NAVIGATING LIFE TRANSITIONS

Supporting clients as they go through major life transitions has been a significant part of my psychotherapy practice. I am now going through several major life transitions of my own. This challenging time has given me the opportunity to contemplate where I’ve been in my life and what may lie ahead, and to use the tools I’ve learned for navigating major upheavals in life.

I have been noticing my intense emotions as I go through the challenges of getting ready to leave our home of ten years, anticipating a move to a new city, and redefining my livelihood as I make this move. What I notice clearly is that this is a grief process (using my grief counselor and psychotherapist lens), and that it is a challenge to the ego and the process of letting go and trusting, rather than trying to control the outcome (using my mindfulness and Buddhist practitioner lens).

Buddhist teachings emphasize that change and impermanence are always happening, moment to moment. However, knowing this intellectually does not help us avoid painful and confusing emotions. In fact, working with those emotions is necessary for navigating life’s changes in a healthy way.

 

The Three-Step Emotional Rescue Plan

Dzogchen Ponlop, in his book Emotional Rescue: How to Work with Your Emotions to Transform Hurt and Confusion into Energy That Heals You, offers a helpful and effective “3-Step Emotional Rescue Plan” for working with and navigating difficult emotions.

Mindful Gap

The first step of the Emotional Rescue Plan is called “Mindful Gap.” In this step, we zoom in to fully experience what we are feeling. As I experience the emotional ups and downs of my current transition process, I first zoom in on what I am experiencing in my body. It might be a tight clenching in my chest or stomach, or a fluttery feeling around my heart. I can then identify the emotion associated with that direct felt sense. That emotion is often fear. I then hold the feeling and breathe into it, giving it some space and letting go of the thoughts that are needlessly intensifying the experience of fear.

Clear Seeing

This leads directly to the second step of the Three Step Plan: “Clear Seeing.” In this step, we zoom out to get a panoramic view of what we are experiencing. In my current groundless state of uncertainty, when I zoom out, I see that my fear relates to not knowing what is coming next for me, as well as a sense of helplessness in knowing that I cannot control the vicissitudes of my current situation. Zooming out to clearly see the whole picture helps me let go of feelings of isolation, knowing that we all, at one time or another, experience the roller coaster of life transitions. Knowing this, I can have greater compassion for myself and less resistance to experiencing the intense emotions that accompany transitions in life.

I also realize that I am experiencing sadness and grief as I navigate my transition process, and let go of many of the trappings of my old life. I remember, based on my knowledge and experience of the grief process, that all transitions and changes entail grief, even those transitions and changes that are positive. We need to say goodbye before we can say hello again.

Letting Go

Saying goodbye to an old way of being is an example of the third step of the Emotional Rescue 3-Step Plan, “Letting Go.” In order to move into the next chapter of my life, I need to let go of some of the trappings and self-identification of the current chapter of my life. Letting go is also a process of accepting what is. In my case, this includes accepting that I have no control over many aspects of relocating and redefining my career.

A Road Map for Navigating Transitions

William Bridges, in his seminal book Transitions:  Making Sense of Life’s Changes, talks about the transition process as a three step process: an ending, the neutral zone and a new beginning.

Endings

Our society does not respect and acknowledge endings the way that many other cultures do. Other than funerals and retirement parties, we have few rituals for acknowledging endings. We are told to “get over it” and not to “cry over spilt milk.”   Bereavement leave is often just a few days, and the bereaved must then put on a happy face and return to work. Our death defying medical culture values cure over comfort and dignified end of life care. The attitudes of our Western society do not encourage us to give ourselves the needed time to experience the fullness of the endings in our lives.

Bridges says that it is important to experience endings in order to fully move on to the next chapter in our lives. He states “the new growth cannot take root on ground still covered with the old habits, attitudes and outlooks because endings are the clearing process.” This clearing process allows us to relax into the neutral zone, the bardo space between the ending and new beginning, with a sense of spacious curiosity rather than anxiety and fear.

The Neutral Zone

It is a common human urge to avoid anxiety and fear by jumping from ending to new beginning. The “neutral zone” is the groundless space of not knowing, and is the most important phase of the process of navigating major life transitions.  Fully experiencing the endings in our life and grieving with appreciation what we are leaving behind can make the neutral zone a fertile time for self-inquiry. “For many people, the breakdown of the ‘old enchantment’ and the old-self image uncovers a hitherto unsuspected awareness,” says Bridges.

The “great emptiness of the neutral zone” provides us with an opportunity to examine our values and discover what is truly important to us now. Although most of us don’t have the opportunity to go on a solo vision quest, as do many American Indians, we can create a personal vision quest, taking time to be alone in silent retreat. Using time alone to meditate, journal or pray allows us to turn away from the outer world, turning inward to contemplate and ultimately discover what we want the next chapter of our life to be.

The New Beginning

Bridges describes the gap between the old life and the new as a process of disintegration and reintegration. Through this process we are renewed. Through renewing ourselves, with patience, equanimity and grace, we can discover what we want to create in the next chapter of our lives, our new beginning, with a sense of satisfaction and peace of mind.

 

References:

Dzogchen Ponlop. (2016). Emotional Rescue: How to Work with Your Emotions to Transform Hurt and Confusion Into Energy That Empowers You. New York: Tarchen/Perigee.

W, Bridges, (2004). Transitions: Making Sense of Life’s Changes (2nd ed.). Cambridge, MA: Da Capo Press.

 

© 2017 Beth S. Patterson, MA, LPC. www.bethspatterson.com. All rights reserved.

WHAT WE CAN LEARN FROM TREES IN WINTER

As the days grow shorter before the Winter Solstice, many of us experience increased sadness or even depression. For example, if we have experienced the loss of a loved one, we may feel intensified grief and loneliness. It can be excruciatingly painful to try to be jolly during the holidays when that’s the last thing we feel. We may even compound these difficult feelings by resisting or judging them, telling ourselves that we “should” be happy.

The process that trees go through in Winter can teach us about the natural cycle of life, not only for trees, but for human beings and all of nature. Trees are dormant in winter as a way to preserve their strength and gather nutrients so that they can bloom again in the spring. The process of dormancy is like animals’ process of hibernation: It is what keeps them alive. Everything in the tree slows down, including their energy, growth and metabolism. They drop their leaves to preserve their energy and strength. In fact, forcing a tree to evade dormancy by keeping it inside may actually harm the tree. Dormancy is part of trees’ natural cycle.

Similarly, it is natural for human beings to slow down and turn inward in winter, to conserve their energy, and allow that energy to be used for spiritual and emotional growth and renewal in the spring. Rather than resisting the natural rhythm of the winter months, we can see this time as an opportunity for profound personal and spiritual growth. In fact, the dark winter months can actually aid us in this process if we allow the darkness to envelop us like a sweet blanket of warmth, allowing us to open our hearts to our shared humanity and the natural rhythms of life.

We can also learn from our ancestors, indigenous peoples and pagan rituals that were timed to the cycle of the seasons. Winter rituals have long involved lighting candles, like the candles we light at Christmas and on Chanukah, also known as the Festival of Lights. These lights universally represent hope, as well as a sense of renewal on the Winter Solstice, which marks the shortest day of the year and the ensuing return of the sun and longer hours of light thereafter. As we tune in to the natural rhythms of Mother Earth, like our ancestors and indigenous peoples did, our bodies naturally align to the ebbs and flows of the cycles of the day and the seasons.

So, how can we be more like the trees and our ancestors in winter? Here are some suggestions:

• Nourish your bodies with hearty winter soups and stews, and warm and comforting beverages.
• If you are prone to depression or the “winter blues” due to the decrease in natural light, get a sunlight box, and get outside on sunny days.
• Take warm baths with Epsom salts and a few drops of lavender essential oil or other calming and soothing oil or bath wash.
• Walk in nature and appreciate the profoundly beautiful quiet of Mother Earth and her creatures in winter. Connect with the land and your body as part of the natural order of things.
• Accept the naturally shorter days, and appreciate what the longer nights have to offer. Hibernate by going to bed earlier. Turn off the TV and your cellphone and other devices and snuggle under warm blankets with a good book and loved ones.
• Nourish your soul. Go on a spiritual retreat, or create your own at home, by setting aside sacred time each day. Turn off all technology (yes, you can do it!), meditate, read spiritually uplifting books, journal, express yourself through writing, art or movement. Set aside a full day of retreat if you can.

As is said in The Book of Ecclesiastes, “To every thing there is a season, and a time to every purpose under Heaven.” Tuning in to, rather than resisting, the natural rhythm of the day and cycle of the seasons can put us in touch with nature, which in turn can heal us and connect us to our fellow human beings, animals, trees and all of nature.

GRIEF AFTER LOSING A MOTHER

I have learned through my work as a grief counselor that losing a mother (or other primary parent) is a profound transition and benchmark in life. I often tell clients that a mother’s death is so primal and deep because we have known our mothers since before we were born. As one grieving daughter recently put it, “When the person who gave us life is removed from our energy field, there is a hole that is hard to fill.”*

I have known about the grief of losing a mother intellectually through my studies, and as a witness to my grieving clients’ pain. I now know deep in my soul, after recently losing my own mother, that nothing can really prepare us for experiencing the death of our mothers. The feeling of my mother’s assuring embrace has buoyed me through the waters, both rough and smooth, sad and joyous, of my life. I am confident that as I move through the raw and acute pain of the beginning of the grief process, I will feel that embrace more and more.

Author LeAnne Schreiber has said, “What I have learned …is that a single death can transform your life, especially if the death is that of your mother or father….It doesn’t matter whether that parent was beloved or resented, whether the relationship was close or distant, warm or cold, harmonious or hotly conflictual. It doesn’t even matter how old you are, or how old your parent was at the time of death. For most people, the death of a parent is life altering.” (retrieved from http://www.oprah.com/spirit/When-a-Parent-Dies-Dealing-with-the-Death-of-a-Parent#ixzz3gSYzgUso).

I often describe families as mobiles, swaying to find balance in the face of life’s challenges. The mother is the anchor or the ballast piece of the mobile, helping the other family members who are part of the mobile maintain a semblance of balance. When that primary figure is taken away from us, the mobile wobbles greatly as it tries to find a new balance.
Part of the grief journey involves finding that new balance, individually and together as a family. In the process of finding this new balance, all of the positive and negative aspects of the family system come to the fore. The primary parent’s death may bind the family members together more strongly than ever before. On the flip side, the neurotic and more negative aspects of the family system are also more painfully apparent. From a systems theory perspective, the purpose of the family system is to find its own balance, however dysfunctional that may be. Without discounting that some families endure serious or abusive dysfunction, generally speaking, the family is made up of perfectly imperfect human beings. That is part of the beautiful complexity of life.

After the death of a loved one, we are left with the question “who am I now?” I am already wondering how I will fill the void of phone calls with my mother when I needed a guiding hand or wanted to share with her a joyous or sad experience. Because of the geographic distance between us, our phone calls often took the place of those reassuring hugs from my mother.
Other issues may arise as we experience our grief. We may realize that there is unfinished business that needs to be resolved. If the mother’s death was unexpected or her decline or death was painful to witness, there may be traumatic elements that need to be healed as part of the grief process.

Allowing ourselves to feel our pain, seeking support and allowing others to support us, taking care of our physical health, and expressing our feelings through journaling, dance, art or other media are some of the tools that will help us as we journey through this important life transition. Gradually, as we go through this process, the acute pain will subside, and we will be left with the nurturing love of our mothers in our hearts to guide us on our path through life.

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* This piece is written from the perspective of what psychiatrist D.W. Winnicott calls the “good enough mother,’ i.e., the mother who provided sufficient nurturance to create a sense of trust and safety in the growing child. It is not meant to ignore the many cases where the mother was not “good enough.” Such situations can complicate the normal grief process, requiring therapy to work through the pain of not having a mother who was good enough, in order to heal and move forward in life.

COPING WITH GRIEF AFTER LOSING YOUR JOB

 

Many of us think that grief should be reserved for the death of a loved one. However, grief can be experienced after any life transition, and one of the biggest life changes is the loss of a job. Here are some tips for coping with job loss.

  1. Remember to have compassion for yourself.

Feelings of shame often arise after losing a job. Shame is one of the most poisonous emotions humans experience. It can lead to self-punishment, which can come in the form of berating yourself for not doing a better job or for making a mistake that led to the job loss. Self-punishment may also play out in negative behaviors like substance abuse or promiscuity. Take time to understand that we all make mistakes, and that no one is perfect – including you. Self-compassion is so important in all aspects of your life. Be gentle and kind with yourself. Take the time to nurture yourself in body and mind. Do things that bring you peace and comfort, such as reading a good novel, getting a massage or taking a warm bath. Do them with the intention of caring for yourself with kindness and compassion, and breathe that into your heart.

  1. Develop skills to banish negative thoughts.

Thoughts of shame, blame, regret and doubt are inevitable after losing a job. The key is to not let those thoughts develop a life of their own. Mindfulness meditation techniques can be particularly helpful at this time. Learn to notice those negative thoughts as soon as they arise. Instead of following a thought, breathe into the feelings in your body that accompany the thought. It might be tightness in your chest or stomach, a clenching of your jaw or some other body sensation. Allow your breath to loosen those physical sensations. When the thoughts come up again, simply breathe into the accompanying body sensations. You may want to enlist the aid of a mindfulness meditation instructor or friend who practices mindfulness if this is a new technique for you.

  1. Take some healthy alone time.

The shame and other negative emotions that accompany losing a job may lead you to want to isolate yourself and avoid social interactions. It is fine to take some time to recover from the shock of losing your job. At the same time, it is important to use that time in a healthy way. Avoid the urge to overindulge in food or alcohol. Exercise can be extremely beneficial to help you combat depression, and the best form of exercise I have found is walking. Feel each footstep as it hits the ground, and when you notice yourself getting lost in negative thoughts, return to feeling your feet hit the ground. Treat yourself to a massage or other activities that help you feel better.

  1. Take some time each day to do something positive.

When we lose a job, we may feel hopeless or even worthless. Do something each day that reminds you of your worth. It may be something as simple as helping an elderly person cross the street, saying hello and smiling to people on the street or giving someone directions. You can offer to help your neighbors walk their dog, or volunteer your time for a cause you believe in. Being of service to others, even in the simplest of ways, will remind you that you are worthy and have something to offer.

  1. Express yourself.

It is so important to get the swirling emotions of grief out of your body in a way that is beneficial. Keeping all that stuff inside will only lead to depression and dis-ease. Keeping a journal is a great way to express yourself, and can help you not only get out all those messy emotions, but also may help you clarify what is now important to you and your next steps on your career path, or if applicable, your path to retirement.   If writing is not easy for you, there are other forms of expression that can also be beneficial, such as drawing or painting, dancing, singing or playing music or simply moving. The important thing is to move that energy outward.

  1. Evaluate and call on your support systems.

One of the most difficult things for me after losing my job many years ago as an attorney in the entertainment business was the loss of people I always believed would be there to support me, especially my colleagues in my corporation. It felt like they were staying away from me because they believed that the loss of my job might be contagious! This is what we in the grief field call a “secondary loss.” That is, the loss of my colleagues, and the lack of support from them was an offshoot of the loss of my job. I was given the opportunity to evaluate who was really there for me and, and to develop a greater appreciation for those who stepped forward to support me on my new path, and to actually allow myself to be vulnerable enough to let them to be of support to me. In retrospect, I now know that this process helped me develop as a compassionate human being in my personal and spiritual life, as well as in my professional life.

  1. Use this time to reflect on what is important to you.

Undoubtedly, people trying to be supportive have told you that losing your job can be a “blessing in disguise.” When you first lose your job, it feels like a blow and not a blessing. While you may not see your job loss as a blessing, it is nonetheless a great opportunity to take the time to reflect on, and perhaps re-evaluate, your passions, priorities and values. For example, when I was laid off from my corporate job as an entertainment lawyer, it felt like a death blow. I no longer knew who I was, because I had so strongly identified myself as my job. When I got over the shock of losing my job, it became apparent to me that I was being given the opportunity to find a new career path that more suited my spiritual path and my personal development. The loss of my corporate job and following the steps described above allowed me to fulfill my dream to become a psychotherapist and grief counselor and to express who I really am.

 

 

           

 

 

           

 

 

 

GRIEF CAN BE MESSY

 

A common complaint of my grief therapy clients is that they don ‘t think they are “grieving right.” I assure them that’s there’s no “right” way to grieve, and that, in fact, grief can be downright messy.

Just from a superficial point of view, the face of a grieving person can be pretty darn messy – bloodshot eyes, runny, red nose, puffy eyelids, red nose and other outward appearances that we might want to hide. Grief can also throw other physical aspects out of whack. Individuals who are grieving may either not sleep well or get too much sleep. Eating patterns can get interrupted as well, and it’s not uncommon for a bereaved person to either lose or gain too much weight.

The emotional side of grief is equally messy and can also be unpredictable. Emotional outbursts can seemingly come out of nowhere. I remember many times after a significant loss sitting in my car at a red light and screaming or pounding on my steering wheel. At times like those, I’m tempted to say to the driver next to me: “Don’t worry. I’m not crazy. I’m just grieving.”

People who pride themselves as being patient and calm can find themselves being angry, irritable, intolerant and impatient in their grief. I reassure clients who are concerned about this that these are normal grief reactions. At the same time, however, I am vigilant as a clinician to make sure these clients are not depressed. There is a major difference between normal grief and depression. Whereas grief, though difficult is usually “normal”, depression is not, and needs additional care.

A pitfall for some grieving clients is that they believe grief should follow an orderly fashion, and may point to the five stages of grief described by Dr. Elizabeth Kubler-Ross, i.e., denial, anger, bargaining, depression and acceptance. Dr. Kubler-Ross never intended for these stages to be linear and predictable, but rather, touchstones in the grief process. We cycle in and out of these stages in a sequence that is neither predictable nor orderly, but rather, can be downright messy. However, if a griever believes these stages to be linear, after experiencing some initial denial, he or she may think “OK, I’m done with that stage. I’ll check it off my list and go on to the anger stage.” They may point to Kubler-Ross’s model as proof that they aren’t grieving “correctly.”

There are many ways to work in a healthy and healing way with the mess that is grief. Because grief’s myriad expressions and emotions are unpredictable, grief can be stressful and exhausting. Therefore, the first step in healing grief is to take care of your physical being, making sure to get enough sleep, eat healthily and get exercise.

Telling the story of your loss can also be immensely helpful, as a way to make meaning of the loss. This will help with the feelings of confusion, helplessness, hopelessness and despair that can accompany grief. In addition, telling the story can help the bereaved maintain an emotional connection to his or her deceased loved one. Telling the story can be done by talking to others, journaling, writing a letter to your loved one, painting, or by any other form of expression. Expression helps to literally push out all of the swirling, messy feelings in a way that makes them workable.

Reaching out for support is also extremely important in working with the mess of grief. Calling on friends, family or one’s spiritual community and calling on one’s inner strengths and resources are all very beneficial in preventing isolation and depression.

Working with the messiness of grief can be like tending an unruly garden. Gently pulling the weeds, giving the dirt nutrients and carefully tending to the growing plants allows them to bloom. Similarly, giving our grief tender loving care can allow the mess of grief to transform into healing and growth.

GRIEF AS AN ESSENTIAL INGREDIENT IN GROWTH AND HEALING

 

As a psychotherapist, I am constantly inspired by my clients’ courage and commitment to change, and their willingness to face their struggles with open eyes, minds and hearts. My clients have taught me that an essential ingredient in overcoming and healing from life’s difficulties is grieving what has been given up in the name of growth– even if it is something negative or dysfunctional like addiction or an abusive relationship.

My work with “Sally” beautifully illustrates the healing power of grief in growth. Sally came to see me regarding her difficult relationship with her mother. It became apparent to me early on that Sally was tethered to her mother and that her mother was controlling, narcissistic and manipulative. Sally clearly loved her mother, and it was understandably difficult for her to see how her life was enmeshed with her mother’s and controlled by her mother’s neediness. Despite being a “grown up” with a keen intellect, wonderful sense of humor and a successful career, Sally still lived with her mother. When declining health forced her mother to enter a nursing home, Sally lived alone for the first time in her forty years of life. At first, she was fearful of living alone, and was unclear about what she wanted in her living situation. Sally has gradually gained more confidence in her ability to live independently, and eventually bought the family home, which is now in her name alone.

More importantly, with the perspective of space and time, Sally was finally able to clearly see who her mother is and the impact she has had in Sally’s life. She has essentially gone through the stages of grief described by Dr. Elizabeth Kubler-Ross, a psychiatrist who delineated the process people in grief experience.

The first experience Dr. Kubler-Ross describes in the grief process is denial. Sally was in denial for many years about her mother’s manipulative and narcissistic nature. People consider denial a “bad” thing, but it is necessary to our survival until we are ready to move on. Sally’s denial allowed her to maintain the status quo, which included career success. It was only when the status quo became uncomfortable and no longer workable that Sally was able to move forward in her process of growth.

The second grief experience described by Kubler-Ross is anger. I was hopeful that at some point in our work together Sally would have the courage to be angry at her mother as a step on her path to separate and differentiate from her. As a deeply spiritual person, Sally believed that anger was “wrong.” It took a while for Sally to understand that there is an inherent wisdom in the energy of anger, simply telling us that something is not right. Sally was ultimately able to express anger about her mother’s manipulation and control. This was a huge factor in Sally’s emotional separation and differentiation from her mother. She was able to use the energy of her anger to make the wise decision to buy the family home.

The next stage in Kubler-Ross’s model, bargaining, played out in a number of ways in Sally’s journey to healing and growth. When her mother first moved to the nursing home, Sally visited her daily, at a great cost to her own health and emotional wellbeing. On the brink of exhaustion, Sally has made a “bargain” with herself to visit her mother less often. This has been a gradual process for her, and has become increasingly easier despite her mother’s protestations as Sally has come face to face with her mother’s control.

When I assess for depression in the grief process, I always listen to how the bereaved talks about the loss. If the focus is inward on what he or she “should” have done, it may indicate depression, whereas if the focus is outward toward what has been lost, it is a sign of healthy grief. Sally rarely presented as depressed in our sessions. However, in her process of healing and asserting her independence, Sally did have some moments of depression. For example, she would berate herself for allowing herself to be manipulated by her mother and not seeing how her mother controlled her. I assured her that she did the best she could at that time, given her mother’s narcissism.

The last stage in the Kubler-Ross model is acceptance. It has been inspiring and beautiful to watch Sally work with the process of acceptance. Acceptance necessarily includes forgiveness. Sally has come a long way in understanding who her mother is, and she now sees that her mother’s mental ills resulted in large part from being emotionally abused by her own mother. Sally has also come a long way in seeing that her mother’s actions toward her were also abusive. She is grieving the opportunities she has missed because of her enmeshment with her mother, and has developed self-understanding and self-forgiveness. In giving up what she considered an idyllic relationship with her mother, Sally has been grieving the loss of what was, while also rejoicing in her new wisdom, confidence and growth.

 

FACING THE GRIEF OF AGING AND EMBRACING YOUR LIFE

I look in the mirror and see new lines on my face, a bit of drooping in places that never drooped before. I could wallow in self-pity and mourn the loss of my youth.  Instead, I choose to celebrate my years and experience.

I reflect on the rich, crazy and wonderful times I experienced in my life – being a hippie in the ‘60s; being a denizen of CBGB’s and part of the burgeoning punk rock scene in NYC in the ‘70s; coming into my own in the ensuing years; experiencing life as an entertainment lawyer, and giving it up to follow my dream to become a psychotherapist.

Here are some tips I have learned for embracing aging and letting go of grieving the loss of youth:

  • Know that wisdom comes from life experience, not from reading about it.
  • Appreciate yourself and what you have learned.
  • Celebrate your accomplishments.
  • Acknowledge your imperfections without judgment.  No one is perfect, young and old alike.
  • Accept your limitations.  So what if you can no longer run a four- minute mile?
  • Embrace patience.
  • Have compassion for yourself, and for all others on this path called human existence.
  • Celebrate impermanence.  After all, if things were permanent, nothing whatsoever would be possible.
  • Relish interdependence.
  • Reinforce your personal sense of spirituality through the beauty of nature, the arts and life’s little miracles.
  • Share your gifts and experience with others, and teach them what you have learned through life’s trials and triumphs.
  • Enjoy the quiet times.
  • Create a list of things you’d like to accomplish, and set about doing them.  It’s not too late.
  • Have a sense of honest humility about the things you’d like to accomplish but know that you may not be able to.  It’s OK.
  • Don’t dwell on regrets.  Again, nobody is perfect.  Acknowledge what you’ve learned from mistakes along the way.
  • Maintain a sense of humor and perspective, and laugh often.

Debunking the Myths of Hospice

As a psychotherapist specializing in grief and loss and as a hospice bereavement coordinator at SolAmor Hospice in Denver, I am saddened by how underutilized hospice care is. This is largely because of people’s misconceptions about hospice: Many people hear the word “hospice” and think it means a place where a loved one goes to give up and die, alone and on too many medications. Nothing can be further from the truth. Hospice is not a place, but a valuable service that supports dying patients and their family members to maintain hope, dignity and quality in all domains of life — physically, emotionally and spiritually — at this important stage in the lives of patients and their loved ones. The services provided by hospice allow a patient to spend his or her final days among family and friends, as alert and comfortable as possible and away from the hospital and dehumanizing high technology equipment. Hospice is about life. When there is nothing more that can be done to cure a disease, there is still much that can be done to enhance the patient’s life and to support the patient and the family.

The Services of Hospice

Hospice care is available to anyone who has a life-threatening condition or terminal illness with a prognosis of six months or less if the illness or condition were to run its normal course, as certified by the patient’s attending physician and a hospice medical director. Nonetheless, many people stay on hospice for more than six months, as long as they continue to meet the foregoing requirement at the end of each certification period. In addition, in electing hospice care, the patient elects palliative or comfort care, rather than curative or life extending treatment. In fact, as discussed further below, palliative or comfort care is a hallmark of hospice care, and hospice clinicians are expert in providing effective pain management.

In keeping with the hospice movement’s mission to provide care in all domains of life, each hospice’s program provides support to the patient and his or her family through the interdisciplinary team, consisting of the medical director, nurses, social workers, home health aides, chaplains, bereavement counselors, volunteer coordinator and volunteers. Also available, if necessary for comfort and quality of life related to the hospice diagnosis, are dieticians, speech, occupational and physical therapists.

What Does Hospice Care Look Like?

After a patient is admitted to the hospice program, each member of his or her clinical team –a registered nurse, social worker, chaplain and home health aide or certified nursing assistant — meets with the patient and his or her family and assess initial physical, emotional, social and spiritual needs and develop a plan of care for the patient, which may change as the patient’s condition changes. It is noteworthy that the patient and family or other caregivers are involved in formulating and changing the plan of care. Psychosocial needs are assessed by the social worker, including any needs for community services, and assessing the need for volunteers to provide companionship or other support, including massage, music or art therapy, or respite for family caregivers. The chaplain will provide spiritual support and also help the patient resource those in his or her spiritual community, as needed. The chaplain, in coordination with the social worker, will also help with funeral or memorial arrangements. The home health aide will assist with bathing and grooming. The need for pre-bereavement support will also be assessed, which is provided by the bereavement coordinator and grief counselors.

Bereavement support is provided for at least one year after the patient’s death to family members and others affected by the death. Many hospices provide this service for thirteen months, to guide the bereaved through the first anniversary of the death.

The Importance of Managing Pain

The management of pain — physical, emotional and spiritual — is one of the most important missions of hospice care. Unrelieved physical pain results in unnecessary suffering in the terminally ill. In a hierarchical needs system, the first step in managing global pain is to manage physical pain. Unfortunately, misconceptions about pain and pain control continue to interfere with the acceptance of hospice care. Some picture loved ones dying in hospice alone and in abject pain. The picture of the terminally ill dying in pain is, unfortunately, historically accurate. Before the advent of the hospice movement, under-treatment of cancer-related pain was common, and the terminally ill did often die alone in hospital beds. “[T]hey were often handled as bundles of physical symptoms or simply as failures of the medical system, But lost in all this ‘expert treatment’ was a human being with fears, questions, desires, needs and rights” (Callanan & Kelley, 1997, p. 25-26).

Fears about over-medication and addiction also discourage the wider use of hospice services. Addiction is very rare in the use of narcotics to treat pain. Hospice clinical staff is specially trained in the effective use of narcotics and other pain-relieving drugs, as well as drugs to counteract the side effects (such as nausea and constipation) of those drugs. In addition, anti-anxiety and anti-depressant drugs are used as needed to enhance the terminally ill patient’s quality of life.

It is impossible to work with a person’s emotional and spiritual pain if he or she is experiencing unrelenting physical pain. Unrelieved physical pain can lead to feelings of hopelessness and fear, and can also cause the patient to isolate him or herself from family and other support. With this in mind, Cicely Saunders, the founder of the modern hospice movement, developed the concept of “total pain”: “an understanding of pain as the complex interaction between physical pain caused by disease and pain caused by mental, emotional and spiritual malaise” (Brown, 2008, p. 190). If the patient is in chronic pain, he or she may give up hope of a peaceful and dignified death. Effective pain control allows the patient to maintain a sense of autonomy and control and focus on quality of life issues, unfinished business and spiritual concerns. Thus, the interdisciplinary team approach of hospice is indispensable for the treatment of “total pain.”

Hospice chaplains, social workers and bereavement counselors, as well as those in the hospice patient’s spiritual community play an important role in maintaining the patient’s quality of life and helping to relieve spiritual and emotional pain. Those facing death commonly search for essence and connectedness (Stephenson & Draucker, 2003, p. 57). Concerns about essence include questioning whether one’s life and death have meaning and purpose, questions about values, doubts and beliefs. Concerns about connectedness stir questions about how one is connected to family and others in one’s life, as well as to a higher being, and also bring to the surface the individual’s unfinished business in his or her relationships.

Listening to a dying patient’s fears and concerns is at the heart of the services provided by hospice (Callanan & Kelley, 1997, p. 28). Fears cited by hospice staff in working with the dying include fear of the process of dying, fear of loss of control, fear for loved ones, fear of dying alone, fear that one’s life has been meaningless, and fear of the unknown (Callanan & Kelley, 1997, p. 27-28).

Conclusion

Impermanence and death are part of the natural order of things, not something to be hidden away in fear and despair. Death and dying are integral parts of human existence, and indeed, of human development and growth. As Elizabeth Kubler-Ross has observed: “If you can begin to see death as an invisible but friendly companion on your life’s journey… you can learn to live your life rather than simply passing through it” (Kubler-Ross, 1975, p. x). Hospice care is available as a companion on that journey, enabling patients and loved ones to embrace this special and sacred stage of life with dignity, autonomy and peace.

References

Brown, G. (2008). Courage: Portraits of Bravery in the Service of Great Causes. New York: Weinstein Books.

Callanan, M. & Kelley, P (1997). Final Gifts: Understanding the Special Awareness Needs and Communications of the Dying. New York: Bantam Books.

Kubler-Ross, E. (1975). Death: The Final Stage of Growth. New York: Simon & Schuster.

Stephenson, P.L. and Draucker, C. B. (2003). The Experience of Spirituality in the Lives of Hospice Patients. Journal of Hospice and Palliative Nursing 5(1), 51-58.

The Use of Narrative Therapy in the Transformative Work of Healing Painful Life Transitions

Helen Keller has said that “the only way to get to the other side is to go through the door.”  This is certainly true in the work of transforming painful emotions, such as those we experience after a divorce, into healing and growth. This process involves allowing ourselves to feel the intense emotions of grief – sadness, anger, despair and other difficult emotions, as well as tapping into our internal strengths and external sources of support.

Narrative therapy and has been used with a wide variety of difficulties and issues, including reactions to a major life transition.  The role of the narrative therapist is as collaborator or co-author with the client.  As such, the narrative therapist partners with the client to explore the stories that give meaning to the client’s life (White, 1995). The The

Narrative therapy is thus an empowering vehicle for “re-authoring lives” (Carr, 1998, p. 468; White, 1995), in which the therapist takes the role of a partner or collaborator with the client, rather than an authority figure (Angell, Dennis & Dumain, 1999).. The narrative therapist partners with the client to create a safe place to feel the emotions of loss and change, and to explore the stories that give meaning to the client’s life. The use of narrative or story is a useful vehicle for making meaning and sense of difficult experiences in our lives, by allowing us to access alternative cognitions and gain self-knowledge.

A narrative therapy tool that is often used in this work is the use of written expression, such as journaling and letter writing.  This can be a powerful vehicle for expressing the emotions of loss and change and accessing the individual’s unique internal strengths and resources.

The collaborative approach of the narrative therapist can be useful for accessing the client’s spiritual strengths by respectful inquiry into the client’s worldviews, including his or her beliefs before the loss, and how they may have changed since the loss, and discussing spiritual and existential issues that arise in this context. (Calhoun & Tedeschi, 2000, p. 167).

As one gets in touch on a deep level with his or her own suffering and resiliency in the face of that suffering, he or she can begin to get a panoramic view of the human condition and tap into his or her spiritual strength. Religious and spiritual beliefs have been observed to be one way in which individuals create meaning and a sense of order and purpose to the human condition and its difficult transitions (Golsworthy & Coyne, 1999; Calhoun & Tedeschi 2000).

Narrative therapy can be an effective tool for working painful emotions and finding new meaning in one’s life.  The process of expression literally takes deep feelings out of the body, externalizing them so that they become workable. Through this process, my clients are able to see that they have some control over their lives, and can tap into their strengths and their inherent wisdom.  With my guidance as a partner on the path of healing painful life transitions, my clients can discover their unique strengths, resources and resiliency, deepen their spiritual beliefs, and enhance the meaning of their lives in the context of the human condition.

The Heroine’s Journey: The Modern Woman’s Quest for Professional and Personal Fulfillment

According to Carl Jung’s theory of human development, the first half of life is devoted to differentiation and development of one’s individual ego, and the goal of the second half of life is integration and a movement toward wholeness, also known as individuation.  Individuation is accomplished by developing the undeveloped side of one’s life.  Traditionally, for men, this entails developing the anima, the feminine capacities for nurturance, feeling and intuition. For women, this entails developing the animus, the masculine capacities for logical thinking, action and assertiveness.

However, my journey as a woman in the second half of life has taken a different path.  As a product of the feminist revolution of the 1960s and 1970s, I spent the first half of my life differentiating in a way that developed my male energy at the expense of my feminine nature.  I became an attorney in the male-oriented entertainment industry, and had to “act like a man” to succeed and survive.  I felt unfulfilled and incomplete as I moved into the second half of my life.  Being a high-powered attorney in New York City was no longer congruent with my changing identity.  As a result, when I turned 50, I become a psychotherapist in order to develop my nurturing, feminine and intuitive side, while also working as an attorney for musicians, and letting go of some of the trappings of my career as a New York corporate attorney.

The Process of Individuation

Carl Jung and Erik Erikson both emphasized adult development in their theories (Crain, 1992, p. 287).  For Erikson, the developmental task in mid-life is a choice between “generativity” and “stagnation.”  Staying on the outward-oriented path of ego development and differentiation without self-reflection can lead to stagnation and spiritual aridity. In contrast, turning inward with introspection in order to attain wholeness and balance in one’s life can lead to ego transcendence, and the ability to give back to younger generations, i.e., generativity.  Jung describes the journey toward integration as “our unconscious striving for centeredness, wholeness and meaning, …and inner urge to balance and reconcile the opposing aspects of our personalities,”  (Crain, 1992, p. 290).

Traditionally, the path to individuation is said to be achieved by developing “those unconscious parts of ourselves that carry the mystery of the sex that is not ours” (Singer, 1992, p. 134).  This model is not relevant for many modern women.  During the differentiation stage of the first half of life, high-achieving women by necessity developed the energy of the male sex, neglecting their feminine energy.  For such women, the path to individuation is a process of reuniting with the feminine qualities of their anima.

The Heroine’s Journey

Maureen Murdock’s book The Heroine’s Journey (1990) describes  the process of individuation for women like me as the “heroine’s journey.”   This journey entails (1) separation from the feminine (generally, the mother); (2) identification with the masculine and gathering of allies; (3) road of trials:  meeting ogres and dragons; (4) finding the boon of success; (4) awakening to feelings of spiritual aridity; (5) initiation and descent to the Goddess; (6) urgent yearning to reconnect with the feminine; (7) healing the mother/daughter split; (8) healing the wounded masculine; and (9) integration of masculine and feminine (Murdock, 1990, p. 5).

Murdock’s description aptly parallels my journey.  I separated from my mother to go to college to find a self-sufficient career.   I identified with my father as a successful professional, and gathered male allies during law school and as professional colleagues.  My road of trials entailed meeting ogres and dragons in the form of male bosses, competitors and back-stabbers.  I nonetheless prevailed and was highly successful.   However, this success became increasingly arid for me, and I descended into depression, yearning to reconnect with my nurturing, feminine spirit. In the process, the mother/daughter split was healed as I found my second half of life calling.

Conclusion

Therapists working with modern women can no longer rely on the traditional Jungian theories about the balancing of anima and animus to help those clients on their path to achieving personal and professional fulfillment.  For myself, I have known for some time that my anima and animus were out of balance, but the literature on the second half of life, emphasizing the development of the animus in women, did not fit my experience, and did not help me.  The heroine’s journey as described by Murdock is the first description I have found that validates my experience.  It is a valuable lesson for those working to assist women today in their search for wholeness and spiritual maturity.

References

Cooper, J.C. (2004).  An illustrated encyclopaieda of traditional symbols. New York:  Thames & Hudson

Crain, W. (1992).  Theories of development:  Concepts and applications (3rd ed.). New York:  Prentice-Hall, Inc.

Murdock, M. (1990). The heroine’s journey:  Woman’s quest for wholeness. Boston:  Shambhala Publications, Inc.

Singer, J. (1994).  Boundaries of the soul:  The practice of Jung’s psychology. New York:  Anchor Books.