communication with burnout, empathy, and attitudes
among primary care physicians. JAMA. 2009;302(12):128493.
doi:10.1001/jama.2009.1384.
3. Gunaratana BH. Eight mindful steps to happiness. Somerville: Wisdom; 2001.
4. van Boekela LC, Brouwersa EMP, van Weeghel J, Garretsena HFL.
Stigma among health professionals towards patients with substance
use disorders and its consequences for healthcare delivery. Syst Rev
Drug Alcohol Depend. 2013;131(12):2335. doi:10.1016/j.
5. Atzema CL, Schull MJ, Tu JV. The effect of a charted history of
depression on emergency department triage and outcomes in patients
with acute myocardial infarction. CMAJ. 2011;183(6):6639.
6. Center C, Davis M, Detre T, etal. Confronting depression and suicide
in physicians: a consensus statement. JAMA. 2003;289(23):31616.
93
7. National mental health survey of doctors and medical students;
2013. Available from: http://www.beyondblue.org.au/about-us/
programs/workplace-and-workforce-program/programs-resourcesand-tools/doctors-mental-health-program. Accessed: 21 March
2014.
8. Leiter MP, Frank E, Matheson TJ. Demands, values, and burnout
relevance for physicians. Can Fam Phys. 2009;55(12):12245.
Available from: http://www.cfp.ca/content/55/12/1224.full.pdf.
Accessed: 21 March 2014.
9. Epstein RM. Mindful practice in action (I): technical competence,
evidence-based medicine and relationship-centered care. Fam, Syst
Health. 2003;21(1):110.
10. Cameron RA, Mazer BL, Deluca JM, Mohile SG, Epstein RM. In
search of compassion: a new taxonomy of compassionate physician
behaviours. Health Expect. 2013;1:114. doi:10.1111/hex.12160.
11. Gilbert P. The compassionate mind: a new approach to life's challenges. Oakland: New Harbinger; 2010.
12. Neff KD. The science of self-compassion. In: Germer C, Siegel
R, editors. Compassion and wisdom in psychotherapy. New York:
Guilford Press; 2012. pp.7992.
13. Fronsdal G. The issue at hand: essays on Buddhist mindfulness
practice. 4th ed. Redwood City, CA: Insight Meditation Center;
2008. http://www.insightmeditationcenter.org/books-articles/theissue-at-hand/. Accessed 21 March 2014.
14. Watzlawick P, Beavin-Bavelas J, Jackson DD. Pragmatics of human
communicationa study of interactional patterns, pathologies and
paradoxes. New York: W. W. Norton; 1967. pp.2952 (Chapter 2,
Some tentative axioms of communication).
15. Right speech with Sharon Salzberg. The journalist and the Buddha:
seeing the way it is now; 2007 Oct 2. Available from: http://deadlinebuddhist.typepad.com/the_deadline_buddhist/2007/10/whyjournalis-1.html. Accessed: 21 March 2014.
16. Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patient-centred care. Health Aff. 2010;7:1310
8. doi:10.1377/hlthaff.2009.0450.
17. Kramer G. Insight Dialogue: the interpersonal path to freedom.
Boston: Shambhala; 2007.
18. Jamison, L. The empathy exams: essays. Minneapolis: Graywolf;
2014.
19. Leung ASO, Epstein RM, Moulton CAE. The competent mind:
beyond cognition In: Hodges BD, Lingard L, editors. Reconsidering medical education in the twenty-first century: the question of
competence. Ithaca, NY: ILR; 2012. pp.15576.
20. Moulton CA, Regehr G, Lingard L, Merritt C, MacRae H. Slowing
down to stay out of trouble in the operating room: remaining attentive in automaticity. Acad Med. 2010;85(10):15717. doi:10.1097/
ACM.0b013e3181f073dd.
Ted Bober, MSW, RSW, is the Associate Director of the Clinical Services at the Ontario Medical Associations Physician and Professional
Health Program (PHP). The PHP works to prevent and mitigate occupational stress, mental health or substance-abuse-related problems in lives
of physicians while promoting well-being and excellence. He has more
than 25 years of experience as a clinician, educator and administrator in mental health and addiction services. Mr. Bober has maintained
a mindfulness practice since the early 1990s and teaches mindfulness
practices to medical students and physicians. The PHP is located in
Toronto, Canada.
17
Close Encounters
Charlotte
I first met Charlotte last year; she was referred by her general
practitioner (GP) who wanted me to assess the need for diuretics. Both the GP and her endocrinologist contended that
she should stop taking these dangerous medications, but she
disagreed. Charlotte had been a pretty heavy smoker; she
95
C. Isnard Bagnis
96
Lisa
Lisa stepped into my office with her son, a tall obese young
man in his twenties presenting with a severe skin disease
affecting his face and hands. Both independently weighed
more than my scales could quantify. Lisa, with a long story
of renal stone disease, recently had been treated for bilateral
stones by endoscopic ureteroscopy. She was referred to me
for a medical approach to her stone disease to prevent recurrence. Comorbid for severe depression she took medications
to control anxiety, sleep disturbance, and depression. Moreover, she was being treated for diabetes and hypertension.
I rapidly concluded that her urinary stones were from uric
acid and explained to her how to prevent stones from recurring. I indicated that we could meet together with our dietician to suggest ways to increase the volume of her drinking,
decrease her salt intake, and increase her bicarbonates input
to decrease urinary pH. In order to improve, she was offered
to either take ten large pills or to drink 1.5L alkaline drinking water a day. Given that we have been running a renal
stone clinic for some time, experience has shown how difficult it is to change dietary and drinking habits, along with
related behaviors. We typically offer a year-long program
to our patients and explain that time is necessary to change
their lifestyles. Patients are followed by the nephrologist, the
dietician, and a nurse and are offered individual and group
educational sessions.
The first few times we met, Lisa appeared to be totally
disconnected, listening to what I was saying but constantly
claiming that it would be impossible for her to follow my
97
C. Isnard Bagnis
98
when fulfilling the many tasks listed in my agenda. As a person who could hardly say no to anyone at work (consistent
with the notion I held that a physicians job involved taking
care of everyones needs), I realized that by discriminately
choosing my engagements I became better able to attend to
them and importantly, I experienced a renewed sense of satisfaction.
Being more mindful has transformed my medical practice. More openness and loving kindness in my clinical approach enables a therapeutic alliance to be developed. Without overlooking the scientific aspects and evidence-based
medical reasoning, mindful care of our patients is the key to
personalized holistic care.
Recently, I offered a pilot course for medical students;
their feedback was encouraging. This suggests that mindful
medical practice may be included as a part of the medical
curriculum in France, as it is elsewhere in the world [2].
References
1. Khaldi C. Apprendre apprendre soin de soi. Rapport final enqute
MBSR. Paris: Universit de Rouen; 2013.
2. Dobkin PL, Hutchinson T. Teaching mindfulness in medical
school: where are we now and where are we going? Med Educ.
2013;47:76879.
18
Richards Embers
Elisabeth Gold
I write this on the winter solstice, the darkest day of the year,
here on the cusp of turning once again toward the light. It is
a 1-year odyssey of coming home, of rekindling fire from
embers. Loving intention and attention stir the embers until,
at long last, flames:
The first duty of love is to listen. [2]
Attention is the rarest and purest form of generosity. [3]
E.Gold()
Family Medicine and Division of Medical Education, Dalhousie
University, Medical Arts Building, 5880 Spring Garden Road,
Suite 308, Halifax, NS B3H 1Y1, Canada
e-mail: elisabeth.gold@dal.ca
99
100
E. Gold
18 Richards Embers
101
102
E. Gold
into silence. We continued to do mindful awareness meditation together for a few minutes at the start of our sessions.
Learning to be quiet, to be still, to say no, and to change his
pattern of rescuing others, Richard realized that he shapeshifted emotions to please others. He now started to build
healthy boundaries rather than trying to fix others, manifesting true compassion which includes self-compassion. He
was no longer responsible for making everyone happy, his
typical role in his birth family. Richard let go of this burden
and, when needed, said no. This dance we all need to learn,
the setting of healthy boundaries.
After the dawn, Richard committed himself to daily formal mindfulness practice. He described letting go of excess
baggage, other peoples stuff. He set the intention to listen
mindfully to others, to notice his wandering mind, and to
come back to others because people need to be heard. He
chose to listen more, to speak mindfully with more ventilation, and to comment less on others experiences. I appreciated Richards emerging wisdom, and resonated with his
view and aspirations.
After the dawn, Richard recognized the importance of the
bodyembodied mind, or bodyfulness. He ate smaller
portions with awareness, and was fundamentally befriending himself. He began to deal with emotions without eating
them. He felt a deeper experience of body, lighter now and
able to move forward.
After the dawn, Richard described his experience as a
veil lifted, a hibernating bear wakes. He cried much less
often in sessions, although still teary at moments when tenderhearted. It was fall now, and there were still tissues on
the table, several boxes later. I looked past Richard at the
moody late-autumn sky and felt glad that Richards season
had transformed.
After the dawn, Richard worked part time as well as volunteered. He enjoyed an array of friends and family, and
overcame isolation by reconnecting. He set healthy boundaries with assertiveness rather than the old habitual pattern of
people pleasing. He once again enjoyed swimming, walking,
yoga, and painting.
After the dawn, Richard recognized his resistance as part
of the mindful journey. He consciously set the intention not
to skip steps, to grow patient. He realized, Nothing outside
of me can do it. He took responsibility on the path of learning to be an adult. Richard knew there was a place for him in
this world and shared with me that he felt love in each cell.
He knew in his heart he was a good person, not a patient, client, consumer, or a case.
After the dawn, Richard asked for and offered a hug when
leaving. We are the same, on this human trek requiring courage and humility. We are unique, equal, and different, dancing to the same music: love and loss, fear and bravery, fortitude and fatigue, avoiding or approaching, closing or opening, birth and death in each moment, and grasping/clinging
18 Richards Embers
103
this spark grows bigger and biggerand as it grows
my vessel becomes lighter and lighterfreer and freer
ready to fly
way up high.
I am home once again.
References
1. Forster E.M. Howards end. Epigraph. London: Edward Arnold;
1910.
2. Tillich P. http://www.brainyquote.com/quotes/quotes/p/paultillic114351.html. Accessed 2 April 2015.
3. Weil S. http://www.wisdomquotes.com/quote/simone-weil-9.html.
Accessed 2 April 2015.
4. Santorelli S. Heal thy self, lessons on mindfulness in medicine.
New York: Bell Tower; 1999. p.20.
5. Trungpa C. The sanity we are born with. London: Shambhala;
2005. p.161.
6. Oliver M. Owls and other fantasies: poems and essays. Boston:
Beacon Press; 2003. p.27.
7. Verghese A. Cutting for stone. Toronto: Vintage; 2009. p.486.
8. Neff K.http://www.self-compassion.org/the-three-element-of-selfcompassion-2. Accessed 2 April 2015.
9. Salzberg S. Real happiness, the power of meditation. New York:
Workman Publishing Company; 2011. p.108.
Elisabeth Gold MD, is a family physician and mother, who currently
works as a psychotherapist, counselor, and medical educator in Halifax,
Canada. She is an associate professor in Family Medicine and the Division of Medical Education at Dalhousie University where she engages
in tutoring, tutor training, and communication skills facilitation. Dr.
Gold is passionate about mindfulness (since 1975), music (plays the
clarinet), writing, whole food, and is continually amazed by mutual
teaching and learning.
19
Joyce Schachter
J.Schachter()
Harmony Health, Ottawa Hospital, 152 Cleopatra Drive, Suite 101,
Ottawa, ON K2G 5X2, Canada
e-mail: jschachter@toh.on.ca
105
106
Its not going to fall down on the road and it doesnt turn
into cancer.
I was worried about that, she smiled as her shoulders
dropped and she exhaled. She dried her tears. I have learned
that these two fears, barely contained, are often unspoken
and best addressed at the first visit.
Will it get worse?
Todays exam is a snapshot of you in time, I said. If it
progresses, it typically takes months or years. Its moderate
now, and this may be the worst it ever gets but its unlikely to
get better. Youve noticed it more over the past couple years.
Hows your body-image and self-esteem doing? She shook
her head, crying new tears, dabbing her eyes.
Its completely understandable. We dont always meet
our own expectations of ourselves, I said, whether or not
those expectations are realistic. She smiled and blew her
nose. We engaged in a brief conversation on the prevalence
of these problems, and I mentioned available treatments, including doing nothing. Then I paused and checked in again.
Too much detail about any particular modality would leave
her emotional reaction behind and with it any therapeutic
engagement. In elective gynecological surgery, we have the
luxury of a mindful pause, when required. When the patient
cries, becomes indignant, refuses treatment, challenges my
expertise, or repeats questions previously answered, it is
time to rest and let the situation simmer.
You mean I can leave it alone? She brightened.
Its not dangerous to live with it the way it is. It wont
make you sick by staying there. It can lead to other problems
like not exercising or socializing, or withdrawing from sex,
I said.
But is it safe to wait?
Reassured about the pace of the natural history of these
conditions, she rejected the idea of surgery and was keen to
pursue limited intervention with pelvic floor exercise, and to
return for reassessment in 6 months.
This was a good place to pause and allow her time to digest information. Patients often react to a diagnosis of prolapse with fear and express a sense of inhabiting a foreign
body sometimes for years. The central tendon where pelvic
floor muscles insert, the perineal body, is attenuated, weakening the supportive root of the pelvis. Body image created
through the senses, including proprioception, is reconfigured with negative or abnormal contributions to a new selfconcept with physical and emotional impact. This reinforces
concomitant lack of exercise and sexual disengagement
which may have adverse effects on wellness.
Cycling through feelings of fear, anger, and powerlessness may occur with a sense of loss of control, in this case
over anatomy and self-concept. The ease of navigating the
transition to resolution depends on anxieties, coping skills,
pain/discomfort tolerance, values, social support, and articulating this in a supportive environment. Mindfulness has
J. Schachter
107
108
J. Schachter
Three months later, Barbara returned for her final checkup. Her bladder and bowel function were normal, she felt
support in her vagina, and her sex life had improved.
Why didnt I do this before? I cant believe the huge
difference its made in my life. I feel normal again. I dont
have to think twice about doing an exercise class, and sex
is so much better. Its liberating. Im telling all my friends,
she said, echoing a common sentiment I have heard from
many women after reconstructive surgery. She thanked me
profusely and hugged me, one of the many reasons I find my
job satisfying.
It seemed that Barbara accurately assessed the importance of travel in her decision but may have overestimated
the importance of sex. She had a strong relationship with
her husband and delaying her surgery to enable travelling
spoke volumes about what her true priorities were. Barbaras
sexual identity was a vital part of herself, but a lower priority
compared to enjoying leisure time and companionship with
her partner. The hierarchy of these values is often recognized
at a critical decision-making point or in hindsight.
Over a 2-year period from initial consultation to postoperative checkup, Barbara eventually chose surgery. What determines the timing of the decision-making process and why
do some patients live with significant discomfort for prolonged periods, while others complain with the emergence
of the first sensation suggesting that something is awry? I
regard this as an analogue to pain tolerance, distributed over
a bell curve similar to other human characteristics. Along a
decision-making path, there are a number of exit points that
may match treatment to needs. Patients may choose conservative therapy and return for surgery years later. I encourage
patients to weigh in on their preferences and treatment goals
to resolve their problems with practical and realistic solutions. Patients presenting with recurrent prolapse say they
sought help earlier because they recognized the symptoms
and chose to act sooner than the first time. Repetition reinforces learning and facilitates adaptation.
109
110
wants surgery, I guide a cursory tour through relevant considerations to ensure they have been adequately reviewed.
Rewinding and replaying through nodes in the decision process creates opportunities for questions, exchanges of useful
information, and explores what the patient may not realize
she did not know, or think to ask. Mindfulness helps fill information gaps to enable informed consent, adjust expectations of outcome, and lessen the tendency toward blame regarding complications. When a patient comes to surgery, and
unfortunately sustains an adverse event, she needs to be able
to remember why she took the risk in the first place. Creating
a story that links patients subjective experience with evidence-based data and experienced medical judgment allows
her to understand its impact on her life more tangibly. Pausing, rewinding, listening, mirroring, confirming, accepting,
and proceeding are mindful ways of ensuring patient and
caregiver move together as a team through the therapeutic
process. Decision aids have also been helpful in this regard
[16]. Mindfulness places equal importance on each step in
decision-making with adjustments to suit the patients needs
and desires at any stage. Action then follows naturally, including living with conditions exactly as they are, sometimes
even with acceptance and grace.
References
1. Kabat-Zinn J. Wherever you go there you are: mindfulness meditation in everyday life. New York: Hyperion; 1994.
2. Kabat-Zinn J. Full catastrophe living: using the wisdom of your
body and mind to face stress, pain and illness. New York: Delta;
1991.
3. Santorelli S. Heal thy self: lessons on mindfulness in medicine.
New York: Bell Tower; 2000.
4. Hahn TN. Peace is every step: the path of mindfulness in everyday
life. New York: Bantam Books; 1992.
5. ACOG Committee Opinion. Surgery and patient choice: the ethics
of decision making. Obstet Gynecol. 2003; 102(5 Pt 1):11016.
6. Barry MJ, Edgeman-Levitan S. Shared decision makingthe pinnacle of patient centered care. NEJM. 2012;366:7801.
7. Engle DE, Arkowitz H. Ambivalence in psychotherapy: facilitating
readiness to change. New York: Guilford; 2006.
J. Schachter
8. Miller WR, Rollnick SR. Motivational interviewing: preparing
people for change. 2nd ed. New York: Guildford; 2002.
9. Al-Badr A. Quality of life. Questionnaires for the assessment
of pelvic organ prolapse: use in clinical practice. Urology.
2013;5(3):1218.
10. Schurch B, Denys P, Kozma CM, Reese PR, Slaton T, Barron R.
Reliability and validity of the incontinence quality of life questionnaire in patients with neurogenic urinary incontinence. Arch Phys
Med Rehabil. 2007;88(5):64652.
11. Gee RE, Corry MP. Patient engagement and shared decision
making in maternity care. Obstet Gynecol. 2012;120(5):9957.
12. OConnor A, Rostom A, Fiset V, Tetroe J, Entwistle V, LlewellynThomas H, Holmes-Rovner M, Barry M, Jones J. Decision aids for
patients facing health treatment or screening decisions: a Cochrane
systematic review. BMJ. 1999;319(7212):7314.
13. OConnor AM, Drake ER, Wells GA, Tugwell P, Laupacis A,
Elmslie T. A survey of the decision-making needs of Canadians
faced with complex health decisions. Health Expect. 2003;6(2):97
109.
14. Elwyn G, OConnor A, Stacey D, Volk R, Edwards A, Coulter A,
etal. The international patient decision aids standards (IPDAS)
collaboration. Developing a quality criteria framework for patient
decision aids: online international Delphi consensus process. BMJ.
2006;333(7565):417.
15. OConnor A, Wennberg J, Lgar F, Llewellyn-Thomas H,
Moulton B, Sepucha K, Sodano A, Staples King J. Towards the
tipping point: accelerating the diffusion of decision aids that help
patients to weigh benefits versus risks. Health Aff. 2007;26(3):
71625
16. Stacey D, Lgar F, Col NF, Bennett CL, Barry MJ, Eden KB,
Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Thomson
R, Trevena L, Wu JHC. Decision aids for people facing health
treatment or screening decisions. Cochrane Database Syst Rev.
2014 (1). Art. No.CD001431. doi:10.1002/14651858.CD001431.
pub4:14.
Joyce Schachter MD MSc FRCSC is an assistant professor of obstetrics and gynecology in the Division of Urogynecology and Reconstructive Pelvic Surgery (URPS) at the University of Ottawa, in Ottawa,
Canada. She is the program director for post-graduate fellowship
training in URPS, manages a full-time clinical practice, and teaches
residents and medical students. She serves on the Physician Health and
Wellness committee at The Ottawa Hospital. Mindfulness is a key element in Dr. Schachters practice. According to Dr. Schachter, mindful
surgical planning empowers and motivates patients to determine elective interventions at their own pace and increases patient satisfaction
with outcome.
20
111
K. Sogge
112
&RPPLWPHQW %HKDYLRXU
&KDQJH3URFHVVHV
'RPLQDQFHRI
WKHIXWXUHRU
SDVW
3UHVHQW
PRPHQW
DZDUHQHVV
/DFNRIFODULW\
RUFRQWDFW
ZLWKYDOXHV
([SHULHQWLDO
$YRLGDQFH
3V\FKRORJLFDO
,QIOH[LELOLW\
&RJQLWLYH
)XVLRQ
&ODULW\
FRQWDFWZLWK
YDOXHV
$FFHSWDQFH
:LOOLQJQHVV
3V\FKRORJLFDO
)OH[LELOLW\
/DFNRIDFWLRQ
RULPSXOVLYLW\
$WWDFKPHQW
WRWKHVWRU\
RIRQHVVHOI
&RPPLWWHG
$FWLRQV
'HIXVLRQ
6HQVHRI6HOI
DV2EVHUYHU
$FFHSWDQFH 0LQGIXOQHVV
3URFHVVHV
Fig. 20.1 The acceptance and commitment therapy model. This figure, also known as the Hexaflex reflects the major dimensions of the
psychological flexibility model developed by Stephen Hayes etal. as
part of relational frame theoretical foundations of acceptance and com-
The session: I am seated in my worn leather chair in my office in a spacious, formerly grand home renovated to a dozen
offices, in Ottawa, Canada. I am between patients savoring
those precious minutes between psychotherapy sessions
where I spend a few moments reconnecting with my breath
and body in the present. I let go of all that has come before,
and with a few deep breaths and maybe a few stretches on
the floor, ready the earth of my body and mind to receive the
new seeds of the patient who will be settling in across from
me in the coming session. I notice there is a slight draft from
the sharp Canadian winter wind moving through the old window with distorted panes to my right. I wonder if I should
block it, and then decide that it is having the helpful effect
of keeping me alert and fresh and I decide to leave it alone.
Relaxing into the chair, I intentionally place my feet on the
floor. I feel the thick, old carpet beneath my feet. I draw a
long in breath and feel the oxygen fill my lungs, expand my
rib cage, lift my chest. My fingertips sense the coolness of
the arms of my chair. The room smells like wood smoke,
a remnant from the ancient fireplace behind me. I drop my
shoulders, rolling them ever so slightly outward and sliding
my scapula down my back. Extending the crown of my head
113
114
sion for her, her family, and her daughter welling up in me.
Perhaps analysis and reason giving are not what is needed
here? However, my problem-solving mind is already at work
in the consultation room. She quickly produces the latest
stack of test results, psychiatric evaluations and assessments,
seeking professional advice to solve the pressing problem of
her daughter. I feel terror in the room. I listen carefully to the
litany of diagnoses, case formulations, and failed treatments.
Understanding the need to know and the felt pressure to
explain and analyze pain, while noting ruefully to myself that
my mind shares the human bent towards fixing and explaining, was I not doing exactly the same thing to myself just a
few minutes ago when this patient entered to the room? I
listen intently for some time, modeling presence and holding
of all this thinking with some lightness, questioning perhaps,
with this stance of not reacting to the daunting list of clinical
problems to be addressed, both the existence of diagnoses
as real entities, and the necessity of being stuck in suffering because of a diagnosis. When my lovely patient pauses
to breathe while in the story of fear, frustration, and agony
left in the wake of serious mental health symptoms, I say, I
think I am getting the picture. So I am hearing that you have
tried everything. I hear how much you want your daughter to
have a good life, and I both hear and see that you are feeling
terrified at the thought that a good quality of life and hopeful
future does not seem possible for your daughter with her current symptoms, the confusing messages about medication,
about diagnoses, about best treatment options, about school.
You are concerned for her, as any good parent would be. As
a parent I identify with your terror! We will discuss your
daughter, and I am confident that I have some ideas on how
to be with this difficult situation in a more workable way.
However, can we just back up for a second and have you
describe what happened right there a few moments ago?
Right where? she asks.
When I noted that you were apologizing and minimizing
all the inconvenience just to find my building. I noticed your
eyes changed or something crossed your face and I was curious about what was going on with you. Then when I noted it
you quickly moved to the next topic. What did you experience there? I respond.
Reflection: In the mindful practice of change in psychotherapy, we clinicians and our patients endeavor to drop our
habits of avoiding or controlling our experience, and seek to
just explore what is, without judgment. In this way, together
we may discover new information that we may have been
pushing out of our awareness, and we may tap into previously ignored resources to expand our range of options for
skillful response to challenges that initially may have seemed
overwhelming or intractable.
The session: She takes a sharp inhalation. Ah yes, I feel
so selfish. This is supposed to be about my daughter. Hmm
(tearing up) right there I felt a surge of grief. I feel like I am
K. Sogge
115
116
K. Sogge
a pretty good day. We came downstairs all dressed and ready to
go. Then it happened. I could see her breathing pick up. I could
see her starting to pace.
That clinician mind inherent in me, always eager to anticipate, mistakenly chimes in, and before I can stop, my lips
mouth Uh oh.
Ah ha! crows my patient victoriously, jumping from her
chair mischievously and pointing at her hypocritical clinician, you did the same thing I USED to do!
Nailed me, I admit with a secret smile of delight. She
is finding freedom I think to myself, What did you do instead? I ask out loud, genuinely curious.
Well I noticed that when she starts to pace my mind
starts to race. I start anticipating another big fight. This time
I didnt do that. Instead of anticipating what I felt was coming, I focused on breathing. I used that 4-4-8 breath. And I
said to myselfI can see she is going down the rabbit hole.
I am not going with her today.
Wow! I clap my hands, again without thinking about it.
You are NOT going down the rabbit hole today.
Thats exactly it. So I didnt go there, she exclaimed. I
said to her Honey I can see this brings up anxiety. I promise
you we are not gone for long. This is a sign that we trust you.
You know that if you really need us we will come home.
Lets do this hon. She didnt like it. The yelling and accusations started, but I didnt react with anger or with hurt like I
have in the past. I could actually feel some more compassion
for her, but at the same time I felt weird, like I was being
more distant.
Hmm thats a thought, I reflect.
Yes and I also had the thought there that maybe this is
being a really bad mother. It is so hard not to believe that
kind of thing, particularly when people who are supposed
to know better than I do imply that I am. She laughs with
sadness. It is a different kind of mothering for sure. It isnt
the same kind of compassion I had for her when she was
a toddler and she skinned her knee and I could scoop her
up in my lap and comfort her and make it all better. It is a
cooler more distant kind of compassion, that lets her know
I can trust her, that she can trust me, and that we are in this
together but
Unable to resist the thoughts going through my mind, I
say Ah, and it includes you doesnt it? You get to be there
but be separate, to be with her but not join her in the rabbit
hole.
Yes that is it! I am here too. I am a mother and a person
too.
That is brilliant. How did it feel? I question.
Terrifying!
And what actually happened?
Well we went out. Just got in the car and went. And yes,
it was hard to be there knowing she might need us. I was
checking my phone all the time; there were a lot of texts. I
had her older sister check in on her. I had to hand the phone
to her father because the texts like I hate you dont get to
him the way they do to me. But we made it through most of
the night and we were home by ten.
And what did you notice?
I noticed that when we got home she hadnt cut. She
took a while to fly by, and then she came and joined me on
the sofa. She cuddled up with me and I noticed she actually
made ME a cup of tea when she made some for herself this
time, which just floored me. I think I can see way through
this.
Reflection: Within me I ask myself: how do we get our
hands, feet and mouths to serve what our hearts contain?
For myself and for my patients, I notice that impulsivity or
inaction are both ways that we get stuck. I intend to support patients in reconnecting to important values, and finding
ways to embody them even in very difficult circumstances is
a way to create vitality and mindful engagement even in the
midst of pain. If engagement is bringing the best in oneself
to a situation, then I intend to help my patient shift from inaction or impulsivity to full engagement, compassion, and
committed values-based action in the face of her painful habitual interactions with her daughter and herself.
The session: Here is my patients second story.
So in my work I get to see a lot of people who are very knowledgeable. They have to solve a lot of problems. They are the top
in their field. This week was pretty tough, because my daughter
has started back to school, so I have been on call basically every
minute of the day. Some days she has made it and some days she
hasnt, but we are doing our best to balance compassion with
this whole skillfulness thing and letting her know that thoughts
are not facts, that emotions are not harmful. So I am exhausted
from doing this all week, staying out of the rabbit hole so to
speak.
Then I am asked to come in and consult with a situation where
all the top brass are there, all in 100% agreement on what must
be done, but the business client doesnt want to follow the recommendations. They are all bringing in articles, studies, the best
arguments to convince the business client that it is absolutely
essential that he follow our recommendations. They are starting
to get angry, are talking about calling in lawyers to force the client to follow their recommendations. Im sitting there listening,
and I realize that it happens to everyone. I am sitting here after
dealing with a major blowout with my daughter this morning,
and I realize it. They are all going down the rabbit hole too.
They have their ideas, their plans, their expertise, their knowledge about what is what, and it doesnt work. It doesnt work,
because they cant see through all of their expertise to who this
person really is. The pattern they are all caught in is the same
pattern I used to get caught in, and still sometimes get caught in,
but I recognize it and get off the train a little earlier now.
So I ask if I can talk to the client independently. I go in, and
all I see is fear. The thing they are asking him to do is contrary to
the way he sees himself, his world, his way of doing things. He
is trying to tell them that and they are not listening. When they
attack and judge him for his view he knows they are attacking
and judging him. Hes not stupid. So he just pulls back. So I sat
with him, listened to him, and then I said, You know, you are
absolutely right. You are the one who has to decide for yourself.
117
You deserve all the information you need in order to make the
right decision for yourself. What do you need? He wanted to
talk to someone else who wasnt part of our organization. So I
arranged it.
And this is the story about how you taught others about not
going down the rabbit hole, I lean back and grin.
Yes. No wonder all of those professionals implied I was
a bad mother, that there was something wrong with our family. It was the only thing they could think of given that they
needed to eliminate symptoms and only had that story to tell
about us. I have just decided that our family cant do that.
My daughter is a human. We are humans. We are good people. This is terrible what has happened, but we dont need to
go down the rabbit hole with everyone else. We can just be
with it in this kind of limbo and respond in a way that admits
that we are not in control of what happens. We are only in
control of how we respond to what happens, and to what we
believe is important. So that is my story for you, yes, about
not joining everyone in going down the rabbit hole.
Reflection: I feel such joy when I see my patients find
a way to vitality. I feel sympathetic joy, when I see this patient, or any patient, find a pathway to contact what will
bring them vitality, even if we cannot solve or eliminate the
problem that initially brought them to call a psychologist and
enter psychotherapy. The story my patient and I are writing
together is not empty of pain, or even of suffering, but as I
see her letting go of thoughts, having compassion, contacting
the present moment, reconnecting to her values, I can sense
the vitality in her growing. Her story, our story, becomes a
story of movement from numbness and disconnection from
the deepest longings of the heart in the presence of pain, to
a story of heart-filled active engagement, compassion, and
committed actions towards values even while pain is present. Together we are in a state of vitality. Together we enter a
moment of wholeness.
The session: In one of our last sessions, my patient arrived to announce
My daughter has fired her mental health team.
I am in good company there, I think and then I decide
to say it, which makes my patient laugh.
And she has returned to classes full time, and is painting
again. Unfortunately she kept me up late last night freaking
outbut the freak out was a good thing. She was freaking
out about getting all her credits in time for applying for university.
It is a bit miraculous for me to imagine that this could be
happening. It makes me a bit anxious to tell you the truth,
she admits.
What is the anxiety about? I query.
That it is too good to be true. Something terrible must be
about to happen, my patient laughs.
118
References
1. Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance
and commitment therapy: model, processes and outcomes. Behav
Res Ther. 2006;44(1):125.
K. Sogge
2. Ost LG. Efficacy of the third wave of behavioral therapies: a systematic review and meta-analysis. Behav Res Ther. 2008;46(3):296321.
3. Powers MB, Zum Vorde Sive Vording MB, Emmelkamp PMG.
Acceptance and commitment therapy: a meta-analytic review. Psychother Psychosom. 2009;78(2):7380.
4. Ruiz FJ. A review of acceptance and commitment therapy (ACT)
empirical evidence: correlational, experimental psychopathology, component and outcome studies. Int J Psychol Psychol Ther.
2010;10(1):12562.
5. Hayes S, Strosahl K, Wilson K. Acceptance and commitment therapy: the process and practice of mindful change. New York: Guilford; 2012.
6. Seigel D. The developing mind. New York: Guilford; 2012.
Kimberly Sogge Ph.D., C.Psych. is a clinical health psychologist in
private practice in Ottawa, Canada, where she offers third-wave psychological interventions (acceptance and commitment therapy (ACT),
mindfulness-based cognitive therapy (MBCT), dialectical behavior
therapy (DBT), and mindfulness-based relapse prevention (MBRP)),
and mindful self compassion (MSC) specializing in work with physicians and other high-performing professionals. She is a Class of 2016
member of the Mindfulness Yoga and Meditation Teacher training program at the Spirit Rock Vipassana meditation in California. Dr. Sogge
has designed and facilitated mindfulness-based interventions since
2004, when she co-taught the first mindfulness-based stress reduction
(MBSR) course offered in the primary care clinics at Student Health
Service of the University of Texas at Austin. She has taught MBSR
to Desert Storm veterans arts-based mindfulness courses to pediatric
patients and families and most recently mini-MBSR courses to faculty and residents at the University of Ottawa, Faculty of Medicine. Her
current mindfulness practice includes sculling on the Ottawa River and
trail running in the Gatineau hills of Quebec.
I Am My Brothers Keeper
21
Dennis L. Dobkin
D.L.Dobkin()
Waterbury Hospital Health Center, Waterbury, CT, USA
e-mail: ddobkinmd@cawtby.com
trust us, or simply did not have the skills to become part of
his own solution.
As I talked to him, another story was percolating in the
background of my mind. My story of Maurices behavior
was drowning out his story. As he told me that he could not
afford the medications and was still drinking, I could not help
but think that his ultimate prognosis was quite poor because
of his attitude. I reasoned that if he could find the money for
alcohol, he could afford medications as I had referred him to
a clinic where medications were quite inexpensive. As I saw
it then, he had not even bothered to obtain these medications.
I was polite but frank. I unconsciously got into my lecture
mode. I told him that if he did not make the effort to take
care of himself, then he would be unlikely to get better and
faced a life of recurrent hospital admissions and poor health.
I thought that his failure to try to care for himself was his
obstacle and that there was little I could do. I could advise
him but I could not force him to care for himself. I silently
blamed him for his circumstances which allowed me to abolish my responsibilities and, for that matter, any remnants of
empathy that remained. I experienced an element of pity but
as far as I could see, it was not my fault and there was little
I could do. I would fulfill my obligations by going through
the motions and leave it up to him to be accountable for his
health.
As predicted, the next several years were punctuated by
recurrent admissions for heart failure with poorly controlled
blood pressures due to non-compliance. I saw him many
times thereafter despite that he was a no pay and hoped the
best for him with little belief that he might get better. I have
dealt for many years with alcoholics and others with drug
problems and did not have much faith in their ability to help
themselves or in my ability to change their course.
I had grown up in a secular Jewish family where compassion for all people was part of our cultural heritage. From an
early age, I knew that being a physician was my aspiration.
I believed that being a physician afforded one the opportunity to heal the sick and change lives. As a young doctor
many years ago, I promised myself to care for people from
119
120
D. L. Dobkin
21 I Am My Brothers Keeper
One last concept guided me as well. The teaching of noself is a difficult notion to comprehend, especially in the
West where the liberal democratic ideal is focused on the individual. This tends to separate people and ignores the basic
connections that we all share as humans. One of the meditations that enabled me to overcome this was the practice of
exchange of self. One mentally identifies with the other
and notices how he feels as a way of developing empathy.
Incorporating this particular sitting meditation practice allowed me to apply it in everyday life.
Recently, I saw Maurice again after a several-year hiatus.
He had just gotten out of jail and was in mild heart failure,
quite hypertensive, and not taking any medications. He was
with his brother who seemed to care about him. He physically looked the same but my view was now quite different.
Being more mindful, I listened to his travails about jail, his
struggles with alcohol and how he was searching for a path
to recover. I activated my meditation skills and applied them
to the clinic setting. I shared his disappointment in himself. I
felt compassion for this young man whose life was not going
well. I could not tell if he had changed or I had changedbut
it did not seem to matter. I felt more involved and somehow
more hopeful. I was able to exchange places with him and
subsequently I viewed him differently.
I no longer thought that he did not care for himself or
that there was little I could do. I did not focus on his bad
121
22
in front of me without a known diagnosis, with no prior records to review, just a person with a story and symptoms
and vital signs and clues. I walked into each room with a
stethoscope around my neck, and these strangers trusted me
to ask intimate questions, to lay hands on their bodies, to
discern the source of their pain, and to plan the course of
their treatment. Suddenly, all the pieces of my educational
path clicked into placeall the basic science and pathology
lectures and physical exam techniquesthis is where I could
see putting it all together. I loved the mystery of it all, the
problem solving, the teamwork, the energy and pace, and the
lulls of broken ankles and toothaches punctuated by the heart
attacks and traumas.
And 15 years later, I still love italthough like all longterm love affairs, the nature and dynamics of the relationship
have changed. In a common scenario, my professional evolution was jump-started and cemented by a personal crisis.
Unlike other personal experiences, this event was so fraught
with life-lesson metaphors that it, in retrospect, is almost
laughable. This touchstone occurred at the end of my second
year of residency. Following the absolutely correct advice to
attend the most rigorous residency program possible, I was
training at a level 1 trauma center, seeing the sickest of the
sick, treating the worst injuries imaginable, and learning from
the best clinical doctors and physician mentors in the world
of emergency medicine. Having attended a medical school
that valued humanism in medicine, championed service as
a calling, and taught empathetic communication skills, I felt
comfortable developing quick rapport with patients. My time
and energy in those early years were dedicated to mastering
procedural and diagnostic skills. I was also focused on learning the art of using all my senses, knowledge, and intuition
to answer the most fundamental and difficult question of any
clinical encounter in the ERis the patient sick or not
sick? The irony is that I had lost the ability to know this
about myself.
I completed my 2nd year of residency with a 12-hour
night shift for the record booksmultiple traumas, critical
patients with pneumonias and strokes, and hours spent quiet-
123
124
T. Coles
125
Patient Encounters
Mr. Y was brought in by the police, his wrists in handcuffs,
one hand wrapped in gauze. A cut to the palm during his
arrest had demanded a pit stop to the ER. I examined his
hand, determined that the injury was superficial without injury to the tendons or nerves or blood vessels. The wound
was cleaned and I placed his palm under a sterile blue towel.
His now uncuffed hand lay still under the bright light as I
numbed the area around the laceration, which was long but
relatively straight. I took a moment and imagined the movement of my hand, piercing of the skin with the needle, pulling, and knotting the suture. He followed my instructions to
stay completely still. As I began stitching, I had a fleeting
thought about the violence that this hand might have done,
the crimes it may have committed. Then the quiet monotony
of suturing took over. When I was finished, 15 even stitches
126
T. Coles
23
Lifeline
Carol Gonsalves
An Uncomfortable Question
Probably not unlike most students accepted to medical
school, I rarely had cause to question my knowledge of myself and the workings of my mind until my clerkship year.
I was academically successful, had strong social supports,
and considered myself to be a well-rounded individual. If
asked who I was I could answer easily with a litany of
roles and extracurricular activities that I believed made me,
me. I had encountered some hardships during my young life,
but nothing that made me question who I was or my roles.
With the advent of clinical care, my very definition of what
I was, who I was, was being challenged as I encountered for
C.Gonsalves()
Department of Medicine, Division of Hematology, Ottawa Blood
Disease Centre, Ottawa Hospital, 501 Smyth Road, Box 201A,
Ottawa, ON K1H 8L6, Canada
e-mail: CGonsalves@ottawahospital.on.ca
127
C. Gonsalves
128
eyes that I had not noticed in the 3 days I had been caring for him. I softened the previously perfunctory tone of
my voice, sat down beside him on his bed, and offered an
encouraging smile as I spoke with him about the steps involved in preparing him for the procedure. Time seemed to
slow down, and the anxiety I had been feeling about past
and future dissipated in that moment. Johns body seemed to
unclench from the knot it was in when I first arrived in the
room. His mother, always present, also seemed to relax. The
change in the dynamics of the interaction between us precipitated by the purposeful attention I was now paying to him,
allowed John to disclose for the first time his fears of how
painful the procedure may be and about not being able to
have his parents with him. I listened, as his caregiver on the
medical team, but also as a fellow human being, understanding of fear and anxiety. Before I left, John asked if I could be
with him during the procedure. He let out a heartfelt sigh of
relief when I told him I could. For the first time during his
admission, a real connection had been established.
After they had wheeled his stretcher into the procedure
room, a nurse and the anesthetist started hooking up various
monitors to John. I stood out of the way but within his line of
vision. I made a conscious effort to pay attention to his nonverbal cues. I had no specific knowledge of the procedure itself; this would have made me exceedingly anxious and selfcritical only a couple of days earlier. I could not change what
I did not know at that moment. The cardiologists and other
professionals in the room were fully in charge of the situation anyway. What I could do however as an inexperienced
third year clerk was equally important. We maintained eye
contact. I smiled at him as the sedation started to take effect.
He was quiet, somewhat relaxed and offered a reassured, if
slightly nervous smile back to me.
The procedure went well. John had the fluid drained from
around his heart without complications. When the sedation
wore off he searched the room anxiously with his eyes and
found me. I held his hand, again, consciously making the effort
to be present and aware at that moment. He visibly relaxed. He
thanked me in a small, relieved voice. He went home a couple
of days later and his parents thanked me for the care.
While I did not choose pediatrics, the experience with
John was a turning point in how I saw my patients. Pediatrics
was better suited to physicians with other dispositionswe
are fortunate that in any given medical school class, there
are a variety of strengths and interests among the group and
everyone usually ends up where they should. I was awarded the prize for best student in the pediatric rotation for my
class which seemed ironic to me at the time given those first
weeks filled with anxiety. But what changed after John was
my awareness of my role on that service, of what I could
and could not do, of the need to mitigate difficult emotions
in order to be fully present and effective in caring for my
patients.
The experience with John was the first I had with the
power of mindfulness. By becoming aware of the present
moment and not merely going through the motions I was
fully and completely engaged and therefore more effective. I continued to experience feelings of stress and doubt,
but instead of feeling overcome by these emotions, I consciously recognized and acknowledged them as being part
of my experience, which allowed me to act from a center of
awareness. Feelings of stress no longer indicated that I was
an incompetent person; they alerted me to the fact that the
situation called for something else (e.g., more information
or preparation). I was able to appreciate the learning issues
gleaned from the clinical cases I later encountered.
23Lifeline
129
situation or person that has contributed to that emotion. Attempting to live mindfullyeven if not always successful
at least gives me a chance to be effective and fully present in
my life on a more regular basis. Understanding that, living
that, has allowed me to appreciate the full catastrophe living, a phrase I have embraced from Kabat-Zinns seminal
book on mindfulness [2]. Mindfulness has taught me not to
take moments for granted, to let myself off the hook once in
a while, to respect the human condition just as it is.
In my clinical practice, I encounter people from all age
groups and comorbid states. I treat patients with terminal
and chronic illness as well as those with acute conditions.
I see patients with varying degrees of insight into their
own health and wellness and consequently varying degrees
of frustration or peace. I try to be aware of these differences and approach each patient with respect. I have had
the opportunity to reinforce my practice by taking part in a
faculty-offered program in mindfulness-based stress reduction (MBSR) for physiciansa full 15 years after that first
life-changing encounter with John. Dr. Kim Sogge [author
of Chap.20], a psychologist trained in MBSR along with
her experienced colleague Gail McEachern, a social worker,
gave that course over a 4-week period to a diverse group of
physicians. Each of us had our own reasons for signing up
for the course, however, the essence of our intentions was
the samewe were seeking to live more fully, and to find
systematic ways to support ourselves and consequently our
patients in that goal. While the activities and homework assignments were familiar from my years of personal study
and practice, it was a gift to have this guidance. I relished
returning to beginners mind and learning from different
perspectives. My instructors and peers taught me about our
similar humanity as well as unique journey. My daily mindful practices were renewed and I brought this energy back
into my clinical practice.
Now, my clinical mindful encounters are less of aha
moments than that with John 15 years ago. They have become a cornerstone of how I practice on a regular basis.
Being mindful in a clinical encounter means engaging with
my patient in language they can understand, in an emotional
tone that is responsive to their concerns and anxieties, with
clear eye contact. I make a conscious effort to sit facing them
as opposed to turning to the computer terminal or standing
which can make it seem as though I am ready to leave any
moment. This allows me to be empathic, without being emotionally drained at the end of the day. Moreover, the communication experience between us is enhanced.
When I am less focused, my body language transmits information that I am distracted either by checking the time
or being anxious about how off-schedule I am, or when I
am writing prescriptions or requisitions while trying to listen to the patients questions. Patients perceive our multitasking; reports reveal that communication breakdown (or
C. Gonsalves
130
A Comfortable Answer
So who am I? I am human. No more, no less. No single role
I play defines me more than this simple noun. I am subject
to all that a human experience can entailfrom sadness,
uncertainty, frustration, and anger, to pleasure, excitement,
and blissful happinesssometimes all in one dayand I am
accepting and grateful of that. How often do I employ mindfulness in my practice? Every day. By being mindful, I can
recognize the humanity in my role as a physician. I aim to act
with compassion and ensure nonjudgment in my interactions
with patients and families. I do not get as regularly stuck in
unpleasant states or in assuming that my thinking represents the true reality at all times. In almost 20 years since
I embarked on my chosen career in medicine, this is what I
have learned: that life is a gift, every moment is worthy of
References
1. Seuss Dr. Oh, the places youll go! New York: Random House;
1990.
2. Kabat-Zinn J. Full catastrophe living. Using the wisdom of your
body and mind to face stress, pain, and illness. New York: Random
House; 1990.
Carol Gonsalves MD, FRCPC, MMEd is a clinician educator in the
Department of Medicine, Division of Hematology, The Ottawa Hospital. Her academic focus is on medical education, specifically in the
areas of needs assessment and curriculum development. She has held
a committee position in Faculty Wellness at the University of Ottawa
since 2008, supporting a specific personal and professional interest in
the benefits of mindfulness on student and physician health since her
own residency training. She holds a committee position on the Mindfulness Curriculum Working Group at the University of Ottawas Faculty
of Medicine, has assisted in editing the course material for this longitudinal curriculum, and is an investigator in research involving a mindfulness curriculum in undergraduate medical education
24
Mark Smilovitch
Introduction
The transition from classroom to the clinical setting is an
exciting and challenging time for medical students as they
begin to apply knowledge and develop clinical judgment
skills. However, many students experience or witness some
degree of disconnect between what is taught during their preclinical studies regarding patient care, and what is observed
during clinical rotations. Empathic patient care and efficient
work habits are often perceived as mutually exclusive, and
this may contribute to student frustration and distress.
The following narratives represent reflections on mindfulness during clinical encounters as experienced by students
during clerkship.
Mindful clinical encounters were more likely to involve
attentive listening, and the ability to focus while limiting
distractions. Mindful clinicians demonstrated an awareness
of self and others, while acknowledging their own thoughts,
feelings, and emotions. Comfort with silence was often described in these encounters, inviting patients an opportunity
to pause as well, reflect, and express their concerns. Mindful
clinicians were noted for being present in the moment, and
establishing a sense of connection with their patients and colleagues. Curiosity and enquiry about patients lives beyond
their illness was often reported in these encounters as well.
Common to many clinical encounters was the observation
that the attitudes demonstrated by clinicians were contagious
in nature. Nursing staff, medical students, and residents were
influenced by the behaviors of both positive and negative
role models. Mindful behaviors elicited more caring in other
team members, while less-mindful behaviors contributed to
increased levels of tension and stress.
Robertson Davies, in a lecture to medical students, describes the characteristics of the mindful medical practitioner
M.Smilovitch()
Cardiology Division, Faculty of Medicine, McGill Programs in Whole
Person Care, Strathcona Anatomy & Dentistry Building, Room M/5
3640 University Street, Montreal, QC H3A OCA, Canada
e-mail: mark.smilovitch@mcgill.ca
131
132
M. Smilovitch
expected from me. In my opinion, the shifts in ideas, task explanations and brief, rapid and insufficient communication,
all reflected non-mindful multitasking. I wonder, is it possible to multitask mindfully? What if my supervisor had
taken an extra 20 s to better explain what he expected from
us and to clarify what was still imprecise for me? What if he
had focused on one task at a time? Being mindful in multitasking involves the complementary abilities of focusing and
shifting attention, one task at a time to better perform each
of them. Also, Dr. OB was frustrated about the situation, but
I do not think he realized until later that I had done what I
thought would be best for patients with limited directives.
One point I would like to emphasize is that Dr. OB is a
professional and trusted physician whom patients and medical students appreciate. I share this consideration completely.
Unfortunately, I believe that, during this particularly stressful night, part of his practice was not mindful and I suffered
from it, as a medical junior clerk.
Laboring Alone
Clerkship obstetrics and gynecology: A surprisingly interesting and rewarding couple of months! There is one encounter,
however, that I will always remember for all the wrong reasons. I entered the room of one of the patients and noticed
several things right away: first that she was laboring alone.
A closer look at her garments and head covering told me she
was of a modest Jewish sect, in which men are not present
during labor and delivery. I felt so sad that she had not a
single person by her side!
Second, I noticed that her nurse was not paying much attention to her; instead she was busying herself with the organization of the room, rearranging things here and there,
instead of coaching her through her contractions. I was
shocked because I had otherwise been thoroughly awed and
inspired with the compassion, dedication, and almost motherly protective instinct that the obstetrical nurses dotted on
and accompanied their patients through the process of giving
birth.
Lastly, I noted the senior staff accompanied by a junior
resident, chatting amicably among themselves, while leaning between the bare, propped up legs of the patient, ignoring her completely but for the occasional glance to track the
progression of the babys head.
A multitude of emotions rushed through me at that time:
anger, sadness, frustration, disbelief, disgust, and contempt. I wondered if they realized what they were doing.
The impact it had on me was huge, perhaps because they
were both male physicians? I do not know. Although a certain degree of habituation can be expected from performing
the same task over and over, as a seasoned physician would,
giving birth is never mundane for the mother in the room. I
133
Mistaken Diagnosis
In medicine, time restraints can influence our interaction with
patients and may impede us from being mindful. In order
to properly diagnose and treat a patients current illness, we
need to know the patient as a whole and understand their
psychosocial and past medical history. One incident where I
witnessed a physician not practicing medicine mindfully was
in a hectic surgical rotation where assumptions were made
and a diagnosis was missed.
Morning rounds in surgery begin at 5:45 a.m. There were
approximately 30 patients to see before making our way to
the operating room for a long day of surgery. We visited each
patient as a group: one resident entered the room to ask a few
questions and perform a brief physical exam, while another
wrote orders for labs and medication, and at the same time
someone wrote a brief note. One patient encounter in this
rotation that marked me was a 65-year-old woman postoperative bypass surgery. When we passed by her room as a
group, we noticed that she was moaning and talking to herself. The resident immediately dismissed her complaints and
labeled her as having delirium. No tests were ordered and
we continued on with the other patients. The following day,
134
M. Smilovitch
135
warmly to us the second time around. I realized that my inexperience and nervousness were barriers to being authentic
with this person in the moment. I felt relieved that this was
not a failure that would define me, but rather a very important lesson.
In terms of the effect this had on the patient, I believe that
at first she was probably irritated by me: annoyed with my
questions, annoyed with seeing another student doctor late at
night in the emergency room. Perhaps she was angry that the
system was not taking good care of her. However, I believe
that we quickly turned the situation around and that she felt
listened to and cared for. All she wanted was someone to hold
her hand and say it was going to be okay. Just a few more
questions and then we had all the information we needed for
that night. All it took was a smile and some reassurance. So
simple. I hope that after our encounter she had renewed faith
in the medical system, realizing there are some doctors and
nurses who are capable of taking the time to pause and make
a human-to-human connection (composed by Eric Lenza).
M. Smilovitch
136
Kindness is Contagious
On the hematology/oncology ward, many of the patients
were seriously ill; some had received bad news on too many
occasions. The ward was full and there was not an empty
bed. This made for hectic days and many patients to be seen.
Each day, the doctor in charge would venture from room to
room and visit patients, answering their questions, and alleviating some of their fears. It was difficult to allocate enough
137
Reference
1.
Robertson D (Editor). The merry heart: reflections on reading,
writing, and the world of books. Selections 19801995. In: Can a
doctor be a humanist? (chap.5). New York: Penguin Books; 1998.
pp.90110.
Mark Smilovitch MD is a cardiologist and associate professor in the
Department of Medicine at McGill University, Montreal, Canada, as
well as on the Faculty of McGill Programs in Whole Person Care. He is
interested in medical education, and is involved in physicianship teaching, with an emphasis on simulation-based learning
25
Stephen Liben
S.Liben()
McGill Programs in Whole Person Care, Faculty of Medicine,
Paediatric Palliative Medicine, Montreal Childrens Hospital,
McGill University, Montreal, QC, Canada
e-mail: stephenliben@gmail.com
Chapter I
139
S. Liben
140
I fall in.
I am lostI am helpless.
It isnt my fault.
It takes me forever to find a way out.
At this point, what she says and what I hear become two
separate streams, and I am left only with the confused jumble
of thoughts going on inside me, as I am no longer able to
hear her spoken words.
What follows are phrases of my fragmented inner dialogue
that have now completely replaced what is actually being told
Chapter II
I walk down the same street.
There is a deep hole in the sidewalk.
I pretend I dont see it.
I fall in again.
I cant believe I am in the same place.
But it isnt my fault.
It still takes a long time to get out.
I am a fourth-year pediatric resident doing a neonatal intensive care unit rotation on hour 18 of my 24-h shift. It is 2
oclock in the morning, the hour when bad things that happen in hospitals tend to happen, when the sickest kids tend
to arrive in the newborn nursery. I am lying down in the on
call room when my pager goes off and I am told to get to the
delivery room, stat, for a baby that is going to be born prematurely (7 weeks before her full-term date). I arrive sleepy and
irritable and accompanied by one of my increasingly common migraine headaches as my unwanted companion. The
baby is born and it becomes obvious within minutes that she
will not be able to breathe on her own. I begin to bag/mask
breath for her and ask for the staff doctor to be called while
we prepare to place a breathing tube into her (intubation) in
order to be able to place her on a ventilator. I am nervous
about the intubation and have never tried before in so young
and small an infant. The staff doctor arrives and she is also
tired but I can feel the calmness and confidence emanating
from her that I know I do not have. I am tired and my head
hurts and I have no confidence and my thoughts are all negative and self-pitying (Why me?) and I am not even aware
of my negative thoughts, my depressed emotional state, and
my tense muscles. I try to intubate and cannot see where to
place the tube. With encouragement from the kind and pa-
tient staff doctor I try again. I fail again. The baby is safe as
we try, but it must hurt to have these tubes stuck in her throat
over and over again. I am asked if I want to try to intubate
again (I know that the staff doctor can easily do this procedure herself at any time and she is only being kind in offering
me the opportunity to improve my skills.). I answer her back
by saying, No I cant try again, I have a headache and I need
to lie down. I walk away before hearing what she has to say
and I shuffle back to the call room and fall into bed. I am
beyond tired and am fed up. I hate the baby for being born. I
hate the staff doctor for being so kind. I hate myself. Why is
the world so unfair?
Chapter III
I walk down the same street.
There is a deep hole in the sidewalk.
I see it is there.
I still fall inits a habit.
My eyes are open.
I know where I am.
It is my fault.
I get out immediately.
141
Chapter IV
I walk down the same street.
There is a deep hole in the sidewalk.
I walk around it.
I am a 44-year-old staff doctor about to leave for an intensive mindfulness retreat in California. I have never been
on a silent retreat before for more than 1 day. I have looked
forward to this retreat for over a year. It is going to be great.
California in the winter (compared to Montreal, Canada).
Nine days of minimal need to interact socially. Good food,
all prepared by others, and just waiting three times a day
to eat it. Walks in the mountains. Face time with world-renowned mindfulness teachers. What could be bad?
Day three of the retreat: I am going crazy. This is madness. It is their fault. What they have set up here is a mental
pressure cooker. Take people out of their usual life, change
the rules of social engagement (i.e., there are none) and have
us sit still from morning to night every day for day after
day! Of course, I am feeling overwhelmed with thoughts
and emotions. I ask to meet with one of the teachers (this
is arranged by leaving a written note asking for a personal
meeting on a posted board). I am going to tell her that I see
through their manipulative set up and I will show them the
error of their ways. I meet the first teacher and tell her everything I am thinking and feeling. She asks, Who do you think
you are to ask to change the way these retreats are run?! I
leave the meeting as angry and self-involved as ever. I then
decide to request a meeting with the intimidating and wellknown head of the whole program. I leave him a note that
morning saying Are you sure you know what you are doing
S. Liben
142
here and are not creating harm with a purposively manipulative brainwashing environment? At lunch, I spy on him
as he eats a few tables away from me. Of course, no eye
contact is allowed so it is hard to know if he even sees me.
Did he see my note from this morning? He gets up and walks
over to where I am sitting and without breaking his stride nor
making any eye or other contact he leaves a note next to my
fork. The note says Meet me at 2:30 in room 1. Room 1,
his room! My ego is simultaneously gratified at the personal
attention (Was that what I was really looking for in all this
fuss I have created, the feeling of being special?) and terrified at now actually going one on one with this intimidating
teacher. We meet and he seems more confused than upset.
What is your problem Stephen, everyone else is grateful for
the quiet and the setting? He does not get what I am angry
aboutDoes not he understand that the reason I am feeling
so angry and agitated is because of what he did in setting up
this retreat the way it is? Why cannot he understand?
I decide that I will (probably? maybe?) leave the retreat
tonight but before I do I ask to see the third teacher. I want
someone to validate that what I am thinking and feeling is
not my fault and that it is because of what they have done
here. I want them to know that I am leaving and it is their
fault for creating such a psychologically unhealthy situation.
My meeting with the third teacher is very different compared
with my previous meetings. This teacher is less well known
than the other two. He hears me out (my speech is now well
practised from having been given to myself hundreds of
times and now twice with the two other teachers). He seems
truly confused and, like the other two teachers, cannot understand what I am so upset about. What is wrong with these
teachers here anyways? Are they so deluded that they cannot
see what is right in front of them? Except the difference with
this teacher is not in what he says, which was essentially the
same thing the other two teachers said, I cannot understand
what you are so upset about Stephen. Rather, it is not what
he says, but how he says it. He was simply concerned and
bothered that I was not OK. His voice transmitted a concern
that I had not heard before. I felt cared for. He said, I understand you may leave the retreat and you should do what you
need to do. I want to tell you that I do hope you will find a
way to stay as your questioning is good and I think you have
something to offer the group.
I walk out of the meeting room and look down the hill at
the gate where I could hail a taxi and just leave. In that moment, I know that if I leave it will be because of me. It will
be because I cannot bear being with myself. There is nothing
happening here other than what I do or do not make of it. If
I leave I will be walking away from what is difficult within
me. I will be walking away from myself. I decide to stay and
see what happens. There is no great awakening. No epiphany.
Just a gradual settling down of my mind. By the end of 9 days,
I wish the retreat and the silence could go on even longer.
Chapter V
I walk down another street.
watch?v=oLiyYcOkV64) shows her being driven in a limousine with her sister and her parents to a music studio where a
recording session has been set up. She then sings a duo with
her recording idol. After we watch the 5-min video, the feeling in the room has been transformed. Her mother is teary
eyed, one of the medical students is crying, two of the residents and myself are holding back tears. Tears of joy, tears
of sorrow, tears of hope, tears of recognition of the beauty
that is this adolescent girl in front of us. Nothing has really
changed in terms of what treatments we can offer her. But in
another sense, everything has changed. We see her. She sees
us. Both she and her parents know we will do everything we
can to see how she can be helped. As we leave the room, the
mood is soulful, touching, and sweet. This is what medicine
can be. This is what life can be. This is another street.
143
26
Cory Ingram
145
C. Ingram
146
four components as means for personal perpetual preparation for caregiving. Not only preparation prior to meeting a
patient but also an ongoing exploration during patient and
family encounters, tempered by mindfulness. I consider this
model as representing a perpetual preparation of mind, body,
and soulone that influences ones spoken and unspoken
exchanges with patients and their families.
Mind
In cultivating my attitude or mindset for seeing patients, I
center my attention on the patient and create awareness for
myself of thoughts that are competing for my attention. In a
busy medical practice, using check points to slow the mind
can be helpful. Examples are: while washing of your hands,
just before knocking on the door, or when reviewing their
chart outside the room.
Mind preparation also requires an awareness of bias, attitudes, and feelings about the patient, their disease, and their
family situation. For example, recognition of how you feel
about a long lost family member placing a dying incapacitated elder through medical tests and procedures that you
thought were fruitless and harmful. Or, how you feel towards
the family member you perceived to be inducing suffering
without hope of improvement. How do you reconcile what
you know to be true of the patients previously stated wishes
to avoid suffering near lifes end and others disrespect for
that? How do you recognize that moral distress and address
it prior to meeting with and during your clinical encounter?
I typically hold mixed emotions when preparing to meet
with families in different phases of setting things right
amongst themselves near lifes end. I certainly am not living
with my own bags packed and ready for departure. There are
a lot of loose ends. I question myself, how would I be in a
similar situation? Will I adhere to the recommendations that
I offer these people? Can I create the space that allows the
healing potential to be fulfilled? Will someone do that for me
when my time to go comes?
OK, am I ready to see this patient? In the time-pressured
work environment of modern medicine this process of mind
preparation happens in the moment and continues during the
encounter. It is not a question of time, or another thing on my
list to check off as done; I believe mind preparation is a key
ingredient of being fully present to the patient and family
and creating a space for healing.
Body/Behavior
Preparation of the body is about attention to practical details.
Given that I have mostly an inpatient clinical practice, conveying respect for patients living situation in the hospital
Soul
Preparation of the soul is for me is an opening of myself,
my soul, to the suffering of another person coupled with the
intent to relieve their suffering. This is hard work. How do
you prepare your soul with openness to your own suffering?
How do you do this with every patient? There are times that
this is inherently difficult. Preparation of the mind and soul
are unique but not separable. The interwoven nature I experience between mind and soul is exemplified in Dr. Balfour
Mounts article, The 10 Commandments of Healing. In it
he lists: be truly present to this moment, trust, attend to your
whole person needs, be open to deeper relating, listen to your
intuition, create, develop your self-reflective skills, be gentle
with yourself, think small, and celebrate [5].
Earlier I mentioned the scorched tree reflected in the
water. Attention to the other and to the self is inherent in
compassionate care. There is a desire not only to bear witness to the suffering of another human being but also to
alleviate that suffering. In its simplest form, being compassionate requires me to suffer with the other. There is a
moment-to-moment emotional toll that requires a simultaneous inward exploration of my soul. The tree reflected in
the water: breath by breath, heartbeat by heartbeat, word for
word, silence by silence.
147
patients I care for reflect on these relationships and their desire to attain resolution. I understand from my personal experience how difficult these situations can be. They want to
make things right and they want to do it quickly.
In the moment of caring for them, I return to mind, body,
and soul with alert attention to how I might experience their
situation given my longings and losses. I am keenly aware
of my feelings and I temper my presence to allow for space
and time for revealing the innate healing capacity within the
patient. Dosing supportive counseling is something not typically taught in medical school. I await an opening or invitation from the patient to offer suggestions. I am continually
aware, breath by breath, moment by moment, that the same
supportive counseling would apply to myself as the wounded healer. I catch myself wondering how the immediacy of
serious illness and the approaching end of life will affect me
and my family.
I may suggest to the patient a new way of looking at one
key topic such as forgiveness. I share approaches to life completion that I learned from my mentor, Ira Byock. I suggest
that forgiveness may be nothing more or less than simply
giving up hope for a better past. It may involve deleting the
details pertaining to the transgressions and ping on the here
and now. Often I share with people the four things that most
people value having said before they are forced to say goodbye. These are: Please forgive me. I forgive you. Thank you.
I love you [14]. I understand the yearning for those four short
sentences to alleviate suffering.
Mindfulness of the suffering of the patient and family and
me in regard to imperfect relationships, love, and forgiveness fosters attunement between us that is authentic in my
experience. Roles and titles fall by the wayside and human
beings are simply caring for one another.
The life completion narrative is at risk of having an ending that many may describe as inadequate. A good ending to
this narrative is typically one whereby people can declare
that there is nothing left unsaid or undone. They desire a positive legacy. They long to die well. How then does human
development factor into the life completion narrative?
Human development and growth continue throughout life
from birth until death [15]. Tasks of development, life review and generatively become more significant for persons
living with a life threatening illness [16, 17]. Physical decline can be accompanied by emotional, psychological, and
spiritual growth [18]. Fostering tasks of life completion require attention to completion of relationships, expressions of
regret, forgiveness, acceptance, gratitude, finding a sense of
meaning, telling ones story, life review and transmission of
knowledge or wisdom to others [19].
Dying well is often thought of in the context of the process
of dying. However, foundational to human development and
the care we all provide, it is more accurate and challenging to
think of dying well with well-being used as an adjective. The
C. Ingram
148
person was not only healed but they also achieved a sense of
wellness fostered by attention to the tasks of life completion
and developmental milestones [20].
care. I am sometimes asked to communicate their desires regarding their relationships. These are topics so difficult to
talk about that they entrust them to me to convey. The situation is one most families never forget. I approach it not as
transference of information, but rather a therapeutic intervention. I am present mind, body, and soul: moment by moment and breath by breath. The situation could be mine. The
people I am speaking to could be my broken family. I have
been privy to broken families that finally heal. I wonder why
it takes serious illness and approaching end of life to jettison
people to a healing space where forgiveness simply happens
and relationships are well and complete.
I have accompanied parents reaching out for someone
else to love their children as much as they do. I have experienced this selfless act on numerous occasions: a parent, who
in the midst of the grief and loss, is searching for a surrogate;
finding hope in a new way. A way distinct from hope for
cure, hope for a gentle death, instead, it is a hope for a love
filled and safe life for their children to have without them. I
never can fully imagine what that is like. I do, nonetheless,
sit very close to the raging emotions of parents dealing with
saying goodbye to their children.
In the midst of being with dying parents, I mentally associate colors to the emotions that arise in our midst: deep
unending matte black captures the emptiness I experience
them expressing as they prepare to say goodbye. It is difficult to celebrate a life well lived when life is ending prematurely. There is a plenty of raw sadness and I experience that
too. I often say, If I am not doing this work who is? It
is not attractive in many ways I suppose, but for me, as the
wounded healer, I cannot imagine doing anything else other
than providing human to human tender loving care for seriously ill and dying patients and their families.
Conclusion
In conclusion, reflecting on the foundations of my mindfulness practice in relation to the narrative of the patient and
my own personal lived experience as a wounded healer has
given me more insight into the therapeutic relationship.
Mindfulness enhances the quality of patient care and furthers
my ability to continue to provide care. Mindfulness supports
our respective healing processes by opening a therapeutic
space for our inherent capacity work through pain. The presence is the key to the therapeutic relationship and therapeutic
communication.
I am convinced that there are other people like me with
strained and broken familial relationships that live with those
scars while providing excellent care for people dealing with
the same. I believe we should share these experiences in an
open forum, like this book. Writing this has been arduous.
Having written this has been a healing experience. I long
149
References
1. Teilhard de Chardin P. The phenomenon of man. New York:
Harper Torchbooks; 1965.
2. Byock IR. Dying well. New York: Riverhead Books; 1997.
3. Ingram C. A paradigm shift: healing, quality of life and a professional choice. J Pain Symptom Manage. 2014;47(1):198201.
4. Newman Bhang T, Iregui JC. Creating a climate for healing: a visual model for goals of care discussions. J Palliat Med.
2013;16(7):718.
5. Mount BM. The 10 commandments of healing. J Cancer Educ.
2006;21(1):501.
6. Hutchinson T. Whole person care. In: Hutchinson T, editor. Whole
person care: a new paradigm for the 21st century. New York:
Springer; 2011.
7. Ingram C. Watch over me: therapeutic conversations in advanced
dementia. In: Rogne L, McCune S, editors. Advance care planning: communicating about matters of life and death. New York:
Springer; 2013. p.187208.
8. Mount BM, Boston PH, Cohen SR. Healing connections: on moving from suffering to a sense of well-being. J Pain Symptom Manage. 2007;33(4):37288.
9. Mount BM. Healing and palliative care: charting our way forward.
Palliat Med. 2003;17:6578.
10. Chochinov H. Dignity and the essence of medicine: the A, B, C,
and D of dignity conserving care. BMJ. 2007;335:1847.
11. Freeman M. Narrative foreclosure in later life: possibilities and
limits. In: Kenyon G, Bohlmeijr E, Randall WL, editors. Storying later life: issues, investigations, and interventions in narrative
gerontology. New York: Oxford University Press; 2011. p.3.
12. de Lange F. Inventing yourself: how older adults deal with the
pressure of late-modern identity construction. In: Kenyon G, Bohlmeijr E, Randall WL, editors. Storying later life: issues, investigations, and interventions in narrative gerontology. New York:
Oxford University Press; 2011. p.5165.
13. Frank A. The necessity and dangers of illness narratives, especially
at the end of life, narrative and stories in health care: illness, dying,
and bereavement. New York: Oxford University Press; 2009.
14. Byock IR. The four things that matter most. New York: Free Press;
2004.
15. Erikson E. The life cycle completed. New York: W. W. Norton &
Company, Inc.; 1998.
16. Steinhauser KE, Alexander SC, Byock IR, George LK, Tulsky JA.
Seriously ill patients discussions of preparation and life completion: an intervention to assist with transition at the end of life. Palliat Support Care. 2009;7(4):393404.
17. Goodard C, Speck P, Martin P, Hall S. Dignity therapy for older
people in care homes: a qualitative study the views of residents and recipients of generatively documents. J Adv Nurs.
2012;69(1):12232.
18. Byock I. The nature of suffering and the nature of opportunity at
the end of life. Clinics Geriatric Med. 1996;12(2):23752.
19. Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre
L, Tulsky JA. Factors considered important at the end of life by
patients, family, physicians, and other care providers. JAMA.
2000;284:247682.
150
20. Puchalski CM. Spirituality and the care of patients at the end-oflife: an essential component of care. Omega. 2007;56(1):3346.
21. Hack TF, McClement SE, Chochinov HM, etal. Learning from
dying patients during their final days: life reflections gleaned from
dignity therapy. Palliat Med. 2010:24(7);71523.
22. Frank V. Mans search for meaning. New York: Washington Square
Press, Simon and Schuster; 1963.
23. Puchalski C, etal. Improving the quality of spiritual care as a
dimension of palliative care: the report of the concensus conference. J Palliat Care. 2009;12(10):885904.
C. Ingram
Dr. Ingramis a Senior Associate Consultant Palliative Medicine,
Assistant Professor of Palliative Medicine Assistant, Professor of Family, Medicine Director of Palliative Medicine Mayo Clinic Health System, and Director of Palliative Medicine Office of Population Health
Management.
27
Tom A. Hutchinson
of the participants was picking someone to play Gary Larson, a cartoonist about whom I knew nothing. I sank into my
seat, adopted a blank look and literally almost fainted when
she asked Tom would you be willing to play this role? And
despite what felt like my better judgement, I stood up and
said yes. I played the role and participated increasingly in the
workshop until after 4 days I felt more alive than I had for
years. I decided that I would do whatever it took to bring this
experience into my life and work.
What did these two experiences have in common? It
seems to me that they shared the key components of love,
facing risk, and trust. In the first case, my mothers love for
me and my love for her and in the second Virginia Satirs
love for human beings and our love for her and the process
that she was leading. They both had an element of pushing
me forward towards what felt like a risky experience. And
there was a trust that somehow things would work out if I
faced what I most feared. It seems to me, that is exactly what
happens when our clinical presence and focus on curing our
patients begins to move into a healing relationship.
Recently, I saw a woman who was dying of a metastatic
cancer at the age of 35. I saw her with her mother. We were
at the point of discussing transfer to the palliative care unit.
The main difficulty for me was being able to face fully that
this young woman was dying and to accept that in a certain
sense this was OK. Despite all of the sadness, it was OK with
her and her mother. The patient explained that it had taken a
lot of work to get to this point. Her mother indicated that she
knew what was happening, and she accepted it without resentment. At one point in the interview, they looked for what
seemed like an eternity into each others eyes. The mother
slowly rose, took a step forward, and they hugged each other.
At that instant, the only feeling in the room was love. It felt
like a profoundly healing moment. The patient was transferred to the palliative care unit the next day.
But how could this be OK? A young woman of 35 with
an abdomen so full of tumour that it was hard to the touch,
a face daily growing more thin and cachectic, frightened
eyes with a staring quality that often seems to accompany
151
T. A. Hutchinson
152
References
1. Needleman J. The heart of philosophy. New York: Alfred A Knopf;
1982. p.4556.
2. Kabat-Zinn J. Coming to our senses. New York: Hyperion; 2005.
p.108.
3. Satir V. The new people making. Mountain View: Science and
Behavior Books; 1988.
4. Hutchinson TA, Brawer JR. The challenge of medical dichotomies and congruent physician-patient relationship in medicine. In:
Hutchinson TA, editor. Whole person care: a new paradigm for the
21st century. New York: Springer; 2011. p.3143.
5. Hutchinson TA, Mount BM, Kearney M. The healing journey. In:
Hutchinson TA, editor. Whole person care: a new paradigm for the
21st century. New York: Springer; 2011. p.2130.
6. Mount BM. Radical presence. McGill University: Montreal. Lecture given to first year medical class, 2014 March 4.
7. Philips D, editor. Heroes: 100 stories of living with kidney failure.
Montreal: Grosvenor; 1998.
8. Rosenberg L. Living in the light of death: on the art of being truly
alive. Boston: Shambala; 2000.
153
of Medicine, McGill University and director of McGill Programes in
Whole Person Care, Montreal, Canada. He is the editor of
A new paradigm for the twenty-first century (Springer Press,
2011) and chaired the First International Congress on Whole Person
Care in Montreal, October, 2013
28
Intentions
Irving etal. [11] noted that 68% of the 110 participants in
the mindfulness-based medical practice program indicated
that their goal was to enhance their clinical practice, be more
present, attentive, and compassionate with their patients.
Bruce and Davies [12], in a study of nine hospice workers
with an average of 16 years of meditation practice, found that
the participants intentions were to face suffering (in others
and themselves), to be open and present to all that transpired
in their interactions with patients. Counselors interviewed by
Rothaupt and Morgan [13] spoke of intentional living, i.e.,
there was no boundary between being aware in and out of the
clinical setting. Connelly [2] wrote:
Practicing mindfulness, I recognized my discomfort and my
habitual pattern. I realized a decision point. I could assume control and make arrangements for his transfer today. But I also saw
that the patients contributions to the decision were lacking. So
before I entered the room, I decided to let go of my control of the
situation and be open to all the possibilities that might arise in
our conversation. I promised myself to listen. (p.89)
155
P. L. Dobkin
156
Attention
Enhanced attention was reported by clinicians in two studies [11, 14]. One family physician interviewed by Beckman
etal. [15] stated:
I am much more attuned to listening. I put a mental stopwatch
in my head. I [now] have a heightened awareness and sensitivity
to peoples conversation. I look at my own communication and
pay much more attention to that. I pay much more attention in
general. (p.817)
Attitudes
Beckman etal. [15] found that 50% of the family physicians
were able to respond nonjudgmentally; they were open, curious, and stayed present in the moment. Irving etal. [11]
and Keane [14] reported that compassion was enhanced.
Non-striving was noted by Irving etal. [11]; clinicians saw
the importance of moving from the practice of doing/fixing
to being when working with patients. Keanes [14] psychotherapists internalized the qualities of acceptance, calm, and
compassion such that who they were as people impacted
how they were with their clients. Nonjudgment and nonreactivity in particular were related to therapist empathy.
Clinicians audio diaries in Nugent etal. [16] revealed that
mindfulness provided the space to stop, reflect, and then
respond (i.e., nonreactivity). The hospice workers in Bruce
and Davis [12] described using the beginners mind (e.g.,
You start to appreciate beauty in places you never saw it
before. p.1337), letting be and trusting the therapeutic process. They described this as, leaning into stillness. There
was a spiritual quality to their responses, especially regarding the Buddhist concept of no self/no separation. For
example, one clinician said:
Our lives are interconnectedyour suffering is my suffering
youre dying and Im going to die. I dont assume that I am independent from the person in the bed. Or in a peculiar way, I dont
assume that I am better off. (p.1337)
Presence
Siegel [7] purports that when one is open and truly present
for another person, one can be attuned to them. Some clinicians interviewed claimed that mindfulness helped them to
be more present to patients [17]. Keanes psychotherapists
mentioned that deeper listening, attunement, and the ability to be present were corollaries of being mindful while
working. Similarly, Beckman etal. [15] in a study with fam-
ily physicians found that 60% of those who took the mindful
practice course increased their capacity to listen attentively
and respond more effectively to others at work (and home).
Nugent et al.s [16] health care professionals echoed this
finding. The hospice workers in Bruce and Davies study
[12] viewed engaged presence not as something brought into
a situation but, rather, as a letting go into a presence that is
always there. Kearsley [4], a radiation oncologist (the author of Chap.8), wrote a narrative that reflected on presence
consistent with mindfulness. His open orientation invited a
patient to tell his story in such a way that it was healing for
both the patient and the doctor.
which is great. You have noticed that being unmindful impedes learning, reduces enjoyment, gets in the way of connecting with people, wastes time, and leaves us vulnerable to
frustration and worry. If being unmindful works for us then
we should practice it but if unmindfulness isnt so useful
then perhaps we might want to cultivate mindfulness instead.
Thanks Peter for being brave and sharing that. I dare say that
others in the group recognized what you were talking about
and I value that you said exactly how it was for you. I encourage you and the whole class to just say it as it is and not
to just say what you think I want to hear.
Patience Patience demonstrates that we understand and
accept that things have their own time for unfolding. This
allows us to simply observe the unfolding of the mind and
body within ourselves, the context in which we are with
other people, and our and others reactions.
Dr. Schachter: We engaged in a brief conversation on
the prevalence of these problems and I mentioned available treatments including doing nothing. Then I paused and
checked in again. Too much detail about any particular modality would leave behind her emotional reaction and with it
any therapeutic engagement. In elective gynecological surgery we have the luxury of a mindful surgical pause. When
the patient cries, becomes indignant, refuses treatment,
challenges my expertise, or repeats questions previously answered, she is overwhelmed and its time to rest and let the
situation simmer.
Dr. Bailey: There was a long period of silence filled with
tension so thick you could slice through it. We waited for
what felt like hours. In these moments of silence, I became
aware of how loudly my heart was pounding. I wondered if
she could hear it. I found my breath and allowed my attention to follow the natural rhythm of my body breathing. I
knew I didnt need to do anything in this moment. I simply
needed to give her time and space. I felt my body relax as I
joined her right where she was. I no longer felt the need to
bite my tongue to avoid breaking the silence. Just then she
spoke.
Beginners Mind In order to be able to see the richness of
the present moment, it helps to cultivate a mind that is willing to see everything as if for the very first time.
Dr. Kearsley: I felt a sense of anticipation, almost excitement, at the prospect of meeting a totally unknown person,
and the prospect of making a difference in whatever opportunities presented themselves. I enjoy the not knowing about
who the next person might be.
Dr. Gold: After the dawn, Richard realized: I am not my
illness, and began to let go of over-identifyingone of the
barriers to self-compassion. He recognized his arrogance and
the pitfalls of comparisons; he knew he was as worthy as others, no more and no less. I noticed that Richard and I were
157
different each time we met, that each visit was the first visit
in a way. I set the intention to let go of expectations and look
and listen in a fresh way.
Trust It is far better to trust your own feelings and intuition
than to get caught up in the authority of experts. If at any
time, something does not feel right to you, pay attention,
examine your feelings, and trust your own basic wisdom
and that of the other.
Dr. Gonsalves: I took another breath. I looked at John
closely, this time with certain eye contact. He had the most
striking wide, blue eyes, I hadnt noticed in the three days
I had been caring for him. I softened the previously perfunctory tone of my voice, sat beside him, and offered an
encouraging smile as I spoke with him about the steps involved in preparing him for the procedure. His body seemed
to unclench from the knot it was in when I first came in the
room. His mother, always present, also seemed to relax her
shoulders and facial muscles. The change in my approach
and the consequent change in the energy of the interaction
we were having seemed to register on a nonverbal level. He
let me in on his fears of how painful the procedure may be,
about not being able to have his mom or dad with him. I
listened, as his caregiver on the medical team, but also as a
fellow human being, understanding fear and anxiety. Before
I left, John asked if I could be with him during the procedure.
He let out a sigh of relief, so innocent and heartfelt, when I
told him I could. For the first time during his admission, a
real connection had been established.
Dr. Lucena: Throughout the first year of the follow-up, a
relationship of trust was built on a weekly basis (fifty minute
sessions). I compare this period of relationship-building to
that described in Saint-Exuperys book, The Little Prince,
where the little prince carefully tames the suspicious fox.
First they meet from a distance, as the fox requires. Then
they get closer, little by little every day. With Emilio the
work required space and time as well. In building trust with
him, two basic rules helped: (1) to be honest always with
Emilio whether or not he liked it and (2) to choose carefully
my words at the moment of truth.
Non-striving There is no objective other than to be conscious of yourself as you are, while inviting the other person
to do the same.
Dr. Kearsley: But, in bearing uncertainty and staying
present, I am continually mindful of attempting to make
a difference despite the unfamiliar seaways of uncertainty through which I navigate. That challenge gives me
strength and reassurance in situations like Carmens, every
time. It means that I also have to believe in mystery, and to
develop a sense of nonattachment to outcomes over which I
have little or no control; on most occasions, I have no idea as
to what type of difference I make.
158
P. L. Dobkin
likely she has not been asked before during team rounds. She
answers, very softly so that we strain to hear her, I love to
sing. I say, How wonderful!
She replies, I have a video of me singing with a famous
singer that was done by the make a wish come true foundation, would you like to see it?
After we watch the 5-minute video the feeling in the room
has changed. Her mother is teary eyed, one of the medical
students is crying, two of the residents and myself are holding back tears. Tears of joy, tears of sorrow, tears of hope,
tears of recognition of the beauty that is this adolescent girl
in front of us. Nothing has really changed in terms of what
treatments we can offer her. But in another sense everything
has changed. We see her. She sees us.
Dr. Sogge: And her tears flow unabated.
There is a dull pain in my chest as I hear her story. I lean
in and breathe. I am with her. We let the tears run down her
face. In a few breaths I say, I am so sorry. Lets try to do
something new here. and then I hand her our economy size
box of tissues.
She laughs at the ridiculously big box, then smiles a bit
through her tears, saying,
God I hate this.
I know I say. I hate that it happens this way too.
Gratitude The quality of reverence, appreciating and being
thankful for the present moment.
Ms. Osorio: Then I feel it, familiar, as I have felt it beforein other situations, with other peoplelike a fresh
breeze entering the room, as the confusion of our words is
gently blown away and the quality of presence fills the space,
drawing us both into the room, into this moment, effortlessly.
Now, there is no trying to practice, no need to explain, no
words piling up. Now, there is simply an opening into what
is happening, guided by words, by silence, by breathand
yes, even by confusionand allowing it all to settle on its
own. Now, we are ready to begin the session, with the time
that we have, meeting one another in the moment. Thats all
that matters.
Dr. Baron: I rang the doorbell. Her husband opened the door
while she was waiting for me in a chair in her living room.
She looked at me and I looked back at her in complete silence.
It was a comfortable silence. Time stood still. I felt peaceful,
appreciating each moment of this simple and powerful encounter. My body was released of tension and my heart was
free of discomfort. I felt in harmony, despite the gravity of the
situation, while attending to her needs and to mine.
Gentleness This attitude is characterized by soft, considerate, and tender quality; soothing, however, not passive,
undisciplined, or indulgent.
Dr. Bailey: Im not sure what happened but Im sensing
some discomfort in the room. Do you feel it too?
Mom maintained her defensive posture and without looking up nodded her head.
I would like to talk about it before we end the visit today.
Id like to understand what happened.
Mom agreed. She asked if we could talk alone. I nodded and invited her to step out into the hall with me while
the kids played in the room. Once outside the room, mom
seemed less angry. Her body language had softened and yet
there was still discomfort there; a kind of nervous energy.
She struggled to find the words to describe what she was
feeling internally. I could tell she was providing me with
hints, hoping I would figure it out and she wouldnt have to
say what seemed so difficult for her to say. I reached out and
took her hand in a gesture of support.
I can see this is difficult for you. Its okay. You can say
whatever you need to say without worrying about how it
sounds. Itll give us a place to start and we can figure it out
as we go along.
This seemed to give her permission to speak from the
heart.
Ms. Osorio: I think my mind is falling in, he says to me.
Please hold me close,
Before I fall,
So I can feel before I fall
I hold him close,
Beside my arm
His tears so warm,
Upon my arm
His hands so withered, dry and cold
He seems so tired, lost and old.
Generosity Giving within a context of love and compassion, without attachment to gain or thought of return.
Dr. Coles: The ER physician is witness to countless intimate moments of pain, fear, stress, and vulnerability. We see
the dark side of life, the subcultures of abuse and neglect, the
realities of poverty and loneliness, the consequences of ignoring the body and spirits true needs. We also bear witness
to moments of inexplicable beauty, compassion, and tenderness. The best kept secret in the field of medicine is this
healers want the very best life for their patients even if they
cant always cure or save them. They serve with a dedication
that threatens to devour them.
Dr. Krasner: Eventually she moved from her apartment in
the Mother House to the memory unit, still within the Mother
House. And I began to make nearly weekly visits to her, each
time finding Norma always at her bedside, always attending
to Sisters personal, emotional, and spiritual needs. I would
sometimes just sit with the two of them, holding conversations about music, speaking of composers and vocal artists,
and learning much more of Sisters own musical performance career. I brought to her recorded talks of a contemplative nature for her and Norma to enjoy, and I during my
visits I listened to old recordings of Sister Josepha singing
159
in choral groups and solo some if the very arias I had grown
up listening to.
Empathy The quality of feeling and understanding another
persons situationtheir perspectives, emotions, actions
(reactions)and communicating this to the person.
Dr. Phillips: Beneath her suffering I had had a glimpse
of a fellow human being who cared deeplyabout her children, her husband, and her connection with others. While I
had found her degree of suffering and desperation for relief
from this to be almost unbearable, I had liked this woman.
Dr. DeKoven: I am worried about her safety and her future fertility. I am well aware that what had initially catapulted her into her unfortunate circumstances was her desire
to have a second child. I understand her desire to have two
children. I am forever grateful that I managed to swing having two healthy kids by age forty. I feel like I just slipped
under the wire.
Loving Kindness This is a quality embodying benevolence,
compassion, and cherishing, all filled with forgiveness and
unconditional love.
Dr. Krasner: But in the end, it is more than simply medical care and connections with the past. It is the continued
unfolding of birth, aging, illness and death that draw us together, within which the lines between healer and patient
blur slightly, at times merging into simple human connection
and kindness.
Dr. Bailey: I took a breath. How would I feel if I had been
abandoned by my mother who still lives locally? Perhaps I
would be angry too. I made space for both my irritation for
their blatant disrespect of their grandmother with any accompanying judgmental thoughts and my appreciation for
the childhood trauma theyve experienced through abandonment. It was from this place that I could respond to the developing chaos in the room with fierce compassion.
Final Reflections
When I reflect on my clinical work, it is clear that being
an MBSR and mindful medical practice instructor makes
a difference, in that each time I teach another course, be it
to patients, medical students, or clinicians, being present in
the moment and responding rather than reacting to events
becomes more natural to me. I feel attuned to the people in
my courses as well as to my patients in individual psychotherapy. Often, before a session begins I simply sit still for
a few minutes to let go of what is going on in my day. This
transitional use of mindfulness was noted by therapists interviewed by Horst etal. [20] as well. Meditation practices can
be transformative, and mindfulness applied to the therapeutic relationship goes beyond cognitive restructuring, stress
160
Closing Remarks
What these narratives offer with open-hearted generosity is a
behind-the-scenes view of clinicians commitment to compassionate patient care. Despite being faced with budget cuts
and restructured health care systems, clinicians continue to
respond in exemplary ways. Just as patients seek cure and
care from their clinicians, this book offers hope that kindness
can prevail in the midst of a demanding medical practice.
References
1. Whyte D. The house of belonging. Langley: Many Rivers; 1997.
Part IV. Belonging to those I know, LOAVES AND FISHES. p.88.
2. Connelly JE. Narrative possibilities: using mindfulness in clinical
practice. Perspect Biol Med. 2005;48(1):8494.
3. Dobie S. Viewpoint: reflections on a well-traveled path: selfawareness, mindful practice, and relationship-centered care as
foundations for medical education. Acad Med. 2007;82(4):4227.
4. Kearsley JH. Wals story: reflections on presence. J Clin Oncol.
2012;30(18):22835.
5. Irving JA, Dobkin PL, Park J. Cultivating mindfulness in health
care professionals: a review of empirical studies of mindfulnessbased stress reduction (MBSR). Complement Ther Clin Pract.
2009;15(2):616.
6. Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B,
Mooney CJ, etal. Association of an educational program in mindful communication with burnout, empathy, and attitudes among
primary care physicians. JAMA. 2009;302(12):128493.
7. Siegel DJ. The mindful therapist: a clinicians guide to mindsight
and neural integration. New York: W. W. Norton & Company;
2010.
P. L. Dobkin
8. Hick SF, Bien T. Mindfulness and the therapeutic relationship.
New York: Guilford; 2008.
9. Escuriex BF, Labb EE. Health care providers mindfulness and
treatment outcomes: a critical review of the research literature.
Mindfulness. 2011;2(4):24253.
10. Shapiro SL, Carlson LE, Astin JA, Freedman B. Mechanisms of
mindfulness. J Clin Psychol. 2006;62(3):37386.
11. Irving J, Park J, Fitzpatrick M, Dobkin PL, Chen A, Hutchinson T.
Experiences of health care professionals enrolled in mindfulnessbased medical practice: a grounded theory model. Mindfulness.
2014;5(1):6071.
12. Bruce A, Davies B. Mindfulness in hospice care: practicing meditation-in-action. Qual Health Res. 2005;15(10):132944.
13. Rothaupt JW, Morgan MM. Counselors and counselor educators practice of mindfulness: a qualitative inquiry. Couns Values.
2007;52(1):4054.
14. Keane A. The influence of therapist mindfulness practice on psychotherapeutic work: a mixed-methods study. Mindfulness. 2014:
5:689703.
15. Beckman HB, Wendland M, Mooney C, Krasner MS, Quill TE,
Suchman AL, etal. The impact of a program in mindful communication on primary care physicians. Acad Med. 2012;87(6):8159.
16. Nugent P, Moss D, Barnes R, Wilks J. Clear(ing) space: mindfulness-based reflective practice. Reflective Prac. 2011;12(1):113.
17. Cohen-Katz J, Wiley S, Capuano T, Baker DM, Deitrick L, Shapiro S. The effects of mindfulness-based stress reduction on nurse
stress and burnout: a qualitative and quantitative study. Part III.
Holist Nurs Pract. 2005;19(2):7886.
18. Bugenthal JFT. The art of the psychotherapist: how to develop the
skills that take psychotherapy beyond science. New York: W.W.
Norton & Company; 1987.
19. Kabat-Zinn J. Full catastrophe living: using the wisdom of your
body and mind to face stress, pain, and illness. New York: Delacorte; 1990.
20. Horst K, Newsom K, Stith S. Client and therapist initial experience
of using mindfulness in therapy. Psychother Res. 2013;23(4):369
80.
21. Brito G. Rethinking mindfulness in the therapeutic relationship.
Mindfulness 2014: 5:351359.
Assoc. Prof. Patricia Lynn Dobkin PhDis a clinical psychologist
specializing in chronic illness and chronic pain. She is an associate
professor in the Department of Medicine at McGill University. As a
certified mindfulness-based stress reduction (MBSR) instructor, she
spearheaded the mindfulness programs for patients, medical students,
residents, physicians, and allied health care professionals at McGill
programs in Whole Person Care. Dr. Dobkin collaborates closely with
Drs. Hutchinson, Liben, and Smilovitch to ensure the quality and integrity of the mindfulness courses and workshops offered at McGill University and other venues (e.g., conference workshops, weekend training
retreats).
Index
Death, 9, 10, 13, 25, 26, 37, 38, 7173, 85, 101, 124, 125, 152
and dying, 71, 129, 152
anticipation of, 64
cardiac,126
premature,148
rapid,53
Decision making womens health, 109
Defusion
cognitive, 111, 115
Dementia,27
vascular,27
Depression, 1, 30, 49, 50, 71, 72, 90, 96, 101
deep,27
history of, 72
Dialectical Behavior Therapy (DBT), 79
Dialectic therapy, 21
Healing, 2, 14, 15, 26, 39, 71, 124, 130, 146, 152
foster, 1, 87
161
162
mutual,99
psychotherapy,111
scriptures,86
source of, 88
Hospice,145
workers,156
House calls, 8, 100
I
Index
benefits of, 74
in action, 53, 54
in medicine, 1
meditation, 20, 21, 26, 33, 34, 88, 156
psychology,102
Mindfulness-based psychotherapy, 111
Mindfulness-Based Stress Reduction (MBSR), 1, 15, 26, 33,
51, 95, 129
Mindful practice, 5, 7, 78, 114, 115, 125, 129, 130, 132, 146
developing a regular, 128, 129
Mindful psychiatrist, 10, 29, 155
Mindful surgical practice, 109
N
Pain, 15, 17, 24, 29, 30, 33, 59, 60, 65, 67, 72, 114, 117, 125,
149
chronic,30
emotional,34
excruciating,31
intensive,32
physical,39
Palliative care, 10, 27, 41, 145, 152
Paranoia,27
Patient-centered decision, 2
Personal growth, 139
Physician burnout, 1
Physician-patient
quality of, 1
Physician self-care, 55
Physician well-being, 1, 146
Poetry and medicine, 7, 50
Presence, 1, 1315, 31, 60, 137, 152, 156
closer,42
empathic,33
practicing, 50, 51
Psychotherapy, 1, 13, 16, 82, 99, 109, 111114, 117
medical,99
163
Index
Q
Qualitative research, 26
R
Sanity,100
fundamental,100
Self as context, 111
Self-reflection, 7, 73, 92, 131
Speech, 14, 29, 30, 33, 71, 91, 92, 120
right,89
skilful, 90, 91
Stress management, 19, 160