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Becoming (and Sustaining) the Bodhisattvas We Already Are

 

MICHAEL KEARNEY AND RADHULE WEININGER

Becoming a healer means remembering who you already are. In Buddhist thought this is referred to as “realizing our Buddha nature.” While this has implications for how we see ourselves as caregivers, it also affects how we see our patients, how we act in clinical situations, and how we practice self-care. Tibetan Buddhist teacher Chögyam Trungpa writes in The Sanity We Are Born With:

 

According to the Buddhist tradition, people inherently possess Buddha-nature; that is, they are basically and intrinsically good. From this point of view, health is intrinsic. That is, health comes first: sickness is secondary. Health is. So, being healthy is being fundamentally wholesome, with body and mind synchronized in a state of being which is indestructible and good. This attitude is not recommended exclusively for patients but also for the helpers and doctors. It can be adopted mutually because this intrinsic basic goodness is always present in any interaction of one human being with another.

 

Seeing that our deepest nature is goodness and health allows us to be in the presence of suffering without burning out or drowning in despair.

The Nature of Suffering and the Nature of Healing

In April 2007, Balfour Mount and his colleagues Pat Boston and Robin Cohen published a research paper called “Healing Connections: On Moving from Suffering to a Sense of Well-Being.” Working with a group of individuals living with terminal disease they asked, “What makes the difference between those who live their final months with what they themselves consider to be good quality of life, and are able to say that they are happy and that their lives have meaning, and those who, despite similar life circumstances, describe themselves as scared, lonely, unhappy, who experience their lives as meaningless and their quality of life as awful?”

To answer these questions they interviewed twenty-one individuals who were equally matched for all the demographics of age, sex, disease status, symptom burden, and socio-economic status. Half of the group appeared to be thriving and happy despite their terminal illness, while the other half appeared to be miserable and unhappy. Using a qualitative research methodology, they interviewed each person and analyzed their results to try to identify differentiating factors.

Their findings can be summarized quite simply: What makes all the difference is the presence or absence of what they call “healing connections.” They identified four key areas in which these healing connections can occur. The first is with ourselves (for example, being happy and at peace in oneself); a second is with other humans; a third is with the phenomenal world (for example, with music or in nature); and finally, there are healing connections with what they called “Ultimate reality, however this was understood by that individual” (while some spoke of God, others spoke of love, and so on). When individuals experienced healing connections in any (it may have been one or more) of these areas, they described their quality of life as good and their lives as meaningful. In contrast, when individuals did not experience healing connections in any of these areas, they described their quality of life as poor and their lives as meaningless.

The individuals in this study, living in the final weeks and days of their lives, are offering us answers to the same existential questions that Siddhartha Gautama asked about the nature of suffering and the nature of healing.

Suffering as a Place of Healing

The bodhisattva is one who chooses to reenter the world of suffering again and again and again for the sake of all beings. It could be said that the bodhisattva’s path into wholeness is suffering. In Western civilization we call this figure “the wounded healer,” the one who knows from experience that suffering, their own and others, is a place of healing.

We have learned a great deal about the dynamics of the wounded healer from Buddhist scholar and environmental activist Joanna Macy. She teaches a powerful process for encouraging compassionate action on behalf of others and our world that she calls “The Work that Reconnects.” There are four steps in the spiral of The Work that Reconnects. The first is gratitude, grounding ourselves in the heart so we have the courage to take the second step of “honoring our pain for the world.” This is the pivotal move in the process, for as we honor our pain for the world, which Joanna describes as turning toward, leaning into, and allowing ourselves to experience our feelings of suffering, something quite unexpected happens. She describes this in the following way in an interview on On Being:

 

We are called to not run from the discomfort and not run from the grief or the feelings of outrage or even fear and that, if we can be fearless, to be with our pain, it turns. It doesn’t stay static. It only doesn’t change if we refuse to look at it, but when we look at it, when we take it in our hands, when we can just be with it and keep breathing, then it turns. It turns to reveal its other face, and the other face of our pain for the world is our love for the world, our absolutely inseparable connectedness with all life.

 

She describes this as a “Tantric flip”: as we allow ourselves to experience our pain for others, we “flip” into a realization of interconnectedness. This flip alters our perspective and brings us to the third step in the spiral process: “seeing with new eyes.” We are in the same world but seeing it in a different way; things look different than before. Realizing our kinship with all life, we long to act to relieve the suffering of others and so, in the fourth and final move in this process, we “go forth” in compassionate action. Here is what this looks like at the bedside:

Joseph was in his early twenties and hospitalized with a severe acute exacerbation of chronic abdominal pain. Palliative care was consulted for recommendations with pain control and to offer him emotional support. His medical situation was very complex. He had been diagnosed with diabetic gastroparesis and the so-called “narcotic bowel syndrome.” We were told, before ever meeting with him, that on no condition was he to have any opioid analgesics as these were exacerbating rather than helping his pain. He had been prescribed opioids over the years for his pain before it was diagnosed for what it was. By this time he had become dependent on them. His life was at a standstill because of his condition and the repeated hospitalizations this necessitated. He had lost his job, and his marriage was under a lot of strain.

When I (Michael) arrived on the floor to see him, I reviewed his chart and spoke with his primary care team. By then it was clear to me that any treatment options I might have suggested had already been considered and explored, all to no avail. I had already received calls from both his gastroenterologist and psychiatrist reiterating that it would be disastrous were I to recommend opioids.

I knew that I was walking into an impossible situation. As I approached his room I was at a feeling of loss. Just before opening the door I paused, took a deep breath, and made a short bodhichitta prayer that I often say to myself at moments such as this, “May all beings be happy.” I knocked and went inside.

Before I finished introducing myself, Joseph interrupted me and said, “I know the narcotics are making things worse, but when this pain comes on bad I just want to die.” I pulled over a chair and sat by the side of his bed and asked him to tell me about what had been happening. I listened as he told the story of his multiple admissions and the many hospitals he had been in, of investigations, of surgeries, of dashed hopes, and of the relentless return of the pain. He spoke of how he knew he was now seen as “drug-seeking” and of how his admissions through the ER had become a traumatic nightmare of pain and judgment. He finished by looking directly at me and saying, “How can you doctors not give someone the one thing that can relieve their suffering? How can you allow someone to continue suffering when you know you have something you could do that could bring them relief? I don’t need narcotics at home. But when I have a pain crisis that brings me to the hospital, I have to have something to help me. And they are the only thing that works.”

As I listened to Joseph I became aware that I was feeling very conflicted. I was deeply moved by his story of suffering and his anxious pleas for help. I wanted to respond, to give him what he was asking for, to make him better, to ease his suffering. And yet I knew I could not do that; I was not able to give him the one thing he wanted from me. I was feeling very uncomfortable. I wanted to get up and leave.

For many years I have been helped in my clinical practice by the image of “the wounded healer,” one who chooses to stay, at times such as this, with her or his own pain and sense of impotence. Again and again I have seen how doing this, while continuing to be present in a heartfelt way to the other who is suffering, can awaken that individual’s own healing potential. Recently, Joanna Macy had inspired me to deepen this practice and given me a way of understanding this in terms of the dynamics of compassion and interconnectedness.

As I sat there listening to Joseph’s story, aware of my pain in the face of his suffering and aware of my inability to do anything to make it better, I remembered the wounded healer, and I remembered Joanna’s teaching. This gave me the encouragement to “hang in there” despite my feelings of discomfort and inadequacy.

I also remembered a short meditation process Radhule had recently developed for just such an occasion as this, one that she calls “The Compassion in Action Process”:

 

      1.   In the face of the other’s suffering, bring your attention inward and downward into the body.

      2.   Notice your physical experience, what is happening right now, in your body, and where.

      3.   Bring your attention to your breath and exhale gently to relax.

      4.   Notice your emotional experience, what feelings are there, and where.

      5.   With the exhale, allow yourself to drop down into the felt-sense of your experience and to linger there for just a little while: “suffer your suffering.”

      6.   Offer compassion to yourself while continuing to breathe gently, holding this experience in your heart.

      7.   When you are ready, once again direct your attention outward and turn toward the other, noticing what you are feeling and what you are seeing.

 

As I brought my attention inward and down into my body, I noticed that my jaw was tightly clenched and that I was feeling achy. Then I brought my attention to the movement of my breath, and in particular to the sensations of the gentle release of the outbreath. I noticed that attending to the exhale in this way allowed me to relax, to loosen, to let go a little. Next, as I attended to what I was feeling about Joseph and his situation, I became aware of a mix of many different emotions. There were feelings of frustration and helplessness at not being able to alleviate his pain, as well as some anxiety about how he was going to react when he realized this, and shame at appearing a failure to my colleagues. At the same time, there were feelings of deep sorrow for this man and his young family who were trapped in such a miserable situation. As I recalled the “pivotal move” in this process, I consciously gave myself permission to drop into the felt-sense of what I was experiencing. There were sensations of rawness and aching around my heart. Though it was uncomfortable to do so, I deliberately chose to let my awareness drop into these sensations, allowing myself to experience what I was experiencing.

After a few moments, I remembered that the next step was to offer compassion to myself. I immediately knew that this would not be easy. I was feeling like a failure, and I could not readily access a sense of warmth or kindness toward myself. Instinctively, I put my hand on my heart and became aware of the gentle sensations of pressure on the wall of my chest. As I did this, images came into my mind’s eye of myself as a doctor. I saw myself arriving at my workplace prepared to do what I could to relieve the suffering of others, day after day, year after year. From the silence of my heart words came: “For the sake of all my relations, may I hold myself with gentleness and care.” With this, a deep sigh swept through me. I continued to breathe gently while holding this experience lightly in my heart as I observed how my body was breathing, spontaneously, effortlessly, without my volition or control. For a few breaths I followed the gentle flow of the breath in this way. As I did so, I recalled words that had come to me earlier that day in my morning’s meditation, “May all that is connected breathe us deeply well . . . May all that is connected breathe us deeply well . . .”

It seemed that allowing myself to experience my feelings of frustration and sorrow for Joseph had unlocked something. A knot in my heart had loosened. I felt my chest expanding and my jaw soften. The deep helplessness and hopelessness I had felt gave way to something that was subtle and hard to name. While there was something timeless about this experience, as I brought my attention back to the here and now and to Joseph sitting before me, I realized that it had only taken a minute or so. And yet even in that short time something essential had come back into balance. Something important had fallen back into place. A wave of warmth and concern for Joseph swept through me. As I listened to him finish speaking, I felt appreciation for his courage and resilience. I expressed my heartfelt gratitude to him for sharing his story with me. Our eyes met. In the silence of that moment I knew that the conversation had just begun.

Sustaining the Bodhisattva with “No-Self-Care”

There are three well-recognized syndromes of occupational stress. Burnout, which arises from the stresses generated between the individual and institutional or bureaucratic processes, resulting in chronic emotional and physical exhaustion, a sense of never quite achieving one’s goals, and feelings of being increasingly detached and disconnected from others and one’s work. What is sometimes called Compassion Fatigue (which from a Buddhist point of view is a misnomer; compassion does not fatigue but rather replenishes us) is more accurately termed secondary traumatic stress disorder, as it describes the effects of being secondarily or vicariously traumatized by another’s suffering. This can lead to the symptoms of post-traumatic stress disorder. Thirdly, there is Moral Distress Syndrome, which occurs when one knows the correct action to take but is powerless to do so. This may result in either the symptoms of burnout or compassion fatigue/secondary traumatic stress disorder, or a mixture of both.

Existing models of self-care operate on the assumption that there is a “self” to take care of. What might be described as the traditional model of self-care advocates having good professional boundaries as protection from the stresses of the workplace and an effective program of rest and renewal on leaving work — cultivating what is referred to as “a healthy work-life balance.” If we were to use a water metaphor for occupational stress, then feeling overwhelmed by work stresses might be seen as “being flooded” or “being underwater,” and the classic approach to self-care as holding one’s breath (having good professional boundaries) and coming up for air (having recreational activities outside of the workplace).

Some newer approaches to self-care emphasize the value of clinician self-awareness or mindfulness. There is an increasing body of data to show that self-awareness is itself protective. Self-awareness can enable the clinician to be highly present, sensitively attuned, well-boundaried, and, most important, heartfelt to another who is suffering in even the most stressful of situations, in a way that allows the clinician to receive as well as give in the clinical encounter, a process that has been called “exquisite empathy.”

Clinicians describe how they emerge from such encounters feeling replenished rather than depleted. Furthermore, self-awareness allows for self-monitoring. For example, if something has triggered a reactive cascade of feelings and an urge to act out, self-awareness enables one to metaphorically press a “mindful pause button” and consider a range of possible options. The clinician can then discern what is most appropriate to this person in these circumstances and choose to respond skillfully and with compassion. While self-awareness involves innate cognitive skills and processes, it can be further developed through four distinct approaches: self-knowledge (“clinician know thyself”), self-empathy (or self-forgiveness), mindfulness (purposeful and nonjudgmental attentiveness to one’s own experience, thoughts, and feelings), and contemplative awareness (the awareness that one’s encounters with others are embedded in bigger and deeper fields of relationships).

Self-awareness allows us to meet the one who suffers with heightened presence, sensitivity, and accuracy. With self-awareness we know both the limits of what we can give and when it is appropriate to be present to the one we care for with a full and open heart. In terms of the water metaphor of occupational stress, self-awareness allows us to breathe underwater as we find regeneration and renewal in the work itself.

We would like to propose a third approach to self-care: “no-self-care.” The core assumption here is that there is not a self to take care of — or, at least, that there is not a self in the sense we usually think of it. The Buddhist concept of anatta refers to the emptiness of the concept of self, to “no-self,” but not in a nihilistic sense. The “no-self” of anatta means “no-solid-separate-permanent-self.” There is self but it is self in relationship — self as part of a much bigger framework and process. This has important implications for how we see ourselves as healers, how we understand healing, and for resilience in the workplace. The “no-self” of anatta means that the healer I already am is fluid, interconnected, and ever changing — that healing is not something that I personally do to or for another. Healing is what naturally happens when we (the other and I) become part of the fluid, interconnected, impermanent, always-changing process that is ultimate reality.

So it is no longer a matter of congratulating ourselves when things go well or blaming ourselves when they don’t. We do our best. We contribute to the process. Then something happens that is, ultimately, not in our control. What is in our control is to set our intention, choose to do what we think is in the best interest of the other, and let go of the outcome. Aware of the interconnectedness of all things, we cultivate the conditions for healing within ourselves and in our relationship with the suffering other. Then, together, we wait to see what emerges.

What then might “no-self-care” look like? If the primary move in traditional models of self-care is to establish good professional boundaries, and if the primary move in newer models of self-care is the cultivation of self-awareness and mindfulness, the primary move in no-self-care is what we call “deep connection practice” — practices that bring us into an experience of self as fluid, porous, permeable, dynamically interconnected, and mutually coarising in what is, as our indigenous brothers and sisters remind us, “a world of relatives.” We can think of deep connection practices as being either “inner” or “outer” depending on where the primary object of our attention is located. Mindfulness of breathing is one example of an “inner” deep connection practice, whereas time in nature is an example of an “outer” deep connection practice.

We each need to discern and customize deep connection practices that work for us. In terms of the water metaphor, we might think of these practices as “breathing holes,” those holes in the ice that seals work hard to keep open during the Arctic winter so that they can move from the frozen world above to their food source below and so that they, and others, have somewhere to breathe. We each need “breathing holes” — places, people, and practices that allow us to move from the frozen world of isolation to the fluid world of relatedness, and that allow us to emerge when necessary and fill our lungs with clear, replenishing air.

Here are some possible questions to reflect on to enable you to identify your own deep connection practices:

 

          What makes me feel most awake, alive, connected?

          What brings me into a lightness of being and a peace of heart?

          What brings me into gratitude?

          What brings me into a sense of deep belonging?

          What awakens my longing to care for all beings?

          When, where, and doing what do I think, “I am glad to be doing this for my great-grandchildren?”

 

To sustain the bodhisattvas that we already are, we need self-knowledge, self-empathy, and mindfulness, each in the context of ongoing deep connection practices, and always in the spirit of bodhichitta, the mind of enlightenment, motivated by compassion for all beings.