Mindful Listening at End-of-Life Chaplain Candidate: Andrew Blake

114 Pages·2010·0.6 MB·English

by  Maia Duerr

MINDFUL LISTENING AT END-OF-LIFE

Mindful Listening at End-of-Life
Chaplain Candidate: Andrew Blake
Upaya Institute
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ABSTRACT

Mindful Listening (ML) is a quality or skill for caregivers which engages our capacity to be present for
another as well as be present in ourselves. By training caregivers in the practice of mindfulness,
including the Four Foundations of Mindfulness (i.e., body, feelings, thoughts, and objects of mind) and
by appreciating the effects of meeting suffering in End-of-Life (EOL) care, ML can help develop a
non-judgmental and compassionate quality of awareness, making it possible for a caregiver to be
present in an unmediated way for a patient. Through acceptance, a quality associated with mindfulness,
caregivers can experience and then offer a more open and relaxed presence, which lessens the tendency
to “fix” situations and establishes a greater sense of interconnectedness with those whom they serve. In
this challenging role, caregivers may experience prolonged periods of stress and moral distress which
may lead to burnout, secondary trauma, and empathy fatigue. For caregivers, the practice of mindful
awareness and mindful listening may offer a preventative measure in a continuum of self-care
strategies. In presenting Mindful Listening at End-of-Life (MLEOL) as a model, I am proposing that
mindfulness and other strategies can enhance the quality of our empathy, compassion and well-being.
This paper considers the latest scientific research into the neural pathways of attention, emotion
regulation and empathy while drawing similarities to the foundations of Buddhist meditation practice
and psychology. As a practical quality and experiential skill for caregivers, MLEOL can transform our
style of listening into a being-with-patients in a way that can foster interconnectedness between oneself
and others, an increased sense of meaningfulness in our work, and greater psychological resilience and
well-being in our practice of caring at end-of-life.
TABLE OF CONTENTS

PART I: INTRODUCTION
CHAPTER ONE: WHAT IS MINDFULNESS AND MINDFUL LISTENING? p. 4
CHAPTER TWO: EARLY BEGINNINGS p. 17

PART II: CONSIDERATIONS FOR A MINDFUL LISTENING MODEL
CHAPTER THREE: THE ROOTS OF EMPATHY AND COMPASSION p. 24
CHAPTER FOUR: EMPATHY OR COMPASSION FATIGUE: THE DEBATE
p. 45
CHAPTER FIVE: MINDFULNESS AND BUDDHIST PSYCHOLOGY
p. 54
CHAPTER SIX: NEUROSIENCE OF ATTENTION AND THE LEFT BRAIN SHIFT p. 62

PART III: TOWARDS A MINDFUL SOCIETY
CHAPTER SEVEN: TRAINING A NEW GENERATION OF MINDFUL CAREGIVERS p. 79
CHAPTER EIGHT: A MINDFUL WORLD: INTERCONNECTEDNESS AND UNITY p. 91

APPENDICES: MINDFUL LISTENING RESOURCES
APPENDIX I: MINDFULNESS PRACTCE AND MINDFUL LISTENING IN DYADS p. 99
APPENDIX II: INSIGHT DIALOGUE INSTRUCTIONS p. 105
APPENDIX III: GROUP MINDFUL LISTENING: THE WAY OF COUNCIL p. 107
REFERENCES AND BIBLIOGRAPHY p. 110
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PART I: INTRODUCTION
CHAPTER ONE
WHAT IS MINDFULNESS AND MINDFUL LISTENING?

I like to live in the sound of water, in the feel of the mountain air.
A sharp reminder hits me: this world still is alive;
it stretches out there shivering toward its own creation, and I'm part of it.
Even my breathing enters into this elaborate give-and-take,
this bowing to sun and moon, day and night, winter, summer, storm,
still—this tranquil chaos that seems to be going somewhere.
This wilderness with a great peacefulness in it.
This motionless turmoil, this everything dance.
William Stafford, Even in Quiet Places

While William James sums up our human experience by saying, “For the moment, what we
attend to is reality” (1958, p. 322), William Stafford, as the above excerpt indicates, suggests where to
place this attention. Sustained and consistent attention on an object, activity or state of mind is the
practice of mindfulness. Mindfulness, in a nutshell, is a process of becoming “familiar with our mind,”
says His Holiness the Dalai Lama (2001). Should we apply the benefits that modern neuroscience has
revealed from the study of mindfulness practice, I think our society and our ways of caring would
progress towards greater well-being. In this paper, I am proposing that the techniques of Buddhist
mindfulness practice be applied to relationship-centred contexts in which caregivers are present and
attentive to the dying. I term this application of mindfulness Mindful Listening at End-of-Life
(MLEOL). MLEOL, deeply rooted in the foundations of the practice of mindfulness and mindful
listening, is a model with which end-of-life (EOL) caregivers can utilize in order to provide more
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considered and effective care and being with the dying. Moreover, MLEOL is important for the
caregiver her/himself since it is, in essence, a strategy for self-care and a preventative measure from
burn-out. It is this latter aspect of MLEOL that is the focus of this paper as I investigate the findings of
neuroscience research and the ancient teachings of Buddhist psychology on mindfulness, and elucidate
the considerations towards a training model of MLEOL.
Over the past ten years, I have been exploring the benefits of teaching EOL caregivers, the
dying, and their families mindfulness practices and, during this chaplaincy program, also the practice of
mindful listening (ML). Mindfulness can sustain caregivers as they strive to function effectively in an
arena where they cannot hope to stop the loss of life by any effort, modest or heroic; mindfulness can
support the dying as they confront the unbearable grief, anger, denial, and fear that accompany dying.
Mindfulness teaches us the skill of pausing and even stopping in an otherwise hectic and stressful
working environment; and mindfulness teaches us that at all times and in all places awareness can be
present.
Like other mindfulness practices, mindful listening is simple, but not necessarily easy. ML, in
general, and MLEOL, in particular, will draw upon the foundations of mindfulness within a
relationship-centred context. In other words, MLEOL will invoke mindfulness in the very challenging
presence of another, the being with another in his or her dying. The rationale for proposing that ML be
the systemic principle guiding EOL care work rests upon the power and efficacy of mindfulness itself,
for mindfulness can foster a presence of mind and a mind of acceptance in the midst of difficult life
situations. As such ML is relevant for professional caregivers, the dying and their family caregivers.
Contemplative and mindfulness practices, aside from their main purpose as a means of spiritual
cultivation, have been known for centuries to be a base for developing self-care and inner resilience. In
our time, neuroscience is investigating the effects of such practices, and the findings demonstrate
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compelling evidence into the efficacy of mindfulness-based practices in addressing stress and
fundamental aspects of our mental health. Some of the major benefits of mindfulness include:
1. developing the ability to override habitual responses or to down regulate (attentional balance);
2. allowing for flexibility of mind, insight and meta-awareness of the bigger picture (cognitive
awareness and mental balance);
3. reducing stress, enhancing a relaxed state and improving our immune response (emotional
stability; resilience and health). (Halifax, 2009)
In addition, mindfulness-based EOL care work is essential because mindfulness practice can
also be supportive in ameliorating both physical and mental suffering. As we mindfully invite the
various aspects of pain (e.g., quality, shape, intensity, location, feelings, thoughts, etc.) into our
awareness, our identification with the source of pain softens. Attention helps us to just be with each
sensation, without focusing on a story which may be convincing us it will never go away. In working
with the dying, I have guided patients in contemplative and mindfulness-based practices that have
brought a qualitative change in their suffering and their pain. Acknowledging and accepting pain in its
many manifestations is, in large part, the crux of the work in EOL care as Dame Cecily Saunders notes:
I realized that we needed not only better pain control but better overall care. People needed the
space to be themselves. I coined the term “total pain,” from my understanding that dying people
have physical, spiritual, psychological and social pain that must be treated. I have been working
that ever since. (cited in Halifax, p. 11)
Moreover, mindfulness-based practices have the capacity not only to deal with pain but also
suffering (or total pain). The alleviating of suffering is the main purpose for which these practices were
originally designed, and there is a nuanced difference between pain and suffering. In this sense,
palliative medicine has come a long way in treating physical pain that accompanies death, yet
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alleviating suffering has not been properly attended to by mainstream medicine. Roshi Joan Halifax
distinguishes pain as our physical experience but suffering as the story we tell ourselves about the pain.
Suffering, then, is the mental suffering that is created by our mind. In its essential teachings, Buddhism
embraces a direct experience of the nature of our mind. Through meditation and other practices that
cultivate compassion, lovingkindness and other altruistic qualities, Buddhism leads us on a path to
untangle and free ourselves, not just from pain, but from our suffering.
In proposing MLEOL, with mindfulness as its core, as a model with which to engage in EOL
caregiving, I am addressing the urgent need to deal with pain and suffering that is constitutive of EOL
situations. In particular, a mindfulness-based approach to EOL work is a resource for alleviating the
suffering or total pain of those who are dying and who are gravely ill; the suffering of family caregivers
and survivors; and the suffering of clinicians, professionals and volunteer caregivers who face burnout,
secondary trauma, and moral distress.
The prescriptions of Buddhist practice may be simple, but understanding how the mind works
or how we can listen, live or die mindfully is not necessarily easy. By exploring mindfulness practices
in conjunction with the development of a quality I call mindful listening, my intention throughout this
paper is to explore resources for caregivers that will nourish them and the dying whom they serve.

What is Mindful Listening?
Samuel Beckett succinctly describes the essence of Mindful Listening when he wrote: “Don't
touch me. Don't question me. Don't speak to me. Be with me!” (my emphasis; cited by Halifax, Upaya
Institute). ML is a mindfulness practice that engages our capacity to be present for another as well as
ourselves. The core elements of the practice are: mindful awareness; compassionate interpersonal
listening; and the Three Qualities of a Peacemaker, namely, Not Knowing, Bearing Witness, and
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Loving Actions. In other words, mindful listening is this contact that we maintain between our inner
experience and another's; it is a process of developing awareness of what happens in our caring for
another.
The challenges of the EOL field necessitate that we develop skills to help sustain ourselves.
Those of us working in stressful circumstances and those facing illness, dying and death can develop
such skills. Often, to our detriment, the way we sustain ourselves is through avoidance keeping busy,
addictive habits, and denial—tactics that operate as ways of distracting ourselves from the physical,
emotional, mental, social and spiritual issues that accompany the dying process.
Mindfulness can have an enormous impact on both the professional and volunteer caregiver
and on the client. For caregivers it teaches us how to rest in the moment and to just be with our client
rather than being preoccupied with our own thoughts and feelings. What does it mean “to rest” and
“just be?” Most of the time we are not truly present! We appear to be listening to our client, yet other
thoughts or feelings are happening with or without our awareness. By learning to be in the moment—
breath-by-breath—we become more aware of our body and inner states, and we become more relaxed
and at ease. This not only brings ease to us, but also this state is nonverbally communicated to those we
are caring for. When we are grounded, our patients and clients can feel this. By noticing what is
happening inside, we begin to recognize moments of discomfort or fear within us, without moving
away from it. We learn to do the same for our client as they face fear. Our intention to be mindful and
aware brings us to the present moment, and this is a powerful gift for the dying and their families. This
work of caring for the dying is not so much about actively doing something; it is about giving our open
heart and full attention to things just as they are. In a sense this is what all of us long for—someone
who cares enough to listen deeply.
Through mindful listening, we can bring our sensitivity to what is happening in us (i.e., bodily
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awareness, feelings, emotions, thoughts, etc.) and what is happening as we hear, observe and feel the
other. We can learn to soften the tendency to judge, analyze, solve, or avoid what is happening. We are
just there. We empathize or sympathize, and then we let that go, too. Compassionate actions and
healing can also arise from this space because we are opening up to this individual and to ourselves
without judgement and without story. The space between us may have moments of awkwardness,
silence and pausing, but we learn to develop a presence from this mindfulness.
What is Mindfulness?
Since mindfulness is foundational to my understanding of ML and MLEOL, the following two
sections will discussed this state and its therapeutic efficacies further. Being mindful is a quality of
human awareness which, with practice, is expressed as compassion. Practice, it has to be stated
emphatically, must come first. Over time, through techniques like following the breath or attention over
and over again to this present moment, we may be able to see things more clearly with less reaction. By
introducing the activity of deep listening to our lives and by being mindful, we may find meaningful
and purposeful connections with others. In “this motionless turmoil” of listening to life to which
Stafford alludes, we might find greater peace and well-being.
Mindfulness has been translated from the East and defined in the West by myriad names, for
example, “sitting meditation,” “calm abiding,” “mindful awareness and presence,” “receptive and
focused attention,” and “wakefulness.” It conveys a process whereby we bring a quality of attention to
our moment-by-moment experience without judgement (Kabbat-Zinn, 1990). In its Eastern origins, it is
given more exotic names, such as shiné, shamatha, vipassana, zazen, shikantanza, dzog chen, all of
which include sitting practices. There are two distinct practices in mindfulness training, one which
develops concentration and the other insight. Shiné, from Tibetan meaning “the development of peace,”
refers to the concentration style of meditation (Trunga, p.4). In Japanese shikantanza, literally “just
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sitting,” refers to objectless awareness which is different from one-pointed and focused-attention
practice (Loori, 2002).
Through the 1980s and 1990s, Jon Kabbat-Zinn pioneered some of the early research into the
benefits of mindfulness practice and introduced the medical and healthcare system to its healing
potential. Kabbat-Zinn, after developing the well-known Mindfulness-Based Stress Reduction (MBSR)
program (1979), now boasts more than two hundred and fifty programs in North American hospitals.
He introduced mindfulness practice within a healthcare context to benefit people in Western society
who otherwise might be uncomfortable with Buddhist traditions and vocabulary (2000).
According to Ruth Baer, “researchers and clinicians who have introduced mindfulness practice.
. .teach these skills independently of the religious and cultural origins” (2003, p. 125). One of many
varied definitions from the Western tradition states that mindfulness is “the state of being attentive to
and aware of what is happening in the moment” (Brown & Ryan, 2003, p. 1). In Mindfulness: A
Proposed Operational Definition, Scott Bishop et al. (2004), a team of eleven authors, explore a two-
component definition of mindfulness which includes attention and awareness. In their inter-disciplinary
and collaborative effort, drawn from the fields of psychiatry, psychology, oncology, preventative and
behavioural medicine, physiology, and with input from the College of Physicians and Surgeons, they
worked to create an operational definition of mindfulness that was “testable.” The first component in
their definition explores our capacity to self-regulate our attention towards our experience of the
moment which allows for increased awareness of inner and outer events as they occur. The second
component addresses the particular way in which we are oriented towards our experience of the
moment, characterized by curiosity, openness, and acceptance (2004).
In looking at the many psychological benefits of mindfulness (Brazier, 1995; Baer, 2003;
Germer, Siegel & Fulton, 2005; Bien, 2006) important emphasis is placed on the role of acceptance,