Much has been made over the past several years about the state of American health care. What it needs, what it does not, and who is responsible for both. Lost in that discussion, however, is the very nontheoretical and yet everyday experience of becoming ill, or facing mortality, and engaging the clinician in hospital rooms that do not distinguish between red and blue states. What happens when politics are trumped by diagnosis?
Since the early 1970s, when she was a medical anthropologist, Mind and Life Fellow and board member Roshi Joan Halifax has been operating at these pivotal moments in human life. A Zen priest, Halifax is the founder, abbot, and head teacher of the Upaya Institute and Zen Center in Santa Fe, New Mexico, which has a central focus on applied Buddhism. The Center also offers programs connected to Halifax’s pioneering professional training program in compassionate end-of-life care: Being with Dying. Being with Dying focuses on developing, in health care professionals, the psychosocial, ethical, and spiritual aspects necessary to care for the dying. Trainings based on it have occurred in hundreds of medical and educational institutions around the world.
Recently, Halifax launched a complementary offering called GRACE. It stands for “Gathering attention,” “Recalling intention,” “Attunement to self/other,” “Considering what will serve,” and “Engaging/ending”—all stages of an internal process clinicians can undertake to stay centered and compassionate while avoiding the burnout that can coincide with the personal distress when in the presence of suffering.
We spoke with Halifax after she moderated Mind and Life’s latest Dialogue with the Dalai Lama on craving, desire, and addiction. The following are excerpts from that exchange.
Was there a moment in your life when you realized that the field of medicine may need the gifts of the contemplative traditions?
Since the 1960s, I’ve been fortunate to have a meditation practice. When I found myself working in a huge hospital in the 70s, along with clinicians, medical students, and patients, I saw that training the mind, cultivating compassion, having attentional balance were essential for those who serve the sick as well as for those who were sick. But meditation was not something that was taught in medical school at that time.
Medicine is an evidence-based discipline. Medical training is often grueling. Compassion is frequently regarded as suspect. It’s been more than 40 years since I conducted my first experiment in meditation with clinicians. Today, Mindfulness-Based Stress Reduction (MBSR) and other similar programs are taught in medical schools in many parts of the world. Upaya’s clinician training is another powerful endeavor. For example, more than 60 clinicians from the University of Virginia have been trained in our program, and clinicians come from around the world to the training. Mind and Life’s contribution to the training has been significant, as it has introduced to a wider world the science of the profound value of the inner life, particularly the importance of training the mind.
Would you say the oft-trumpeted idea of dispassion in medicine as a means to diagnose accurately is therefore a false notion?
I feel that the diagnostic process is enhanced with attention and empathy, a grounding in self-attunement—being aware of one’s own somatic, affective, and cognitive biases—and insight and compassion. That’s why I developed the process called GRACE. After a clinician “gathers” her attention, “recalling intention” reminds her to remember that she is there to serve and to aid in ending suffering, the ethical basis of care. “Attunement” is about connecting with our somatic, affective, and cognitive responses to the patient—this is an active part of bearing witness: You first “sense” into your own subjective experience, then into the patient’s. Most clinicians jump right into diagnosing the patient before getting a sense of their own biases. Our own unconscious biases are often at work and can distort our perception of what is really going on. Another interesting value in this process of “attunement” is how it primes the neural networks associated with empathy.
This relates to Mind and Life Fellow Tania Singer’s work.
Yes. When Tania shared her research on interoceptivity and empathy, I was struck by her findings, and my colleagues—Drs. Tony Back and Cynda Rushton—and I did a major revision of Upaya’s clinician training curriculum based on the work of neuroscience and social psychology. I then developed a heuristic model of compassion when I realized that you can’t teach compassion without training in attention, prosocial affect, intention, insight, and embodiment. In other words, compassion is made up of non-compassion elements. I see compassion as the great key to being an accomplished clinician.
In the GRACE process, you note that seeing a patient’s suffering as not one’s own is essential in helping a clinician not to be overwhelmed by the suffering. But does “detachment” oppose the process of empathy that GRACE encourages?
In fact, GRACE, the application of the compassion model, is not about developing empathy, but about fostering compassion. It is not that empathy is a bad thing. Not at all. However, it is only one element in the compassion process. For example, if a clinician is over-empathic, distress can follow, and compassion is not possible. Daniel Batson, Nancy Eisenberg, and Tania Singer have made clear cases for the necessity of regulating empathic arousal so as not to slide into personal distress. Empathic arousal is necessary—we have to feel something!—but feeling too much can push us over the edge into states of distress that give rise to fear-based responses, including moral outrage, avoidance or abandonment of the patient, or numbing, as well as self-protective responses termed “selfish prosocial behavior.” Some people are naturally able to regulate their empathic responses. For others, this is not so easy, and distress increases and resilience decreases. So learning to recognize signs of empathic distress is important.
How does a person regulate empathy?
There are a number of approaches, including recognizing that your patient’s suffering, on some level, is not your own. This uses a cognitive appraisal process that allows you to feel but not be overwhelmed. In my years of working with clinicians, the loss of boundaries in the clinical process with attendant empathic distress is one of the greatest causes for clinician suffering, clinician distress, and clinician breakdown. Consider the impact of pathological altruism: vital exhaustion, secondary trauma, moral distress, horizontal and vertical hostility, and structural violence. Clinicians can benefit profoundly from reflective and meditative practices that stabilize the mental continuum, enhance prosociality and insight, and cultivate a strong ethical base.
How are the obstacles to compassion in a medical setting related to our reluctance to accept death as inevitable? In other words, isn’t a part of compassion coming to an understanding that medicine cannot save us? Otherwise, compassion begins to appear like ego, doesn’t it? That a doctor or nurse must save a life at all costs to fulfill his or her purpose.
Life is precious. Clinicians know this; this is why most have gone into medicine. Doctors and nurses want to end suffering and prevent death. This is a profound value in medicine. At the same time, a subtle and insidious distortion exists within medicine, which is to avoid death at all costs. And the costs can be great, not only to patients, but to families and clinicians as well. Death is normal; it is inevitable. So how do we balance these two things: that death cannot ultimately be avoided, and that the clinician’s work is to keep death at bay? I think we live in an either/or world; somehow it is difficult for us to hold contraries, and this is a contrary: how to do the best we can to support life and at the same time rest in the wisdom of not being attached to outcomes.
How do we do that?
I keep returning to the great value of mind training. Meditation was long looked at as something exotic and marginal. Doctors and nurses would ask, “Why spend time doing nothing?” Well, a very different picture is emerging at this time. For clinicians, “doing nothing” is what might be needed, mentally and interpersonally. Or to put this another way, the value of your doctor or your nurse being stable, present, kind, alert, and compassionate cannot be underestimated. There is really only one path to cultivating this collection of qualities, and this is through training the mind.
It’s fascinating that attention forms the base of compassion in much of your work. How do we ensure that gateway in a world that almost demands distraction? How do we make attention “seductive” again or even once more a matter of etiquette?
We do live in a world where our attention has been co-opted by market forces, as well as by fear and addiction. We are more easily manipulated when our attention is divided, dispersed, or distracted. Techniques that train in attention, such as those in Buddhism, are based on the selfless intention to be of benefit to others. So, we can say that attention and intention influence each other. In the end, altruism, kindness, and compassion are mental qualities that give life meaning and enhance the well-being of all. The case for prosociality is very compelling, to say the least. And distraction and poor attentional balance is tiring, to put it mildly!
When you consider all the work you’ve done on death and dying, what do you feel people still don’t understand about the process or need to realize before they enter it?
I entered the end-of-life care field in the early 70s because, of all the disciplines in medicine, working with dying people is where fundamental existential questions exist. We will all die. We all want to die well. And we can never really penetrate the mystery of death. It is the contemplation of our own mortality and the mortality of those whom we love that can give life meaning. Our priorities become clear, our relationships more cherished, our purpose for being alive can become more grounded in selfless compassion. The value of meditation practice, of training the mind and the heart, cannot be underestimated in relation to the truth that we will face death sooner or later. Having a mind that is clear, grounded, open to not-knowing, kind, at ease with change, stable, and able to let go—what can be more valuable as we die or as we care for those who are facing death?