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Abiding in liminal space(s) : inscribing mindful living/dying with(in) end-of-life care Bruce, Winifred Anne 2002-12-31

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A b i d i n g i n L i m i n a l Space(s): Inscribing M i n d f u l Living/Dying With(In) End-of-Life Car  by  W . Anne Bruce  R . N . , Victoria General Hospital (Halifax), 1977 B . S . N . , University of Victoria, 1992  A thesis submitted in partial fulfillment of the requirements for the degree of  D O C T O R OF PHILOSOPHY  in  T H E F A C U L T Y OF G R A D U A T E STUDIES S C H O O L OF NURSPNG  We agcepPthis thesis as conforming to the required standard  T H E UNIVERSITY OF BRITISH C O L U M B I A October 2002 © Winifred Anne Bruce, 2002  In presenting degree  this  thesis  in partial  fulfilment  of the requirements  at the University of British Columbia, I agree  freely available for reference and study. I further copying  of this  department  or  agree  that the Library shall make it that permission for extensive  thesis for scholarly purposes may be granted by his or  her representatives.  It  is  by the head  understood  publication of this thesis for financial gain shall not be allowed permission.  Department-of  3C.KQQ\  Q-P  The University of British Columbia Vancouver, Canada  Date  DE-6  (2/88)  Oct-  n  ,^ooa  K)U/S>'  for an advanced  that  without  of my  copying or my written  ABSTRACT Abiding in Liminal Spaces: Inscribing Mindful Living/Dying With(In) End-of-Life Care Mind-body approaches such as mindfulness meditation are increasingly incorporated into health care. Despite a growing interest in mindfulness, its Buddhist philosophical underpinnings remain unexplored in nursing. Without an awareness o f the nondualistic assumptions embedded in mindfulness and Buddhism, interpretations o f this Eastern practice are limited. This inquiry engages Buddhist philosophical thought and the experiences o f meditation practitioners. The purpose o f this study was to explore mindfulness by those who regularly practiced mindfulness meditation and were caregivers in a Zen hospice or living with a life threatening illness. Approximately ten weeks o f residency in a Zen monastery, and participation in day-to-day volunteer caregiving in the Zen hospice were undertaken. Indepth unstructured conversations were conducted; mindful, open-ended reflexivity (Varela, Thompson, & Rosch, 1991) and koan construction were used in ongoing analyses and interpretation. Theoretical explorations in this inquiry constitute and reflect knowledge(s) about that which is unknowable, indistinct, and ambiguous. The inquiry addresses how we may point to 'that' which is beyond words with attention given to language and what happens with/in language as we write and are written through texts. Unconventional forms and writing are used to question conventional privileging o f representational binaries that value words over silence, life over death, clarity over paradox, and knowing over unknowing. Death, re-interpreted in the Buddhist sense o f the participants, is constructed as momentary experience occurring each mind-moment. Life is not necessarily privileged over death, but rather is seen as a doubling o f living/dying intertwining within momentary awareness. A re-configuring o f living/dying is suggested that differs from Western perspectives where ' l i v i n g ' holds hegemony over 'dying'. Death is situated in the midst o/ —liminal space(s) o f being/not being and ubiquitous change while mindfulness meditation is seen as a parallel process providing an embodied realization o f this transience. :  These perspectives may help nurses and health care professionals go beyond dualistic views and provide guidance for abiding in the midst o f suffering that may be beyond words. Further inquiry into non-conceptual awareness and its relationship with health and wellness is needed.  11  T A B L E OF CONTENTS  ABSTRACT T A B L E OF CONTENTS LIST OF TABLES ACKNOWLEDGEMENTS DEDICATION STRAND O N E -  G/round of Inquiry  G/round Introduction Purpose Background Buddhism in North America Establishing Intention Locating the Inquiry and Inquirer Edges o f Modernist V i e w s Edges o f Non-Modernist V i e w s Attending to Language  Locating Theoretical Context (s) o f Buddhism Buddhism in Nursing Theorizing Eastern and Western Philosophical V i e w s Twofold Truth Buddhism G/round o f Buddhist Thought Four Noble Truths Nonduality Self/No-self  Meditation Practice Introduction to Meditation Meditation and Relaxation Types o f Meditation Concentration Mindfulness  iii  STRAND TWO ~  Diverse Voices in End-Of-Life  48  Changing Conceptualizations o f Death Contemporary Hospice/Palliative Care Movement Shifting ground- Hospice and Palliation Shifting ground ~ Humanist and Transpersonal Orientations Meditation and Dying: Death o f the Body, Death o f the Self Integrating East and West ~ Zen Hospice Project  49 51 52 54 58 61  Mindfulness Meditation and Health Current Inquiry Missing Voices  64 65 69  STRAND T H R E E -  71  Path of Inquiry  Introduction Mindful Reflexivity Reflexive Approaches Reflection and Reflexivity Mindful, Open-ended Reflexivity  72 76 76 76 78  Inquiry Design , Locating Sites and Negotiating Access Inviting Participation Generating Data Reflexive Participation Audiotaped Conversations  80 . 80 85 89 89 93  Engaging with Texts - Practical Considerations Audiotaped Conversations Ensuring Ethical Inquiry Approaches to Interpretation Preliminary Approaches in Analysis and Interpretation Strategies o f Mindful Reflexivity Steps along the path Koans  iv  95 95 99 100 100 102 103 107  STRAND F O U R -  F r u i t i o n of I n q u i r y  FRUITION KOAN COMMENTARY Dying as Interesting Re/cognizing M i n d Situating M i n d Constituting M i n d as Doubling Existential Questioning Situating Birth-and-Death Non-Existential Questioning Doubling of Life-and-Death Examining the Play o f M i n d Meditation and Dying as Parallel Processes Turing Inwardly Outward Silences Inter/play of Silence Letting G o Letting G o of Fixed M i n d Letting G o of Time Linear time Cyclical time Present time Dissolution Martin's Dissolution Story Dissolution o f Elements Inner and Outer Manifestations of Elements Sophia's Dissolution Story  Hospice Care as Meditation-in-Action Intentionality of Service Caregiving W i t h a Unique V i e w Engaging and Being Engaged Cultivating U n / K n o w i n g Discovering More Possibilities Doubling: Seeing Differently Realizing Impermanence Resting In Groundlessness VERSE  STRAND FIVE ~  Discussion and Implications  Introduction Situating within Nursing Philosophy Resonance and Disjunctures Presence/ Absence K n o w i n g / Un/knowing Re-configuring Death L i v i n g / Dying Further Implications Relevance for Nursing Practice Relevance for Nursing Education Relevance for Future Inquiry  STAND SIX ~  Lingering Meditation  REFERENCES  APPENDICES Appendix A : Copy o f Consent Form Appendix B : Copy o f Conversation Questions  vi  LIST OF TABLES TABLE 1:  Demographic profile o f inquiry participants  TABLE 2:  Inner and outer manifestations o f elements  i.  vii  ACKNOWLEDGEMENTS Although writing a dissertation often feels like a solitary endeavour, the solitude is teaming with people who have been accompanying me along the way. To these teachers, friends, and family, I am deeply indebted. To my committee members, who gave me the freedom to follow my inclinations and 'suffer the questions,' I extend my heartfelt thanks. Dr. Betty Davies has provided unwavering gentleness and opened opportunities to engage in additional research projects and publishing experiences that have inadvertently benefited this project. Dr. Joy Johnson has been an insightful role model with enthusiasm and openness to learn from each other, and was invaluable in her support for obtaining funding for this inquiry. Although busy and in great demand, Joy and Betty always appeared unhurried, available, and sincerely interested in this inquiry. Dr. Ted A o k i was a mentor and sensei (master teacher) in cracking open wor(l)ds and assumptions. Ted's teaching through his richly textured handwritten messages or conversations over coffee, infused vitality and possibility throughout this inquiry process. A n d finally, Dr. Heesoon B a i has been a kindred spirit. Heesoon's thoughtful questioning, strong philosophical training, and interest in Buddhadharma have provided a touchstone for this writing. This project could not have happened without the support o f Zen Hospice Project. Thank-you to Zuza Engler, Silvia Fiscallini, Brad Byrum, and Frank Ostaseski for their generous invitation into Zen Hospice. I am grateful to the study volunteers for sharing their experiences and wisdom, and the Hartford Street Zen Center H I V - A I D S sitting group for welcoming me into their fold. In addition, thank-you to Michael Wenger, Paul Hallar, Jen Hagar, and A l i s o n Jordan who made my stay at the San Fransisco Zen Center an embodied experience o f loving-kindness. The hidden skills and tenacity o f friends who stayed the course over these years cannot go unnoticed. Nine bows (Zen form o f appreciation) to Barb Moffat, Katherine Doranne McGeean, Stephen Swick, and Jacques LaCroix for their editorial sensibilities and warm friendships. In addition, thanks to Camilla Morrow, Sonia MacPherson, and W i l l i e Chen for persistent telephone contact and endless discussions about all matters esoteric. For earthly concerns, I thank Bev McCarthy for her soups, Barb's insistence on maintaining our seasonal opera tickets, and my sister Susan for her unbounded kindnesses. I would like to acknowledge the generous financial support from the Social Sciences and Humanities Research Council o f Canada, the Michael Smith Foundation for Health Research, U B C School o f Nursing, and U B C Green College. Finally, I am most grateful to my parents, Sophia and Thomas Bruce, for so many reasons including their good humour, unfailing compassion, and grounded optimism.  viii  DEDICATION  This thesis is dedicated to my parents Sophia (Starks) Bruce and Thomas Anthony Bruce  ix  STRAND ONE ~ G/ROUND OF INQUIRY  A day without thinking about death is a wasted day Zopa Rinpoche  G/ROUND  In Indian mythology, Indra was a God who attached all phenomena with visible and invisible strands weaving together a universal net. Earth, trees, clouds, mountains, sky, passion, aggression, creativity, women, men, and children, all were connected in Indra's expansive net. At the intersections of these strands, Indra tied dulcimer bells. In that way, as one part of the net was pulled or moved, the bells would ring; when the sound of a bell was heard, awareness of interconnectedness arose becoming another strand of consideration in one's weave. W h e n the bells were ignored, an illusion of separation and independence reigned; the outcome could be destructive, reverberating throughout the net.  Simultaneously we read and weave anew. Texere, meaning to weave, is the Latin root of the word 'text' . The text(s) constituting this inquiry are woven from many strands into and from a medley of voices and interpretive locations. Like any text, those texts embedded within these pages come into being upon reading and intertwining with those of the reader. In these inter-textual spaces lie boundless possibilities for other st(r)ands to arise. 1  The impetus for this inquiry comes from various threads that include an interest in our culturally woven patterns of dying and death. In particular this study addresses Buddhist practices of mindfulness and, like Indra's net, its attention to the interconnections and spaces of weaving, the weaver, and the woven. The inquiry is a study of mindfully living/dying and its inter-textual spaces with mindfulness as the ground of inquiry, the path of inquiring, and the sound of its fruition  ' Hawkins, J . M . & Allen, R. (Eds.). (1991). The Oxford Encyclopedic English Dictionary. New York: Oxford University Press.  2  Buddhist in Tibetan is nangpa. It means "inside-er": someone who seeks the truth not outside, but within the nature o f mind. A l l Buddhist teachings are aimed at the single point: to look into the nature o f the mind, and so free us from the fear o f death and help us realize the truth o f life. (Sogyal, 1993)  Introduction During the past 20 years, I have been exposed to alternative approaches to health and wellness through living and working in Bangladesh, Nepal and India. These experiences have heightened my interest in the study and research o f mind-body connections and in particular, I am drawn to the philosophical views and practices o f Buddhist meditation and its relationship to the experience o f death and dying. Buddhism is a 2500-year-old tradition that contemplates the experiences o f birth, old age, sickness and death. A s a practice and philosophical perspective, this tradition has much to offer from its theoretical and practical approaches to working directly with mind and emotions. Compelling evidence suggests that mind-body interactions are at the root o f both health and disease (Pelletier, 1992). Although extensive evidence illustrates the positive health outcomes o f mindfulness meditation in responding to anxiety, chronic pain, and stress (Kabat-Zinn, Lipworth, Burney, 1985), little is known about the experience o f meditation by those facing the inevitability o f death or caring for those who are dying. Recent studies within palliative care nursing urge further exploration o f mind-body approaches such as meditation in supporting end-of-life care (Adams, Hershatter & Morritz, 1991).  3  Purpose The purpose o f this inquiry is to explore the experience o f mindfulness by those who regularly practice mindfulness meditation and who are living-with-dying or caring for persons at the end o f life. M y curiosity lies in the constructions and experience o f mindfull awareness within a Buddhist framework in order to expand our understanding o f mindfulness as a meditative practice and its influence in shaping one's relationship with living/dying and death. Background: Growing Interest in Alternative Health Approaches Mindfulness meditation has entered the North American lexicon in recent years as part o f the plethora o f alternative health care practices now available. Alternative approaches to conventional biomedicine are being used by a growing number o f Canadians as the limits o f allopathic medicine are recognized and prolonged chronic illness and living with life-threatening illnesses increase. In a national survey, 42% o f adult Canadians reported having tried alternative therapies (Angus Reid, 1997). Although the use o f alternative therapies, including meditation, seems like a recent phenomenon, ancient traditions and non-Western approaches to healing have offered differing understandings o f health, illness, dying, and death. It is only recently however, that nonmedical forms o f health and healing have been popularized in the West (Eisenberg et al., 1998). Although meditation in some form is found in most cultures (Taylor, 1999), Asian traditions o f meditation are the primary source for most health care practices integrating mind-body approaches. A s these practices are adapted into Western cultures, their roots in Eastern philosophical thought must be explored i f trustworthy interpretations are to be made.  4  Buddhism in North America Buddhism has been declared the fastest growing religion in Britain with estimates o f 130,000 practicing Buddhist in the United Kingdom (Sibley, 1997). In Canada, 163,500 Canadians identified their religious affiliation as Buddhist in the 1991 census (Canada, 1991), with between 3 to 4 million identified Buddhists in the United States, o f which about 800,000 are converts (Baumann, 1997). Historically, Buddhism originated in the life and words o f Siddhartha Gautama (Shakyamuni Buddha), who lived and taught from approximately 566-486 B C E in what is known today as Nepal (Williams, 1989). Buddhism is often described in Western literature as an Asian psychology, a philosophy, and a religion (Conze, 1951; Corless, 1989). However, as Buddhism is non-theistic, some scholars argue that it cannot be considered a religion but rather is more accurately understood as a philosophy ( V o n Glasenappp, 1970). Most inquiry using theoretical frameworks drawn from Buddhist systems o f thought is found within transpersonal psychology; increasingly, however, Buddhism is being examined in domains such as psychotherapy (Epstein, 1995; Welwood, 1996; West, 1987), nursing (Coberly, 1993), and hospice care (Ostaseski, 1994). Even so, Stephen Batchelor (1997) asserts that Buddhism is primarily a  method.  Batchelor cautions that fascination with Buddhist theorizing o f mind and human experience may overshadow the practice o f 'awareness' or paying attention that underlies all Buddhist theory. Buddhism is a method for fostering attention that must be investigated and tried out; it is an empirical practice rather than a theoretical position. (Batchelor, 1997)  5  What Siddhartha taught was how to work with one's mind through cultivating awareness. He challenged people to pay attention and through paying attention to appreciate how the mind works in perceiving  and interpreting  both the experience and the experiencer.  Buddhism has been part o f North American cultural experience for more than a century. Ryuken Williams and Queen (1999) chronicled Buddhism in the Unites States, identifying what they call recognizable patterns o f hybridized American Buddhism. Historically, Buddhism has accommodated cultural mingling during its transplantation throughout A s i a and seems to be continuing this process o f hybridization in Europe and North America. In its newest North American form, Ryuken Williams and Queen identify: democratization  (the emphasis on lay practice and the rise o f women in  membership and leadership); pragmatism  (an emphasis on ritual practice including  meditation, and chanting); and engagement  (broadening spiritual practice to benefit  society and all people; politicization) as the marks o f emerging Buddhism in the West.  Establishing Intention In preparing to write about my intentions and motives for this inquiry, I began by reflecting upon my own story and how 1 first became interested in Buddhism and the inevitability o f dying. I went to the closet and wrestled with an old suitcase perched up on the shelf beside a stack o f sweaters. This tan coloured leather case was a graduation gift from my parents when I received my R N diploma in 1977.1 remember delighting in the gift and all it carried— a symbol o f travel, exploration, learning, and my parents' blessings for the open road. O f course this suitcase never came with me when I traveled; a backpack was more suitable for where I was going. Nevertheless, this suitcase houses  6  the texts o f my adult life, journals dating back to the 1970s, stories and notes written while attending courses and 'talks' in India and Nepal where I was first exposed to Buddhist teachings. A few photos are scattered about, but there are mostly journals, textual images from the journey(ing)... A s I gently rummaged through the suitcase, a sweet smell o f sandalwood and flower oils wafted out. Smells that evoke Mother India, time passed, and existential angst. In preparing to write my story, I lay down on the couch with a stack o f journals and read through each book. Tattered notebooks unable to hide their scars from being tucked into backpacks or jammed into overstuffed suitcases. Neatly scripted entries, jagged characters etched out on bumpy roads, fluid letters flowing from opium induced clarity and insight. There I sat reading each episode as the noonday sun crossed the sky and evening's darkness brought me back. What pleasure, to journey back through a life. A s I returned the journals to their places and hoisted the suitcase back up to its perch, I wondered about this past life and the woman who wrote those lines so many years ago. Who was she? Who am I? H o w am I reconstructing the past in the present moment, constructing motives and intentions for this inquiry through threads woven from past stories? A few days later, I came across a quote by Rosemary Sullivan (1995) who so clearly articulates where the intent o f this inquiry is nestled:  7  W e live our lives as narratives, examining them, interrogating ourselves, attempting to make our stories cohere. Like the novel of a good writer, we do not will our own plot. The plot evolves moment by moment out of accident, contingency, intuitive leaps. Yet we believe there's something that's consistently us—call it our personality, our character— that strings the narrative together. W e believe this identity we call ourselves is shaped by deep structures in our minds laid down in childhood by the intrigues of our culture shaping our thinking, and by our own desire. W e are willing to accept that the self is infinitely complex, but we are not quite willing to give it up. (xiv, italics added) Yet, what happens for those who are willing to try to give it up through the regular practice o f meditation? What does it mean to loosen one's grasp on fixed identity and live without believing in a coherent story? For someone who believes that it is possible to let go, even just a little, how does their experience of 'being' in the world differ? What stories do they tell? H o w do they construct a self in the telling, knowing that the protagonist 'evolves moment by moment out of accident, contingency, intuitive leaps'? A n d what o f dying? If there is no fixed self to hold on to, then who dies? H o w does such a person relate to living and dying? A n d finally, is there something we can learn from their experiences that may help others? These were some questions I explored through conversations with people who were regularly practicing mindfulness meditation and examining the assumption of a core, coherent, identity.  8  Locating the Inquiry and Inquirer  H o w we perceive reality and the nature o f knowledge is said to be crucial in determining the lenses through which we conduct our inquiry. From the research question, to one's perception o f what constitutes 'data', the inquirer's location(s) w i l l govern the directions taken. Explicit identification o f one's orientation to particular philosophical view(s) is suggested as a vital component o f thoughtful qualitative study (Roger & Cowles, 1993). The lens through which 1 interpret the world is multi-hued. In part, my worldview is shaped by my role and educational preparation i n nursing and in  M y first introduction to any philosophical reading began while working as a volunteer nurse in Bangladesh on assignment with Save the Children Fund. The experience of poverty and military dictatorship in Bangladesh was unsettling and sparked age-old questions: why is there such disparity?; things are not as I thought— what does it mean?; is there a grand purpose?; what is real and how do we know?; and what are we called to do? The books I found in the British Library in Dacca to begin my formative exploration included: D. T. Suzuki's (1971) W h a t i s Z e n , and Gendlin's (1981) F o c u s i n g . Buddhism, and western transpersonal psychology provided the reference points and experiential exercises into what has become an ongoing inquiry  part, by my interest and practice in Buddhist interpretations o f life and suffering. Consequently, this study ventures into unfamiliar spaces that challenge Western, and academic, approaches to inquiry. Even so, this first Strand maps the g/round by setting the stage, so to speak, and explores the context(s) and key concepts in which the inquiry is located. This process is neither definitive nor elaborate, but is intended to situate the inquiry/inquirer at the edges between conventional, modernist, nursing discourse o f science/practice, and Buddhist philosophy and awareness practices.  9  Edges o f modernist views Traditionally in nursing, the model for generating knowledge has been embedded within a modernist discourse o f science. This model has shifted in the past 20 years, recognizing the necessity o f interpretive and phenomenological approaches to inquiry. Even so, despite advances in qualitative research, the distinctions between different aspects o f reality and epistemologies to access and understand varying domains o f experience are not explicit in nursing literature (Wolfer, 1993). The issue is not that different ways o f knowing exist, nor that disparate epistemologies are necessary in constructing knowledge within diverse aspects o f reality. Rather, the issue remains one o f the dominance and privileging o f scientific, modernist discourse in Western thinking and consequently in nursing theorizing and practice. To illustrate, David A l l e n (1995) maintains that nursing as a discipline and practice continues to adhere to foundationalism, that is, anchoring knowledge statements by "referring to ahistorical, non-social, non-contextual criteria" (p. 174). Even in interpretive traditions, foundationalism is demonstrated through "finding the correct meaning o f a text" or insuring that one has "a valid meaning" (p. 174). A l l e n suggests that although most interpretive researchers align themselves with a nonfoundational perspective, the texts are imbued with inferences to convince the reader that the 'findings' are anchored in an objective reality. Although the subjective-objective debate may seem like an old contention, I agree with A l l e n that the appeal o f foundationalism remains a dominant force in nursing texts and practices. It is for this reason, that care and attention have been given in this inquiry to language use and form, in order to interrupt  10  my own habituation (as a product o f a modernist academy) into discursive spaces o f foundationalism. Similarly, scientism is a matter o f putting too high a value on science as a branch of learning in comparison with other ways o f knowing (Dzurec & Abraham, 1993). With scientism, the belief is that science is the most beneficial form o f learning and as  Is this old argument of scientism still relevant in these 'post' post-modern times?  such, it is good for all domains, including spirituality and philosophy, to be placed on a scientific footing. Consequently, we see scholars claim to have made history, politics, ethics or aesthetics into a science and assume that these claims o f scientific status are desirable (Sorell, 1991).  It seems to be- recent educational experiences have reinforced my view that modernist perspectives remain a solid option for many. This inquiry does not reject, but questions the continued privileging of this position  In nursing, K i k u c h i and Simmons (1986) provide examples in which nurse researchers attempt to answer philosophical questions such as, 'What is the nature o f health?' or 'What is the purpose o f caring?' using exclusively scientific means, thereby demonstrating nursing's vulnerability to scientism. Edges o f non-modernist views Recognizing different modes o f reality (e.g. the body-mind-spirit, ambiguity, paradox) is difficult within the limited scope o f language and ways o f knowing in science (Wilber, 1998; Wolfer, 1993). For example, conventional scientific knowledge focuses on what is said, thereby excluding what is unsaid, or unsayable; and by concentrating on what is certain and knowable, we exclude the ambiguous, unknowable and paradoxical. Conventional models o f scientific knowledge depend on exclusion, and function to privilege one voice or perspective over another. Through valuing what we can know  11  within a fixed idea o f what is acceptable, modernist discourse often characterizes that which is unknowable, such as death, into problems to be solved rather than to be lived fully. In nursing, it is time to develop discourse(s) that w i l l help people to live with/in uncertainty and find new ways to create and promote diverse perspectives. For example, perspectives embedded in ambiguity are necessarily located at contested sites. Postcolonial writer H o m i Bhaba (1990) calls this location, third  space—  a  generative space that "enables other positions to emerge" (p. 211). Educator David Jardine (1992) calls this a space o f "original difficulty" where there is "always something left to say, with all the difficulty, risk, and ambiguity that such generativity entails; the ambiguous nature o f life i t s e l f (p. 199). In this inquiry, ambiguity and uncertainty are invited as contested sites, signifying a multiplicity o f interpretations. Re-conceptualizing ambiguity, uncertainty, and the 'unsaid' in this way, allows for other possibilities o f how nursing can be enacted. Without discarding conventional nursing science discourse, this inquiry is located at its margins and ventures forth into sites without solid g/round. The intent is not to reject modernity and science and replace them with wisdom traditions such as Buddhism; instead, my interest is to move in-between these discursive spaces in a way that neither excludes i n an oppositional binary nor tries to merge understandings o f science and Buddhism. In this way, the inquiry is attempting to reflect Bhabha's (1990) 'third space', a space o f potentiality for something new, and in what A o k i (1996a) calls metonymic gaps between modernist and non-modernist discourses. Exploring metonymic moments in this way has required particular attention to language and form.  12  Attending to language I write in order to learn something that I didn't know before I wrote it. I was taught, however, as perhaps you were too, to not write until I know what I wanted to say, until my points were organized and outlined. N o surprise, this static writing model coheres with mechanistic scientism... (Richardson, 1994, p. 516)  Writers such as Laurel Richardson beckon us to lean into ambiguity and a process of writing that is perhaps uncomfortable in its groundlessness. Ted A o k i (1996b) also invites us to linger in sites o f possibility through careful attention to what goes on with/in language as we write and are written through our texts. In cultivating alternatives to scientism and creating spaces o f possibility in this inquiry, language and form are interrogated and playfully explored. Specifically, experimentation with the use o f personal story fragments, randomly placed quotations, disruptions, hyphenation, and word slashing (i.e. g/round) are incorporated. For example, the hyphenation and interrupting o f words is an approach to which I was introduced during a course led by Dr. Ted A o k i . This heuristic is also used by non-modernist writers including Trinh M i n - h a (1992) and Helene Cixous (1997). The simple act o f disrupting a wor(l)d asserts a position that simultaneously supports multi-vocal texts while challenging demands for singular, univocal clarity. Slashing signifiers does not reject any particular interpretation, but de-centres the dominant meaning while opening up the reader and writer to other possibilities. For example, in using the title G/round,  one interpretation conveys a starting  place for this inquiry that is both a beginning and not a beginning but rather, a place that is neither firm nor solid, yet is still ground. The slash introduces a 'doubling' exposing an uncertainty o f language and a multitude o f possible interpretations. These textual  13  disruptions also unsettle the momentary continuity o f the reader and open up other possibilities, learning something we did not know before; meeting other possible selves. Such language is apropos for exploring ambiguous sites o f living/dying and meditative awareness.  A talent for speaking differently, rather than for arguing well, is the chief instrument o f cultural change. -Richard Rorty  2  2  Cited in Batchelor (1997)  14  Theoretical Context(s) of B u d d h i s m Buddhism in Nursing Theorizing Thus far in the Western world most nursing disciplinary knowledge, including that concerning death and dying and palliative care, has been shaped by Western philosophical views. However, this exclusive influence is slowly changing. Hanchett (1992) claims that Eastern philosophy has already contributed directly and indirectly to the development o f nursing frameworks. In addition, Sarter (1988) suggests, "It is time that serious attention be paid to the formal systems o f thought o f the East, both ancient and modern, so that accurate interpretation and application, rather than vague references, can be made" (pp. 58-59). Other authors assert that recognition o f multiple aspects o f reality and ways o f knowing cannot be understood using Western philosophy and science alone (Wilber, 1990; Wolfer, 1993). Therefore, investigations and knowledge claims about the more 'indistinct' aspects o f human experience including suffering, health within illness, and living while dying require a philosophical view that provides a theoretical understanding along with open spaces for new possibilities as yet unconstituted.. Eastern and Western Philosophical V i e w s What follows are broad brush strokes i n exploring the differences in philosophical thinking within Eastern and Western traditions. A s the underlying ontological  Hanchett (1992) proposes that Rogers' Science of Unitary Human Beings includes areas of similarity with concepts used in Tibetan Buddhist philosophy including direct valid perception, karma, and emptiness. Although some similarities in worldviews can be drawn, Hanchett offers a simplified presentation of complex Buddhist notions that provides a good beginning but could benefit from stronger linkages between these two worldviews. 3  15  assumptions in this study are embedded in Buddhist views, some basic philosophical tenets and their relationship to Western thought are inscribed. Although philosophical investigations into the nature o f reality and knowing are shared by both Western and Eastern philosophies, the distinction between these perspectives can be found in their foci and unique methodologies. Ontology, as a branch o f Western philosophy, is defined in different ways within the literature. Flew (1984) describes ontology as a branch o f metaphysics that focuses on the study o f existence that differentiates what is 'real existence' rather than 'mere appearance'. Johnson (1995) provides a broader definition and includes the nature o f existent objects within the purview o f ontology. In other words, Johnson defines ontology (Western) as a branch o f philosophy that is concerned with what exists and what does not exist; the nature o f being or 'isness'. That a pine is - its isness - indicates its ontological character. Ontological questions o f this genre explore the nature o f reality, what can be known about reality, and the nature o f Being in beings. Such privileging o f presence and Being is particularly Western in view and dominates most nursing and thanantology literature . But what o f 5  Non-Being and 'absence'? What o f the space in the midst o f presence/absence, neither being nor non-being, but possibly in-between? The distinction between Being and Non-Being, and determining Being or the 'limited' as superior objects o f investigation in Western thought, has been attributed to  1 am perhaps over simplifying by using the geo-philosophical terms East and West. Eastern philosophy in this inquiry refers primarily to Buddhist philosophy although Eastern thought often includes Confucianism, Taoism, and Shintoism. Western philosophy is used here to refer to Greek philosophers, enlightenment, romantic, and idealist thinkers. Post-structuralist and postmodern philosophers do not fit easily into these categories and attests to a growing complexity and danger in using categorical labels. However, for the purpose of the inquiry, I will forge ahead knowing these distinctions are constantly changing and perhaps meaningless. Thanatology is a word meaning the study of death and dying derived from the Greek Thanatos, in mythology the twin of Hypnos, meaning sleep (Kastenbaum & Kastenbaum, 1993).  4  5  16  Greek philosophers (Fung, 1948). In Eastern philosophy, this situation is often reversed wherein Non-Being or the 'unlimited' are more highly valued. These seemingly opposing positions are grounded in epistemological and discursive differences that are explained in part by the types o f concepts and language traditionally employed in Eastern and Western philosophies. Northrope (cited in Fung, 1948) suggests there are two major types o f concepts that characterize the Eastern and Western systems o f thought; concepts achieved by intuition  and/or by postulation.  Although juxtaposing Eastern and Western thought in  this way reinforces a dualistic perspective, my intent is to provide a starting point to better understand the more abstract position o f nonduality posited in Buddhist philosophy presented later. What follows is an interpretation o f how Eastern and Western philosophical views differ, and explores what it means to be located somewhere inbetween. To begin, an exploration o f conceptual thinking informed by intuition or postulation differs in Eastern and Western thought. A concept emerging through intuition is one in which meaning is given by something through direct perception. For example, the sound  o f light, or as Northrope states, "Blue in the sense of the sensed colour is a  concept by intuition" (Fung, 1948, p. 23). Languaging concepts o f this genre leans towards ambiguity, poetics, inference, and open-endedness. O n the other hand, a concept by postulation is one in which the meaning is designated by deductive theory and logical inference, "Blue in the sense o f the number o f wavelengths in electro-magnetic theory" (p. 23) is a concept by postulation. Language used to inscribe such concepts aims for precision, certainty, and definition. In contrasting these conceptual perspectives  17  Northrope points out that Being and the 'limited' are distinct indistinct.  whereas the others are  Western philosophies usually begin with concepts by postulation thereby  privileging the 'distinct' or 'presence', while Eastern philosophies often start with intuition and perspectives that privilege a lack o f inherent existence, or 'absence'. A second fundamental difference between Western and Eastern philosophies lies in their respective methodologies (Fung, 1948). In Western philosophical analyses, attempts are made to make distinctions and determine what an object o f inquiry is; this is known as a positive method. In comparison, Eastern analyses attempt to eliminate distinctions and infer what the object is not; this is referred to as a negative method. To Kant and other Western philosophers because the unknowable is unknowable, one can say nothing about it and so it is better to abandon metaphysics entirely. But those accustomed to this (unknowable) negative method, it is taken for granted that since the unknowable is unknowable, we should say nothing about it. The business o f metaphysics is not to say something about the unknowable but to say something about the fact that the unknowable is unknowable, one does know after all, something about it. (Fung, p. 337) Fung argues that such positive and negative methods o f analyses do not contradict but complement each other as is demonstrated in some Buddhist systems o f thought. Furthermore, "it is the combination o f the two (positive and negative) that w i l l produce the philosophy o f the future" (Fung, p. 342). Prophetically, these words were written before the logocentrism o f Western thinking was challenged and reinscribed by so-called postmodernist philosophers including Derrida's deconstructionism.  6  Post-structuralist, postmodern thinkers do not fit neatly into these distinctions o f East/West thought, but cross the boundaries with antifoundational critiques o f any inherited way o f thinking. For example, Smith (1999) asserts that within postmodern  See Loy (1992) Healing deconstruction: Postmodern thought in Buddhism and Christianity for an analysis of Derrida's deconstruction and its influence on the religion versus science debates. 6  18  thinking nothing can be known purely on its own as an inherently existent phenomenon, but only as it bears relationship with something else or others. Therefore, the interdependence and contextual embeddedness o f any knowing cannot be extricated. Expressed another way, knowledges are not fixed or stable but constitutive,  that is,  "arising as an answer to particular questions o f a given time and place" (p. 123). Emphases have shifted from an essentialized reality o f modernity to a de-centred, highly interpretive and constructed blending o f being/not-being and knowing/unknowing. Binary positions are no longer tenable, and the ground, we now realize, is moving.  Twofold Truth Twofold truth was inscribed by Buddhist scholar Nagarjuna (Corless, 1989) in The Root  Verses  on the Middle,  responding to the question of the nature o f reality. This  treatise is perhaps why Buddhism has been thought to lean towards nihilism. However, Nagarjuna does not negate reality per se, but affirms, through eight negations refuting concepts and ideas about  reality. Reality, he says, "is not characterized by coming into  being, passing away, termination, non-termination, unity, difference, movement into the future, or movement away from the past" (p. 228). To be expected then, Nagarjuna points only to ultimate reality in the negative—what is not. Nagarjuna also asserts that although ultimate truth can only be pointed to in the negative, conventional truth establishes that some things exist and others do not, and that there is a universe or material world in which we live and function. In addition, Nagarjuna suggests  Reality according to Buddhists is kinetic, not static; but logic on the other hand, imagines a reality stabilized in concepts and names. The ultimate aim of Buddhist logic is to explain the relation between a moving reality and the static constructions of thought. Stcherbatsky cited in Komito (1987)  19  that when we look for the substantiality o f this conventional, material world we cannot find it. In other words, like an onion that is solid and real, when we peel down the layers there is nothing that is solidly, independently existent. Or, as physics has shown us, the nutrinos are there and yet not there. What is o f interest in this inquiry, is to explore spaces between these twofold truths o f kinetic reality that is moving and alive.... and yet includes stabilized realities o f concept.  Buddhism Buddhism values direct experience as a way o f knowing rather than abstract logical inference alone; a brief introduction to mindfulness and the experience o f awareness w i l l provide the ground for more theoretical discussions o f Buddhist thought. This is followed by a brief survey o f the basic tenets shared by all schools o f Buddhism and includes: 1 ) the four noble truths, 2) a view o f nonduality, and 3) the lack o f an inherently existing ' s e l f . A Story o f Mindfulness Adele was an old Russian, Jewish woman staying with us at the Zen hospice. I got the call that she was dying and came to her room to find her curled over in bed, gasping for a breath. Her eyes were wide open with fear. A n attendant tried to reassure her, " Y o u don't have to be frightened." A n d Adele replied through her gasps, "If it was happening to you, you'd be frightened. Believe me." The attendant began stroking her while she continued to heave. " Y o u ' r e awfully cold", the attendant said. A n d Adele, again through her gasps, replied, " O f course I'm cold. I'm almost dead!" A s I began to attend to her, I listened closely to try to understand what was actually needed. While she was gasping for air, she was struggling to push the air out again. In the middle, right in between the breaths, was the place o f relief. I said simply, "Right there, right in between the in-breath and the out-breath there's a little place in which I've seen you resting. Can you put your attention there for just a moment? A n d , for an instant, she rested there. It was as i f something washed over her face; her eyes softened and the fear dissipated.  20  Sitting on the meditation cushion, we watch the mind do its myriad activities; we need to be able to sit still, to listen, not knowing what w i l l come next, to suspend judgement at least for the moment- so that whatever needs to arise w i l l be able to do so. A t the hospice, it's not appreciably different. We sit at the bedside and we listen.... A t the heart o f it, all we can really offer each other is our full attention. Frank Ostaseski, 1994 (p.39) Mindfulness is a both a process and a condition o f paying attention, o f attending to whatever is happening without judgment. A s in Adele's story, awareness o f momentary stillness between thoughts or breaths is a space without struggle. In understanding mindfulness, it may be helpful to begin by addressing its opposite, and something most o f us may be more familiar with— mindlessness.  For example, most o f us, especially when  we are busy, live in a disembodied way, that is, we are not actually aware o f where we are, what we are doing or what is happening around us. Our body and mind are uncoordinated and we are living ' i n our heads', so to speak. Nevertheless, the world usually wakes us up when suddenly we realize we've misplaced our keys, or can't find our glasses that are perched on our heads. Compared with this kind o f absent-mindedness, a more troubling aspect o f mindlessness is the over-reliance on already determined conceptual  categories.  Langer  (1992) associates habitual and automatic behaviour that occurs with little or no conscious awareness with a state o f mindlessness. For example, caregivers who rely heavily on diagnostic concepts such as, 'the First Nations woman with the hip in room 2", may obscure their ability to see what is going on in a given situation. Another illustration comes from a colleague doing an ethnographic study. After several months o f observing in hospital settings she stated, "I just didn't see things any more." Apparently the novelty and newness had worn off and she was seeing more through predetermined conceptions  21  of what she thought rather than what was happening in the moment. Langer, a psychologist, has done extensive research demonstrating the negative implications o f mindlessness for learning, behavioural competence, memory, and health (Langer & Imber, 1979; Langer et al. 1987, 1988). The disconnected attitude o f mindlessness in everyday life is one that habitually distances us from our own experience: From a point o f view o f meditation, humans are not trapped forever in this abstract attitude. The dissociation o f mind from body, o f awareness from experience, is the result o f habit, and these habits can be broken. A s the meditator again and again interrupts the flow o f discursive thought and returns to be present with his breath or daily activity, there is a gradual taming o f the mind's restlessness. One begins to be able to see the restlessness as such and to become patient with it, rather than becoming automatically lost in it. Eventually meditators report periods o f a more panoramic perspective. This is called awareness. (Varela, Thompson & Rosch, 1991, p. 26) Likewise, mindfulness is a state o f conscious awareness and a process wherein: .. .the mind is present in embodied every day experience; mindfulness techniques are designed to lead the mind back from its theories and preoccupations, back from the abstract attitude to the situation o f one's experience itself. (Varela et al., p.22) The theory and practice o f mindfulness are not mysterious or mystical. The aims are simply to come to know one's mental process as thoroughly as possible. Subsequently, this familiarity o f how our mind works and an appreciation o f our thinking patterns allows us (as patients, caregivers or inquirers) to be aware o f the process o f perceiving itself— how interpretation and understanding are happening. Cultivation and practice o f mindfulness is traditionally fostered through meditation.  22  The G/round o f Buddhist Thought There are three major schools o f Buddhism: Theravadin (practiced in Sri Lanka, Thailand, Burma, Korea), Mahayana (Japanese Zen, Chinese Chan and Indo-Tibetan), and Vajrayana (practiced in Tibet and Japan). A l l three traditions have growing numbers o f adherents in North America and differ somewhat in their doctrines and practices. Nevertheless, the following basic tenets are attributed to the teachings o f the historical Buddha and are shared by all schools. What is interpreted here as 'basic Buddhism' is drawn from texts written by Buddhist scholars, meditation masters, and by a generation o f Westerners trained in Buddhist philosophy and meditative practices. These teachers and practitioners have led the way in interpreting practices and theoretical underpinnings o f Buddhism in the West. In addition, I draw on my experiences primarily with Tibetan Buddhist teachers in Nepal, India, the United States, and Canada . 7  F o u r Noble Truths If Buddhism can be said to have a goal, it is to understand the nature o f mind so that one can be free from suffering and be o f benefit to others i n our quest for happiness (Nyima, 1987). This broad intention is based on four assumptions or conventional 'truths' that provide the ground o f 'why' one would engage in meditation practice. First is the truth o f duhkha  (Sanskrit) that has been translated as a repeated sense o f lack or  'dissatisfaction' in one's life; there is always something not quite right or not quite  1 am appreciative and acknowledge the teachings from H.H. the Dalai Lama, Lama Zopa, Lama-Yeshe, Dzongzar Khentse Rimpoche and Chogyam Trungpa. In particular, Chogyam Trungpa Rinpoche, an artist, poet, meditation master and founder of Naropa Institute, an accredited university offering academic studies and contemplative education curriculum, was my principal teacher before his death in 1987.  7  23  enough (Loy, 1996; Trungpa, 1973). Human existence is said to be marked by: 1) the realization o f impermanence o f all phenomena (the transitory nature o f all existence); 2) realization o f no independent self, T , or separate identity; and 3) an underlying 'unsatisfactoriness' or pervasive undercurrent o f anxiety despite periods o f happiness and appreciation. From a Buddhist view, to acknowledge and confront this sense o f dissatisfaction, a form o f suffering, in our experience is the first step in relieving it. Due to Buddhism's emphasis on this inherent suffering o f all beings, it is often misunderstood as a negative or depressing philosophy. However, our discomfort in acknowledging an inner sense o f lack is perhaps also related to Western cultural tendencies towards consumerism and its paradoxical suffering embedded in constantly wanting, continuous striving, and resisting sustained fulfillment or satisfaction. It seems that Buddhism is more pragmatic than pessimistic. The four noble truths not only acknowledge human suffering as a natural, inevitable occurrence, but the remaining 'truths' also suggest a rationale for the cause o f suffering and propose a way out. The second noble truth addresses the question o f why and how such dissatisfaction and anxiety arise. Recognizing impermanence, one can see how trying to hold on and clinging to that which is always changing is a source o f suffering (i.e. clinging to our youth). Although moments o f satisfaction and joy arise and pass away, clinging to such experience often leads to fear o f losing what we have or hoping conditions w i l l not change. According to Buddhist thought, the most problematic attachment is holding on to a fixed sense o f T . This aspect o f Buddhism is particularly relevant as existentialist questions arise, namely 'who am I" and 'who dies?'  24  The third truth underlying Buddhism is that to let go o f struggling for permanence and a secure sense o f T is a way to free ourselves from suffering. Through insight into the constantly changing nature of phenomena, we can let go o f trying to make things other than they are and learn to ride with the constantly changing flow o f human experience. A n d finally, the fourth truth is a prescription or way out; how to experience constant change in life without solidifying experience into a binary o f ' s e l f and 'other' and therefore decrease suffering. Conventional Buddhist teachings propose a three-fold training in ethics and action (shila),  meditation (samadhi)  and wisdom  (panna)  (Rothberg, 1999). Each aspect o f the training overlaps and subsumes the others. In summary, the four noble truths provide a logic for why human beings experience suffering, seek lasting relief from suffering, and suggest an approach towards attaining such relief.  Nonduality N o concept is more ambiguous, or important, in Asian philosophical thought than nonduality (Loy, 1988). In part, this seems to be the crux o f Nagarjuna's (see pg. 17) refusal to assert a position except through what 'is not'. Nonduality addresses that which cannot be articulated through the dualism o f language. Although notions o f nonduality may seem counterintuitive, they may also provide an alternative to modernist binaries. In part, this counter-intuition arises because most o f us interpret our world by clearly distinguishing ' s e l f and 'other', 'this' and 'that'. Furthermore, it is claimed that this kind of dualistic experience can be understood from the perspective o f nonduality, but not in reverse (Loy, 1988). This w i l l , I hope, become clearer as this strand unfolds.  25  Put simply, duality can be understood as a separation o f reality into discrete entities (e.g. self versus other, this versus that, being versus non-being) resulting in a "superimposition o f thought-constructions" onto our experience (Loy, 1988, p. 181). Consequently, we experience reality as distinct entities interacting causally in time and space (e.g. I am sitting at the computer weaving thoughts into sentences). In contrast, nonduality is experiencing the world without holding on or believing in solid distinctions and boundaries. Instead, experience is open-ended where thinker, thought, and thinking are transparent; action and actor are in/separable and perceiver and perceived are seen as ultimately indistinguishable. Most o f us have nondual moments when there is simple experience without distinction o f "I am experiencing." Traditional texts identify moments of shock, orgasm and the moment o f death as examples o f non-dual experiences (Sogyal,1993). Buddhist ontology asserts that ultimate reality is nondual (see previous discussion o f Twofold Truth). Y o u may object that this assertion is itself a dualist claim! Buddhist writers suggest that nonduality is only understood by referencing that which is being denied. Understandably then, these discussions are limited by the nature o f conventional languages that lead to paradox and self-negation. In his text Nonduality, L o y (1988) presents three aspects o f nonduality. These include: nonduality o f thinking, nonduality o f phenomena, and nondifference o f subject and object. A l l three aspects are inter-related and overlap but for simplicity are presented separately. A s an important Buddhist concept framing the ontological-epistemological orientations o f this inquiry, these three aspects are explored in some detail.  26  To begin, nonduality  of thinking  refers to thinking that avoids dualistic concepts  rather than the mind's usual tendency to dichotomize and impose thought-constructs onto experience. One effect o f dichotomizing is to promote choice o f one entity over another: life over death, success over failure, and self over other. Ironically however, in each case the opposite (life) gains meaning only through negating its opposite (death) resulting in an irony that by affirming one half (life) one maintains its opposite (death), the side we choose to avoid in choosing the former. We can't have one without the other; they are interdependent. Therefore, we can understand life and death as opposites, or we can view each as embedded in and dependent upon the other. In describing an exemplar o f nondual thinking, David Loy (1988, 1996) uses the example o f wisdom or Prajna  (Sanskrit). Wisdom differs from knowledge in that it has  no specific content that can be gained or grasped. Knowledge, on the other hand, is related to consciousness (vijnana).  Consciousness, in this Buddhist sense, is only one  mode o f knowing that is inherently dualistic— there is no consciousness without an object of consciousness. Conscious experience requires a subject/object relationship (Varela, 8  1991). Instead, wisdom is described as "knowing i n which there is no distinction between the knower, that which is known, and the act o f knowing" (p. 135). Such knowing or wisdom is different from a way o f knowing that functions by conceptualizing and discriminating one thing from another. Rather, wisdom is 'knowing' that life and death are inseparable. In Buddhist philosophy wisdom is a privileged way o f knowing that  All schools of Buddhism agree that each human sense (mind is the sixth sense) has a different consciousness and objects of consciousness (eye consciousness, etc). Therefore each moment of experience has a different object of experience and a different experiencer. Usually we impute continuity onto our experience without distinguishing its momentariness creating an illusion of coherence (Varela, et al. 1991). 8  27  underlies conceptual processes. Therefore, it follows that nondual thinking can understand dual thinking, but not vice versa. The second aspect addresses nonduality  of phenomena  in the world. Again,  parallel processes can be applied here. For example, the mind's tendency to dichotomize superimposes dualistic thinking onto fluid experience. Subsequently, we experience a world o f discrete objects (including a sense o f ' y o u ' and 'me') interacting causally in time and space. Reification o f this process renders concepts including 'sickness,' 'meditation,' 'life,' and 'death' into concrete, solid entities that separate us from direct moment-to-moment experience. Why is this understood as problematic? From a Buddhist view, separation o f self from experience leads to a sense o f alienation and over-reliance upon mental constructions as 'real.' Such illusion and alienation often leads to suffering, anxiety and dissatisfaction. A metaphor to illustrate the second form, nonduality o f phenomena, is the rainbow. Just as a rainbow projected through a prism onto a wall can never be grasped, our language presents the conceptual noun rainbow as / / i t was something graspable, solid and real. Both the rainbow and a 'sense o f s e l f are viewed within Buddhism as interactive clusters o f processes dependent on causes and conditions and empty o f 'essence' or a fixed core (Batchelor, 1997). One could argue, i f the rainbow dancing on the wall is not really there, what is ' i t ' that we are perceiving? It is suggested that the noun rainbow is a useful conceptualization as it supports an understanding o f the complex processes resulting in a rainbow's appearance. However, to mistake the appearance o f a rainbow for a solid entity w i l l result in frustration and dissatisfaction when one tries to hold on or find ' i t ' . A s vigilantly as one looks, there is no graspable,  28  solid materiality that is rainbow-ness. The dancing rainbow is a phenomenon arising due to causes and conditions, and is not fixed or solid. Such reasoning applies equally to all phenomena including our sense o f T and 'me'. The third and final aspect o f nonduality is the nondifference of subject and object. Asserting a sense o f subject separate from that which is experienced is understood as illusion; a mental construction o f duality. Again, Buddhist philosophy claims that all experience is ultimately nondual. Our usual interpretation o f experience as dualistic is merely a conventional truth and creation o f mind that can be deconstructed and uncreated through the practice o f meditation. Consequently, the questions arising in this inquiry included: 1) how is the experience o f nondifference o f subject and object expressed, 2) how does nondual experience shape one's experience o f dying and caring for those who are dying, and 3) how might Buddhist practitioners construct understanding(s) o f dying and palliative care practices in different ways? Self /No-self The assumption o f no fixed, independent self informs all understanding o f human experience from a Buddhist view and has been expressed in several different ways throughout the dissertation. Buddhism views self or ego as a fiction that is not necessarily problematic (Epstein, 1998). However, our tendency to fixate on this heuristic ' s e l f and privilege its existence at the expense o f other connections with one's life-world leads to unquenchable desire and suffering. H o w we come to experience the world as / / w e were solid and 'real' can be understood through a theory o f ego development. The term ego is understood differently from that o f Freud in psychoanalytic theory. Ego here refers to an incessant activity o f  29  identifying with the objects o f consciousness (thoughts, feelings) and holding on to anything that maintains our sense o f self-identity, separateness, and individualism (Welwood, 1979). Such repeated activity creates an imaginary ' s e l f and 'other' and the binaries o f subject and object. Claxton (1986) explains, The sense o f self is hard to examine because it forms the stage on which all our actions are performed, the screen onto which all our experience is projected; and i f it is untrue, warped or slanted, then the whole drama o f a life is distorted...But those who pursue [a] critical, [self-]examination to the end are, like "those who go down to the woods today', sure o f a B i g Surprise- there is no stage, no screen, no ground, no experience, no knower, no self. It is all going on in mid-air. (Raeburn & Rootman, 1998, p. 52, parentheses  added)  From a Buddhist view we are offered tools for working with our minds in order to relax the grip on ego and appreciate the processes o f making and unmaking our sense o f self. This process o f self/ego development is known in Buddhism as the five aggregates or skandhas  (Sanskrit). These five aggregates constitute one model o f how we experience 9  'reality' and together comprise a matrix that we identify with as personality or T . The five aggregates are identified as: forms, feelings, perception-impulses, conceptformations, and streams o f consciousness (see Vanderkooi, 1997). It is difficult to discuss these notions without inferring (inaccurately) a solidity and separate stage process. For example, the five aggregates are misleadingly presented as discrete processes with the T as a solid entity separate from the awareness by which these processes are seen. Such are the limits o f language in efforts to explain  what must be experienced to be understood.  See Joseph Goldstein (1987) and Mipham Rinpoche (1997) for a detailed description of the theory of The 'Wheel of Life' is another model of human existence that is represented iconographically depicting twelve interdependent aspects of human experience ('self becoming) known as nidanas that constitute the theory of Dependent Origination. The twelve nidanas occur in a flickering moment of experience that can be deconstructed through meditative awareness into its various stages and potentially be interrupted. Through awareness, the process of becoming can be interrupted leading to freedom from clinging to a sense of'self, and the perpetuation of one's experience of suffering.  9  skandhas.  30  Further, the theory o f aggregates is used as a heuristic to assist in our understanding o f fear, frustration, and the painful aspects o f life which are linked to beliefs in a fixed 'sense o f s e l f (Trungpa, 1975). Self-formation The importance o f understanding the process  o f self-formation and how we  construct our experience o f reality is important in this inquiry for two reasons. First, threats to this constructed self or self-dissolution are integral to the dying process (Levine, 1982). Second, Buddhist texts maintain that the practice o f meditation provides a way to see the construction o f self as it is happening and therefore opens the meditator to a realization o f the simultaneous doubling o f self and selflessness. Such realization allows the meditator to see the relative existence o f a self that functions in the world yet does not exist independent o f causes and conditions. Although the process o f self development continues from moment-to-moment, we have glimpses in the open spaces between thoughts (Welwood, 1996). Through careful attention to thought processes using meditation, it is claimed that meditators learn to 'see' the ever-changing matrix o f self-constituting-self. Difficult emotions such as fear, craving, anger, and anxiety are predicated on a perception o f a solid, essential self (Epstein, 1995). Epstein explains that through mindfulness, the constructed nature o f self can be fully appreciated. Self, it turns out, is a metaphor for a process that we do not understand, a metaphor for that which knows. The insight practices [mindfulness] reveal that such a metaphor is unnecessary, even disruptive. It is enough, these practices reveal, to open to the ongoing process o f knowing without imputing someone behind it all....To reach this point requires not the obliteration o f ego but the development o f mental faculties beyond those that are conventionally accepted as adequate for 'normal' functioning. The progress o f meditation is one route to such development, (p. 155, parenthesis added)  31  In sum, ' s e l f is understood as a process that is constantly 'becoming' from moment-to-moment. Likewise, our sense o f self is embedded within stories being constructed moment-to-moment as we inter-act with/in our world. From a Buddhist view, i f we are attached and grasp tightly to our sense o f self and its stories, any threat to this identity w i l l certainly result in some form o f suffering. From this view, the threat o f not 'existing' as a solid, essentialized being is the source o f great fear (as a form o f death) (Loy, 1996). A Buddhist view is seemingly pragmatic. That is, although we can do nothing to eradicate the inevitability o f death, we have a prescriptive approach (meditation for example) to address the fear and anxiety o f impermanence and noninherent existence. Moreover, experiencing the constructed nature o f self can be both fearful and liberating. Instead o f thinking o f oneself as a fixed nugget in a shifting current o f mental and physical processes, we might consider ourself as a narrative that transforms these processes into an unfolding story. Our life is a story being continuously related to others through every detail o f our being. (Batchelor, 1997, p. 104) The notion o f self as a process is not unique to Buddhism. Although traditional Western views consider self as a unitary and cohesive entity, some postmodern and postcolonial writers describe self as a 'polyphonic novel' (Bakhtin, 1986), dependent on cultural conventions and language use. Nevertheless, much postmodern writing has been critiqued for what is viewed as nihilistic tendencies; that is, where emphasis on the nonexistence o f self renders life meaningless. N i h i l i s m is said to arise when we realize that our most cherished beliefs are empty and yet we are incapable o f living without them (Nishitani, 1982). T/here in the experiential realm o f being able to live well without  32  believing in the solidity o f one's constructions, is where Buddhism has practical guidance (that can be tested). It is in these spaces between nihilism and essentialism where meditation offers a middle path we can t/read.  33  Meditation Practice  What is this heavy sadness that envelops  Time past and time future  and  A l l o w but a little consciousness. To be conscious is not to be in time But only in time can the moment in the rose-garden, The moment in the arbour where the rain beat, The moment i n the draughty church at smokefall Be remembered; involved with past and future. Only through time time is conquered. T.S. Eliot  wants to suffocate,  that I fight against, punching out at the world, finding complaint everywhere. This sadness lies underground, Surfacing unexpectedly through a fissure, the happy face, of ubiquitous smiles that all is (s)well. A crack in the mask. Is this vulnerability, The tender heart o f sadness that makes one's heart break, when seeing beauty in snow-capped mountains, or a dancing plastic bag  My  first  India.  experience  with  It was a 10-day  We were  asked  meditation  silent  to maintain  contact  and physical  writing  letters  silence,  gestures,  or in journals.  avoid  participating  idea  was to simply  practice  was in  retreat. avoid  We were  in any kind be present  of with  from  asked  of wounds not healed, of a life set adrift in a sea buffeted by winds and gales in all directions  eye  and abstain  swirling in the wind? Or is this the sadness o f lost loves,  without destiny or shore?  to  distraction....the our own  Sad, Sob, Weep,  experience.  Hurt, Heavy Hollow (W)hole. Simple words pointing to, a simplicity o f human pain and suffering  Slowing  down.  becoming simply being  Everything  painfully sit still?  here  now.  boring.  Be present  slowing  down  suffering and human pain.  and  Why is it so difficult to the experience  of  to  It's part o f being alive I guess Nothing to do about it, except feel . Not  grasping and dwelling, but  leaning into the pain and heaviness, feeling its textures, its slipperiness, its bottomless depths, opening up and  passing away.  Empty heart so full, it hurts.  35  The practice o f meditation, as with many The discursiveness commenting  of mind  chatters  on this and that, wondering  or that person  sitting  about  why I m doing  wondering  about  the erratic  emotions  and feelings,  wondering. airy  There  room;  sitting  about  in the meditation  Wondering  this  hall.  wondering,  of  thoughts,  ceaselessly  we are, sitting  quietly  in silence  our  order to do nothing, one must apply some effort and technique. There are marked  this at all,  patterns  with  things in life, seems to contain paradox. In  away  in a  large  bellowing  minds.  stages o f development. Perhaps this is what most attracted me to Buddhist philosophy and meditation many years ago. In the West we assume that mystical experiences and contemplative spaces are ineffable. From an Eastern perspective this is an erroneous assumption. According to B r o w n (1986), most o f the West's mystics practiced in isolation and may account for this view.  As the days pass  the texture  changes.  Cool  A quality  of settling  spaciousness hold  opens  present,  Feeling  slowly  hot boredom,  down,  calmness  up. The struggle  on to this or that starts  Just sitting. being  boredom,  of boredom  indifference. and to keep busy to  to let go. Letting  the body, the simplicity  the vast open  sky of  go. of  awareness.  However in the East, meditation practice was part o f the larger social organization. For example in Tibet, some o f the monasteries housed thousands o f monks who spent most of their lives studying and doing meditation practice. Consequently, forums for debate to discuss meditation experiences were available. In these kinds o f traditions where meditation was socially organized, a  The process o f perception has a kind o f standingstill quality. A stalemate in which comments and remarks become unimportant, and seeing things as they are becomes the real thing. Like a frog sitting in the middle o f a big puddle, with rain constantly falling on it. The frog simply winks its eyes at each raindrop that falls on it, but it doesn't change its posture (Trungpa, 1996)  technical language for meditation experience evolved. ThisJanguage and body o f knowledge has been refined over the generations and like math or hermeneutics, the language is intelligible only to those who are familiar with the experience. Even so, the language developed in order to assist meditators understand and compare his or her experiences with a larger body o f  36  teaching. The language and complex There  are talks presented  explain  the theory  training  our minds.  of contemplative eons, since gone  behind  what  of  'inner  have  time.  Some  years  learned  it and see. Examine  experience o f our mind. Simply experiencing  studiedfor  enthusiasts  exploring  and compare  of  happens,  They  it for  our life directly is what meditation seems to be about.  have  the nature what  that arise. and offer  theoretical explanations are not the direct  sciences'  been  how it functions,  and systems  they have  direct  this experience  The so-called  recorded  identifying  the patterns  to help  traditions  into caves for  mind;  in the evenings  share  scrutiny.  with your  Try  own  experience.  Instructions  Well  and good for  dweller  with  a job  yogis  in caves,  but I am an  and day-to-day  urban  responsibilities.  Sit in a comfortable position with your back straight and upright, not too tight, not too loose. Eyes are open and cast down about six feet in front. The gaze is 'soft'. Be aware o f your body; bringing your awareness to the physical sensations o f sitting on the chair or cushion, Now, place your awareness on your breathing. Be aware o f breathing in and out, going out with the out-breath.  Label  the thoughts  thinking  and come  back  to the  present. Slowly  a distinction  present here passes plans  arises.  and being  present difference  lost in a world  us by while "....nothing  between  A qualitative  we 're busy new, yet  and not in  being  of abstraction.... making  fresh.  other  "life  A s your mind wanders off in thought, gently bring your awareness back to breathing. Notice whatever arises in the mind, Thoughts, sensations, feelings. A s the mind wanders off, gently place the awareness on the breath.  37  Trungpa Rinpoche explains that when As the days pass dimension Impermanence feelings, grasping between  in silence,  of experience  the  becomes  and constant  emotions,  ideas.  hold, struggling. thoughts.  flow  Awareness Glimpses  Gap. Open  dwelling on thoughts, we are just producing  multi-layered more of  evident.  more thoughts and never experiencing any o f  thoughts, of holding of  on,  space  them. In fact, we do not even know we are  sky.  thinking but are often lost in our fantasies. Suddenly awareness; little gaps o f waking up from our reverie, aware we have been lost in thought. Even though we can direct our attention, we cannot hang on to mindfulness. N o matter what thoughts o f good and bad, happy and sad, arise in the mind, i f you remain naturally relaxed, without fabrication, the mind itself abides as naked, v i v i d luminous awareness, free from "What is happiness? This is happiness;" What is sadness? This is sadness." this is the nature o f the mind o f all sentient beings. (Khenpo Gangshar)  A s I experience the quality o f struggle in my daily life: a sense o f being rushed, being late, being scattered; I can wake up in the middle of it— being here—mindful, aware. When this happens, there is a realization o f nothing tangible about the struggle or the struggler. There is just awareness o f what is happening. This awareness has a quality o f spaciousness with room to move, space enough to get things done without all o f the extra energy invested in the struggling. Just doing it.  38  Hedda and I have been in Kopan Monastery for almost two weeks. It seems like months, perhaps years. M y sense o f time has shifted since leaving Canada, and here on top o f R i n g the bells that still can ring. Forget your perfect offering. There is a crack in everything. That's how the light gets in. Leonard Cohen  Kopan mountain, time is marked by dulcet gongs and shades o f silence. This monthlong course is called L a m - R i m , a Tibetan title translated as Graduated Enlightenment.  Path  to  I understand the graduated  part, as time stretches out and out and the boredom seeps in as the hours sitting in silence drag on and on excruciatingly. But 1 still don't understand what enlightenment means. Maybe it's literal, to enlighten, to understand or see clearly, to lighten up and not take life so seriously? It's odd though, the silence allows a quality o f heaviness to arise and then suddenly.. .snap!... everything seems simple, uncomplicated and basically Fifth-month rain— poems posted to the wall, peeled off, leave traces. Matsuo Basho (1644-94)  good. It all seems to circle around being right here in the midst o f whatever is happening, in the thick, sticky layers o f boredom and bliss. During the first few days, we practiced 'functional silence' which means we talk //' there is a need and when doing so, to speak with mindfulness and awareness. But now, in our second week we keep "noble silence'. The silence is deafening. I can see it in our faces, in the outbursts o f laughing, or sighs. We're getting to know the textures and  39  subtle pathways o f our minds, becoming familiar, coming home. A t the same time we're resisting, protesting, and fearing the White dew ~ one drop on each thorn  space, open ended now. Afraid i f I go out ^  Q^.^j-g^  a n c  j i  e  a  n  m  t  o  m  e  s  might disappear... Matsuo Basho  Lighting the lantern the yellow chrysanthemums lose their colour. Matsuo Basho  40  ji  e n c e  \  Introduction to Meditation The word meditate  is often associated in the West as engaging in thought or  contemplation. Meditate comes from the Latin root 'medi,  meaning 'middle' (Random  House, 1983) with other possible interpretations including: abiding in the middle, resting in the midst, and re/turning to an in-between. The purpose or intent o f meditating from a Buddhist view is to recognize unconditioned  awareness  that constitutes human nature  (Trungpa, 1973). In the gaps between thoughts we can access an awareness that is always available, is not created or manufactured, and is always present. Such unconditioned awareness is before thought, and therefore free from all reference points, including a basic duality o f self and other. Contrary to what we might believe, it is not the " s e l f who is aware, but rather all thoughts o f self and emotions arise within (in the middle of) unconditioned awareness. Human nature is understood to be inherently aware, awake, intelligent, and compassionate (Trungpa 1973). Meditation is a practice embedded in this expansive view o f human nature. Increasingly, interest in meditation and Eastern techniques o f consciousness transformation is growing in North America. While mystical awakening in some form is found in most cultures, Asian traditions o f meditation are the primary source for most health care settings integrating these practices (Kabat-Zinn et al. 1992). In trying to inscribe meditation, it is important to consider these practices within the cultural and wisdom traditions in which they are embedded. For example, what distinguishes Buddhist meditation is its premise o f nonduality  that is understood to be not only  revelatory but personally liberating (Loy, 1988). A s Buddhist meditation practices are adapted into Western cultures, the underlying theoretical premises need to be understood  41  i f trustworthy interpretations are to be made (Taylor, 1999). Towards this end, I explore meditation generally as a family o f practices that 'train' attention in order to cultivate awareness, followed by a specific focus on the theoretic roots o f mindfulness meditation that is emphasized in this inquiry. A s a generic term, meditation refers to disciplines that cultivate particular ways o f paying attention in one's life. The disciplines range from the act o f inward contemplation, to placing attention on an object o f meditation, to the experience o f complete absorption in the object o f attention (Murphy & Donovan, 1999; Walsh ,1982). A t the same time there exit some misleading understandings o f meditation commonly held in North America. For example, meditation is often understood to be: 1) a state o f relaxation; 2) a dissociated state in which one experiences a trance-like condition, and 3) a mystical state in which higher realities or religious objects are experienced (Varela, et al., 1991). Although these perceptions are not inaccurate, they are misleading. The implication is that meditation is something applied in order to get away from the mundane, perhaps stressful, state o f reality. Verala and colleagues (1991) explain that meditation is intended to be quite the opposite. Rather than moving away from, meditation actually assists in moving closer to, whatever one is experiencing. Meditation is described as seeing our psychological situation very precisely and directly. The practice o f meditation develops one's capacity to: Abide wakefully within whatever experience is arising. When there is no identification either with the observer or the observed, awareness remains undisturbed by any divisions, and a new freedom, freshness, clarity, and compassion become available. (Welwood, 1996, p. 109) Therefore, meditation can be viewed as the intentional self-regulation o f attention from moment to moment (Goleman, 1991).  42  Meditation and Relaxation Meditative approaches have traditionally been established within consciousness disciplines such as Buddhism and Hindu yoga and were used for personal development and spiritual growth (Craven, 1989; Rothberg, 1999). Although some researchers construct meditation as essentially a relaxation response (e.g. Bennett & Trinder, 1977), others maintain it is a unique state o f consciousness (e.g. Dunn, Hartigan & Mikulas, 1999). One reason this confusion exists is because many meditation practices combine relaxation (sitting quietly with eyes closed and an accepting attitude) with concentration and mindfulness strategies. In a recent study, Dunn et al. (1999) examined electroencephalographic ( E E G ) recordings using 19 scalp recording sites to differentiate between mindfulness and concentration forms o f meditation and a normal relaxation control condition. Admittedly, though the sample size is small (N=10), their findings show that E E G results from concentration and mindfulness meditation produce different cortical patterns than with relaxation behaviours (sitting quietly with eyes closed). Coupled with subjective reports o f the participants, the authors suggest that the two meditation practices generated qualitatively different conscious states from relaxation. Relaxation may be integral to or a by-product o f meditation, nevertheless, there are significant differences in both the objectives and instructions between relaxation training and meditation. Presenting meditation practices as relaxation skills alone  is both  incongruent with the traditions from which meditation arises, and reinforces a medicalized conceptualization o f these practices by applying a technique to relieve symptoms. Kabat-Zinn (1996) suggests that the goals o f relaxation training are primarily to relieve symptoms o f tension and achieve a low autonomic arousal. Relaxation techniques are often used as needed to combat stress and anxiety. In contrast, Kabat-Zinn 43  holds that "meditation is practiced for its own sake, and cultivated daily regardless o f circumstances" (p. 162). If one can say there is a goal, it is to cultivate curiosity and insight into the nature o f mind, and experience directly what is present from moment to moment. Therefore, meditation is viewed as the intentional self-regulation o f attention from moment to moment. Relaxation is a possible outcome but is not necessary to meditation itself. Types o f Meditation The two most commonly used categorizations o f meditation in health care literature are concentration  and mindfulness  techniques. The distinction between these  two is based primarily on the way in which attention or awareness is directed (Delmonte, 1987; Goleman, 1988; Miller, 1993; Shapiro, 1987; West, 1987).  Concentration meditation Concentration meditation involves placing one's attention on a single object such as the breath, a sound (mantra), or a visualized color, etc. Such techniques intentionally limit awareness to the object o f attention and whenever the mind wanders away it is gently redirected back to the object o f attention (Delmonte, 1987). The mind gradually focuses solely on the object o f meditation while conceptual thinking is progressively peripheral or suspended. A s one's concentration increases, background mental chatter decreases and states o f calmness, relaxation and equanimity arise (Vanderkooi, 1997). A t the same time, the binary sense o f subject and object begins to blur. Everyday experiences o f focused concentration can evoke similar results; a sense o f time and ' s e l f are lost, there is merely an experience o f total absorption.  44  Concentration meditation is practiced in many contemplative traditions and was popularized in North America in the form o f transcendental meditation  (TM).  Transcendental meditation is a classic form o f Hindu mantra meditation developed into a program using English terms and published scientific evidence as support (Bogart, 1991; Miller, 1993; Murphy & Donovan, 1999). The most prolific research on meditation since the 1960s has been the study o f T M .  Mindfulness meditation In comparison, mindfulness meditation has its roots in Theravada Buddhism where it is known as sattipatana  vipassana  or insight meditation. Unlike concentration,  awareness is not focused on one object. Rather, mindfulness involves open receptivity and awareness o f all stimulation, while evaluation, analysis, or classification, are suspended (Dunn et al., 1999). Mindfulness awareness is referred to in various ways: detached self-observation (detatchment infers without judgement or interpretation) (Kabat-Zinn, 1982), bare attention (Goldstein, 1987), or choiceless awareness (Humphreys, 1985). A s many who have practiced meditation w i l l report, practicing selfawareness without judgement is not an easy endeavour. Simply noticing thoughts, emotions and sensations as they arise and pass away is difficult. In sitting quietly 'paying attention', the mind has a tendency to wander and become involved in 'thinking', resulting in temporary loss o f attention from what is happening. In mindfulness meditation, no thought or sensation is considered a distraction, including a wandering mind (Kabat-Zinn, 1982). Unlike concentration where one intentionally limits awareness to the object o f attention (e.g. breath), in mindfulness one is aware o f whatever arises in the mind, only returning to the object o f attention when one  45  becomes 'lost' in thought. When the meditator becomes aware they are no longer attending to what is arising in the mind but are fully engaged in thinking (lost in the content o f the mind without awareness o f the process o f thinking), then his/her awareness is gently returned to an object o f attention (breath) until awareness is stabilized. Unlike concentration that narrows attention to a particular object, mindfulness opens up to whatever arises; no thoughts or sensations are accorded privilege. For example, in KabatZinn's work with chronic pain sufferers, he explains how the potential benefit o f this kind of meditation depends on the person's ability to observe intense feeling in the body as bare sensation. With repeated practice, people are able to intentionally adopt an attitude o f detached awareness toward a sensation and to observe with similar detachment the accompanying (but separate) internal dialogue that labels and defines the sensation as 'pain' or 'discomfort'. Based on Buddhist theory o f the mind, by observing such discursive thinking ("it's painful") as separate from the bare body sensation, the emotional and cognitive reactions can lose considerable power and urgency. Consequently, the sense o f struggling and suffering are reduced (Kabat-Zinn). These principles apply equally to all other sensations including fear, calm, and loss o f control (Trungpa, 1975; 1988) A s sadness or panic arise during meditation, these experiences are gently noted without rejection or being embraced along with their accompanying discursive stories and attempts to make sense o f it. A l l feelings and thoughts are recognized as impermanent phenomena that arise and pass away. Awareness o f bare sensations and thoughts are disentangled from the interpretive 'story' that is  46  attached to the experience. Such distinction accords some 'space' between one's direct experience and the interpretive frame in responding.  10  When awareness is open in the body, we tend not to get so lost in our head, we don't get so confused by the flux o f mental conditions and states o f mind. Staying at the level o f sensation the body allows us to see everything much more clearly within that field o f awareness. It is non-verbal awareness that is available all the time. (Levine, 1989, p. 124)  In summary, concentration meditation can be viewed as 'single-pointed' focus o f attention whereas mindfulness explores the breadth and clarity o f awareness. Mindfulness has an immediate applicability to a wide variety o f present-moment experiences and has a quality of'ordinariness' (Kabat-Zinn et al., 1992). A s such, the perception o f ordinariness makes mindfulness meditation accessible to a broad range o f people with different motivations and life concerns and can be applied to actions (walking, turning patients, listening) as well as formal sitting meditation.  1 0  For a more theoretical explanation of the relationship between mind and body, see explanations by H . H .  the Dalai Lama (pp. 164-170, Varela, 1997)  47  STRAND TWO ~ DIVERSE VOICES IN END-OF-LIFE C A R E  The etymology o f 'sadness', like 'satisfied' and 'sated' is full and whole, warm and heavy flows underground, surfacing permeating like winter's l i g h t pale and pure. Perching by the hospice bed, gently caressing your hand, resting, just resting, as time collapses into now. Y o u no longer awaken but lie prone—inert, trying to pass over all struggles left behind bittersweet... Sitting, I know that I am sitting, breathing, I know that I am breathing, and wonder i f you are aware o f what is happening... in the space(s) between and around us.... Resting tenderly, still, W i t h no-where to go~ now-here beyond words awaiting...  D I V E R S E V O I C E S IN E N D - O F - L I F E C A R E Changing conceptualizations of Death The inescapable fact that death awaits us all is a powerful incentive to explore differing perspectives o f dying and death. Over the past century, Western understandings of death and dying have drifted, almost exclusively, into the province o f science and medicine. Yet, we have much to learn from other knowledge and wisdom traditions; many o f the world's cultures and great religions have considered dying an art that can be learned. Most cultures, before the rise o f secularism, have had instructions on the art o f dying. For example, shamanic traditions and indigenous peoples have preserved and orally transmitted their rites and rituals o f dying (see Webb, 1997). Judaism's mystical teachings o f the Kabbala and Zohar and the textual instructions o f the Egyptian or the Tibetan Book of the Dead have guided the dying and their caregivers for hundreds o f years. Nevertheless, an application o f technology and the dominance o f scientific perspectives have undermined our understanding o f dying as a normal process that can be learned. Consequently, this has led to the silence or taboo that is said to be characteristic of the modern attitude o f denying death. T w o views o f death in modernity seem to currently dominate: first, physical death is sequestered from the public domain, and second, the public discourse on death is dominated by Western medicine (Littlewood, 1993; Mellor, 1993). The first view is challenged by arguments that death denial is overstated. Banerjee (2000) suggests that death is not so much denied as it is 'managed' and 'organized' and thereby devalued in the process. The view o f death denial is also challenged by the media's powerful sensationalizing and its role in shaping our  49  understanding o f death and bereavement (Walter, Littlewood & Pickering, 1995; Mellor). Meanwhile, the dominant role o f medicine in public discourse o f death remains intact. C l i v e Seal (1998) suggests that Western social and cultural life involves dichotomizing and turning away from the inevitability o f death towards a focus on life. He submits that the formation o f self-identity and constructions o f death and dying are culturally determined; we need only look at other cultural perspectives to see the degree to which our own identities are culturally constituted. To illustrate, contrast a Buddhist perception o f the inseparability o f living/dying with a modernist view that sees death as either threatening to make life meaningless, or prompts us to engage in activities to defend ourselves against death. A modernist view is based on facts that the body eventually dies but can be maintained for increasingly long periods. Dying is defined as a biological process—a function o f the body. A n y metaphysical aspect o f death is relegated as a personal and 10  cultural belief system that is inexplicable, at present, from a scientific standpoint. The medical classification o f death under the rubric o f disease further illustrates Western medicine's influence i n the public discourse. However, growing public distrust in biomedical solutions for those facing death and caring for the terminally ill has been linked to the emerging role and prominence o f hospice/palliative care movements (Dudgeon, 1992; James, 1992).  Rhodes and Vedder (1983) claim death is defined as the absence of brain waves and following two EEGs that are flat, even if mechanical supports are keeping the heart and lungs functioning, the patient is considered clinically dead. i 0  50  Contemporary hospice/palliative care movement The founding o f modern hospice/palliative care has been attributed to Cicely Saunders who opened St. Christopher's Hospice in England in 1967. A re-establishment of hospices was viewed by Saunders as a revival o f services and institutions for the dying that originated in Christian monastic orders (Phipps, 1988). In the early 1970s, the hospice movement spread across England and North America. B y 1995 there were 726 hospice and palliative care services identified in the U K ; 2, 514 services in the U S A and Carribbean; and 580 in Canada (Doyle, 1997). Contemporary models o f hospice/palliative care have taken different forms. For example, free-standing hospices proliferated in the U K while the United States leaned towards home-care based programs and, in Canada, palliative care programs tend to be within hospital settings (Ferris & Cummings, 1995). Despite the difference i n models, the philosophy and principles o f hospice/palliative care remain focused on individualized, family-centered and compassionate care o f the whole person at the end o f life. The provision o f symptom control with a focus on pain management was an important aim o f hospice care from its inception. Saunders' concept o f 'total pain' that includes the physical, emotional and spiritual aspects o f suffering introduced a holistic perspective o f the patient (Saunders & Baines, 1983). In addition, a holistic view o f the person extended to the family as requiring care, and as such introduced the family as the 'unit o f care' into hospice. A humanistic view that each individual has a unique response to his or her experience has been deeply incorporated into the hospice philosophy. Throughout the hospice movement emphasis has shifted from curing to providing compassionate treatment o f the dying person rather than aggressively treating an already  51  fatal illness. Currently, palliative care encompasses a broad scope that includes services at the time o f diagnosis through to death and into the bereavement period.  Shifting ground ~ Hospice and Palliation Within the end-of-life writing(s), hospice and palliative care are terms that are often used interchangeably. During the 1970s and 1980s most o f this literature conjoined the terms with an understanding o f their mutual meaning; educational programs involved in teaching palliative/hospice care rarely distinguished between the two (Cummings & Stajduhar, 1993). Meanwhile, in October, 2001 the Canadian Palliative Care Association ( C P C A ) was officially renamed the Canadian Hospice Palliative Care Association ( C H P C A ) to minimize confusion and endorse both terms equally. Although used interchangeably i n Canada, the etymologies o f 'hospice' and 'palliative care' provide insight into a growing controversy about their meanings in other jurisdictions such as the United States. 'Hospice', derived from hospitium, (Latin), described a place where those in need would go for assistance (Phipps, 1988) and is also the root for the words hospital, hostel, hotel, and hospitality. 'Palliative' derives from palliare  (to palliate) meaning to cloak or cover, "to cover the disease through relieving  or masking the symptoms" (Victoria Hospice Society, 1993, p. 1). A n emerging debate is questioning the growing acceptance and role played by the medical establishment in hospice/palliative care. Tensions arising from perceptions o f medical encroachment and the negative implications o f institutionalizing hospice care are now beginning to surface. Byock (1998) states that in the United States, the term 'palliative care' is frequently presented as an alternative to hospice. This alternative is often a modified approach, that is, palliative care is slowly being used for pre-existing  52  pain clinics, consult services by a single health care provider (rather than an interdisciplinary team), and often focuses primarily on the relief o f physical suffering (rather than total pain), and assistance with treatment decision making. O n one side o f the controversy, hospice care is viewed as the gold standard with concerns that the philosophy and approach are being threatened as these modifications to the original approach are introduced. O n the other side are those who believe that hospice is too restrictive and limited in terms o f the number o f people who can be served. Some argue that a more flexible and expanded approach is needed to meet a growing demand (Doyle, Hanks, & MacDonald, 1998). Seale (1998) interprets the controversy as an interplay o f discourses; the modernist discourse o f medicine and the 'revivalist' discourse o f hospice. A s a sociologist, Seale's interest lies in seeing how people appropriate these different meta-narratives and, "as 'system-representatives' seek to mould the subjectivities o f the people for whom they care" (p. 117). In the context o f this study, the interplay also includes the discourse o f Buddhism within North American culture and how these discourses interact in the lives o f hospice residents and caregivers. For the purpose o f this inquiry however, hospice and palliative care are used interchangeably i n support o f the original spirit o f these terms and also in congruence with the Canadian Hospice Palliative Care Association's inclusive stance: Palliative care, as a philosophy o f care, is the combination o f active and compassionate therapies intended to comfort and support individuals who are living with a life-threatening illness. During periods o f illness and bereavement, palliative care strives to meet physical, psychological, social and spiritual expectations and needs, while remaining sensitive to personal, cultural and religious values, beliefs and practices. Palliative care may be combined with therapies aimed at reducing or curing the illness, or it may be the total focus o f care. Palliative care is planned and delivered through the collaborative efforts o f an interdisciplinary team including the individual, family, caregivers and service providers. It  53  should be available to the individual and his/her family at any time during the illness trajectory and bereavement. While many service providers may be able to deliver some o f the therapies that provide comfort and support, the services o f a specialized palliative care program may be required as the degree o f distress, discomfort and dysfunction increases. Integral to effective palliative care is the provision o f opportunity and support for the caregivers and service providers to work through their own emotions and grief related to the care they are providing. ( C P C A , 1995, p. 12)  Shifting ground ~ Humanist and Transpersonal Orientations In addition to shifting conceptualizations o f how palliative and hospice care are understood, there is growing interest in returning to other traditions and to the art o f dying or artes moriendi (Webb, 1997). Perhaps this response is due to continued x1  concerns about death and Western medicine's inadequacy in addressing this human experience. O r perhaps, as Seale (1998) suggests, we are searching for new cultural scripts for interpreting dying. T w o assertions presented by Seale (1998) regarding contemporary constructions of dying and death have parallels with Buddhism's non-modern perspectives on dying. Although I remain unclear how these observations fit in, they seem noteworthy. First, Seale suggests that traditional warrior-hero narratives have given way to pervasive 'psychological discourses' rendering new forms o f hero in Western culture; namely, the inner-adventurer hero. This narrative emphasizes inner journeys and a "deeply rooted cultural obligation to be free" (p. 120). Seale ties this newly emerging narrative to  " Artes Moriendi is a tradition found in 15th century Christian guidebooks for the dying. The guides offered both practical advice, as well as encouragement and assurance to the dying that they will be able to safely travel through the unknown territory ahead (Webb, 1997). In using this term, 1 am not referring specifically to these ancient Christian texts, but rather to the broader notion of the art of dying.  54  broader currents o f patient-centered care in constructing a contemporary discourse o f death. According to Seale, death in hospice is presented as orderly, and an inner quest facilitated by knowing guides. Such a discourse o f inner-hero with guides to facilitate the final journey is also familiar in Buddhist texts such as Chogyam Trungpa's (1984) Sacred Path of the Warrior and The Tibetan Book of the Dead (Fremantle & Trungpa, 1975). Warriorship is understood as, "the path o f bravery, that is open to any human being who seeks a genuine and fearless existence" (p. 13). The battle metaphor evokes bravery required in living the "experiences and challenge o f being human" (p. 13). These parallels also contain equally significant differences such as the understanding o f ' s e l f (and 'freedom') as presented in the Buddhist theoretical context o f this inquiry. The second observation offered by Seale (1998) that is expanded upon in this inquiry, is that hospice can be understood as an institutional construction o f liminal space for the dying. He suggests that in this unarticulated space conventional rules do not necessarily apply, hierarchies are loosened, and a relative lack o f structure prevails. Interestingly, creation o f such borderland spaces can be within buildings, but also as a separate state of mind. Parallels linking this with Bhabha's (1990) third space and A o k i ' s (1996) metonymic moments can be drawn. Similarly, Buddhist views o f nonduality and no-self are reminiscent o f Seale's liminal space where a lack o f solid structure is fostered. Interest and public awareness about death and dying are growing steadily. Recent thanatological literature has expanded from the early humanistic perspectives pioneered by Elizabeth Kubler-Ross, and Cecily Saunders' hospice movement, to transpersonal themes in end-of-life (Levine, 1982, 1997; Weisman, 1995). Given that people are living longer with life-threatening illnesses, they are looking beyond individualized humanistic  55  care and taking the process o f living with dying one step further than in hospice care. That is, there appears to be a shift towards adopting a transpersonal perspective  12  wherein  the very process o f dying is seen as an opportunity for personal and spiritual growth through conscious living and conscious dying (Levine, 1982; Sogyal, 1992; Webb, 1997). Transpersonal psychology is a relatively new branch in the discipline o f psychology that studies psychospiritual development and transpersonal dimensions o f human experience (Valle, 1998). Abraham Maslow, one o f the first psychologists to explore and promote transpersonal psychology as a discrete branch, believed that there were states o f awareness in which a human being could transcend the ordinary limits o f individual identity and experience. Transpersonal dimensions include experiences in which self-identity, "extends beyond (trans) the individual or personal to encompass wider aspects o f humankind, life, psyche, and cosmos" (Walsh & Vaughan, 1993, p.3). Valle describes transpersonal dimensions o f human experience as those experiences and events in life that leave one transformed, experiences that are impossible to explain to others, i f not to ourselves, that alter the very fabric o f one's being in the world. In the literature, it is unclear how the concepts of'spirituality' and 'transpersonal dimensions' are distinguished. Some authors use the term 'psychospiritual' to define transpersonal dimensions, leaving the reader to assume that the terms 'spirituality' and 'transpersonal' dimensions are interchangeable. I sense that the language o f 'transpersonal' removes this 'psychospiritual' phenomenon away from a metaphysics o f spirit into the potentially scientific realm o f mind and psychology. In doing so, notions o f spirituality can more easily move into the health science literature (see Raeburn &  Buddhism is often described by Westerners as an Asian psychology and is frequently included in the branch of psychology known as transpersonal psychology (Wilber, 1998). 1 2  56  Rootman 1998, as an example). Within this inquiry, I avoid using the term 'spirituality', not for this reason, but because it is a term firmly rooted in Western traditions and not easily translated into non-Western and non-modernist traditions such as Buddhism. Inquiry into the subtle and complex aspects o f human experience o f living/dying is required as interest in dying and death grows. Those who consider themselves nonreligious are also interested in pursuing a deeper understanding o f human experience beyond materialism. Baby boomers are drawing on our generation's own experiences in a search for spiritual guidance at death. In the process we are reexamining transcendent moments o f all sorts. This can mean meditation and prayer, but it can also include music, art dance, diet, intensive psychotherapies, dreamwork, hypnosis, even psychedelics or hallucinogenic drugs. (Webb, 1997, p. 260)  The changing conceptualization o f dying and death as an opportunity for personal and spiritual growth is congruent with Buddhist perspectives on living and dying and is supported by the underlying assumptions o f this inquiry.  57  Meditation and Dying: Death o f the Body, Death o f the Self  Stephen Levine (1982) in his book, Who Dies?, presents an alternative conceptualization o f dying from one o f loss and fear towards a normalized, compassionate understanding o f human transition. Levine is a longtime practitioner o f Buddhist meditation, and draws upon the theory and practice o f meditation in guiding the reader towards opening to death through learning to let go o f each moment and opening fully to the next moment o f experience, that is, "to die consciously moment to moment" (p. 249). Levine asserts that through meditation practice, we experience the rising and passing away o f ever changing mind states that we strongly identify with as 'me'. Through repeated observations o f the arising  For many, disease is the way back into life. (Levine, 1982, p. 204)  and passing o f our identity, one begins to experience its impermanence. Birth and death are evoked at a very deep level. Again, we return to a central notion o f self/no-self within Buddhism and the experiences o f fear and suffering when the sense o f self is threatened. Theoretically, through the practice o f meditation and seeing the moment-tomoment birth and death o f the mind, the  Letting go of the will to live does not mean creating a will to die. Both are attachments to the body, both are based on mistaken identity. As long as death is the enemy, life is a struggle. (Levine, 1982, p. 205)  impermanent and transitory nature o f our experience, including fear and suffering, becomes increasingly clear and more workable. Levine suggests that once one begins to experience how the content o f mind is constantly changing, the sense o f a solid independent ' s e l f begins to soften and a quality o f  58  equanimity arises.  13  The development o f equanimity through such experiences o f self-  dissolution is reported elsewhere (Kornfield, 1979) and is in keeping with traditional texts describing meditative development (Epstein, 1995). Although no research was found to support these claims in relation to the experience o f dying, Kornfield's (1979) descriptive study aimed at mapping a range o f meditative experience that included equanimity. In this study Kornfield focused on people who were practicing mindfulness meditation during five two-week and one threemonth intensive training periods. Findings from this study illustrate how intense emotions such as fear or anxiety do not necessarily decrease through meditation, but that one's response to intense emotional and cognitive experiences may change; the experiences became reportedly less threatening. Kornfield's study used open-ended questions in a questionnaire and student-teacher interviews held every second day. Following the interviews, notes were made on the descriptions provided by the students/meditators. In total, over 100 two-week students and 63 three-month students participated in the study. Data analysis included categorizing unusual experiences and insights into 22 categories. Participants reported a growing ability to adapt easily in the face o f extreme bodily and mental changes. A m o n g practitioners with strong concentration and mindfulness, periods o f strong fear and insecurity were reported. These periods o f intense emotion usually resolved by "surrender, by fully experiencing them, leading to a greater development o f equanimity" (p. 54). A s noted earlier by Varela et al. (1991), meditation facilitates experiencing whatever arises while distinguishing the direct sensory experience from an abstracted interpretation accompanying a sensory event.  Equanimity (Upeksa, Skt.) is translated as impartiality that is distinguished from indifference. Equanimity is like, "an utterly calm ocean: the mind is completely even" (Wallace, 1999, p. 151). 13  59  Therefore, intense sensations of'fear' can be experienced and distinguished from the cognitive, interpretive story about the fear experience. From a Buddhist perspective, we can use our lives to prepare for death; meditation is one practical way o f doing this. Specific meditation practices draw on the experience o f self-forming and guide the meditators in visualizing and rehearsing the stages o f dissolution in preparation for active dying. Sogyal Rinpoche (1993) and Levine (1982) have written practical guidebooks explaining the application o f these meditation practices in preparation for dying. It is clear i n these texts however, that the emphasis is on an interrelationship o f living and dying. Preparation for death can be cultivated through regular mindfulness practice and becoming familiar with the inevitability o f death through daily contemplation. Lama Zopa once said jokingly during a retreat in Nepal, " A day without thinking about death is a wasted day" (personal communication).  Being with someone who is dying is like looking into a very clear and detailed mirror o f our own individual process. If we have the understanding, courage, and patience with ourselves, we can see our own fears, defense, guilt, anger, attachments, desire -all o f it- surface to the foreground o f this living mirror. (Sharp cited in Coberly, 1997).  60  Integrating East and West ~Zen Hospice Project Zen Hospice Project (ZHP) was founded in 1987 as a program o f the San Francisco Zen Center integrating Western hospice care with Buddhist philosophical views and practice. The project is guided by a community-based Board o f Directors, six employees and over 100 volunteers who are recruited because o f their interest in exploring their own spiritual and personal growth (Zenhospice, 2000; Moore, 1996). What makes Z H P unique is its training and education in the fundamentals o f hospice care within a broader context o f Buddhist mindfulness practice. Applications for volunteers are considered from applicants who have a meditation practice and share a commitment to bringing together "spiritual insight and practical social action" (personal communication, Z . Engler, Z H P Volunteer Coordinator). The Zen Hospice Project is dedicated to the following mission: o  To establish and maintain a program o f hospice services in collaboration with community services to mindfully and compassionately serve people approaching death.  o  To train and support volunteers to assist people facing life threatening illness and their family/friends in a manner that meets what the families understand to be their physical, emotional and spiritual needs.  o  T o establish and maintain a model center.  o  To provide educational programs with a foundation in Buddhist teachings that foster awareness and compassion in facing death.  61  Zen Hospice Project has three central programs in meeting these goals: a) its own residential program, b) a residential hospice unit i n a public hospital, and c) education programs for the public and volunteers. The residential program serves adults with a life expectancy o f 3 to 6 months who are often homeless or without family. Residents are referred from hospitals and health care professionals with prior assessment and informed consent. The Guest House is the site o f the original residence hospice and remains Z H P ' s residential program. Moore (1996) explains how the Guest House was established after volunteers first started seeing clients where they lived, on the streets, or in hotels. A s people became progressively i l l , they were transferred to non-hospice units in local hospitals and often died alone, without the supports o f end-of-life care. Clients could not stay i n their hotels or receive home care nursing without a primary caregiver that was required by visiting nurses. Further, due to the lack o f a fixed address, many could not receive government entitlements. Moore explains how Zen Guest House was created to provide a fixed address where volunteers could act as primary caregivers. This allowed visiting nurses to see several clients at one location and provided clients with hospice services. The Guest House continues to function in a five-bedroom Victorian home with community-based care. Medical management and 24-hour hospice level care are provided through a collaborative organization, Hospice by the Bay. In addition, the Laguna Honda Hospital has a 28-bed hospice unit with a hospice program created with the initiative o f Z H P in 1988. This program provides a model for private collaboration i n palliative/hospice care. Through continued partnership, Z H P staff and volunteers work as part o f an interdisciplinary team providing comprehensive care.  62  A s with most non-profit hospice programs, volunteers are the heart o f the project. The Z H P supports a mutually beneficial relationship between volunteer caregivers and individuals facing death. Volunteers are provided with 40 hours o f training certified by the California Sate Nurses Association and commit to 100 hours o f service (Moore, 1996). The training includes the fundamentals o f care, such as listening, bathing, turning and skin-care; however, the basis o f the training is mindfulness. Meditation practice is taught and encouraged as an ongoing practice to assist volunteers in deepening their relationship with suffering and dying while cultivating mindful and compassionate approaches to care. A s one o f the founders Frank Ostaseski notes, "Crossing the threshold o f a room o f someone who's dying is a remarkable time to pay very close attention" (Moore, p. 30). Monthly support meetings for volunteers are offered in providing ongoing training, a forum for community building, and the integration o f personal growth/spiritual practice with hospice care (Zenhospice, 2000). While meditation or a spiritual practice is encouraged for volunteers, there is no requirement o f residents who come to the hospice for care. The potential for imposing a belief system on vulnerable residents is noted by Ostaseski, "the conscious dying movement can sometimes become simply another agenda, another burden to place on the heart and mind o f the patient" (Moore, p. 28). Furthermore, "Zen Hospice Project is designed to take people as they are, assisting them in closing out their lives without asking them to accept another person's belief system" (p. 28). Interestingly, many indicators pointed to the Z H P as the ideal place for engaging in this inquiry about mindfulness and its relationship to dying and death. In general, the long history and unique service o f Z H P provided a special opportunity to learn from and  63  with an experienced hospice community. While Vancouver has two free-standing adult hospices and one children's hospice, the unique focus on mindfulness and Buddhism within a hospice setting is not (yet) available in Canada.  Mindfulness Meditation and Health: Voices from the Literature In the past 25 years, scientific investigation into meditation has grown prolifically. A review o f the literature has revealed a clear void in qualitative understandings o f meditation or experiences o f meditation practice. Selected literature on mindfulness meditation is re-viewed to illustrate the differing voices and configurations o f meditation in the literature, followed by identifying those voices that are absent. Most o f the available research conceptualizes meditation as a self-care practice and emphasizes its potential for relaxation and stress reduction. However, more recent inquiries address the contemplative components o f meditation and its role in fostering spiritual growth and understanding (Astin, 1997; Hawkes, H u l l , Thalman & Richins, 1995). Murphy and Donovan (1999) conducted an extensive review o f inquiries into the physical and psychological effects o f meditation from 1931-1996. Most o f the 1300 studies examine concentration practices such as transcendental meditation, with mindfulness/awareness gaining attention in the late 1970s. With the strong emphasis on meditation as a health care intervention and a dominance o f quantitative research, the physiology o f meditation has received more attention than any other dimensions o f meditative experience. Nevertheless, physiological outcomes remain the center o f most research efforts into meditation. A re/view o f studies emphasizing mindfulness  64  meditation vis-a-vis stress, anxiety, pain management and the experience o f mindfulness itself is presented. These studies pertain directly to end-of-life concerns and therefore provide a framework for exploring the inquiry literature into meditation.  Current Inquiry into Meditation Mindfulness meditation has been adapted by Kabat-Zinn (1990) into a mindfulness-based stress reduction ( M B S R ) program. Kabat-Zinn's model has contributed enormously in introducing Eastern meditative practices and perspectives into health care settings and provides the largest body o f scientific inquiry into mindfulness practices within this domain. Meditation is presented as practicing the simple act o f carefully paying attention and experiencing one's life in the present moment. This 8week program has been adapted and used with diverse populations including persons with human immunodeficiency virus disease (Wheeler, Grossman, & Lippman, 1997), inner-city settings with low income Hispanic participants (Roth, 1997), medical students (Shapiro, Schwartz & Bonner, 1998), nursing students (Bruce, Young, Turner, V a n derWal & Linden, 2002) and generic undergraduate students (Astin, 1997). Kabat-Zinn and colleagues have documented the clinical effects o f mindfulness meditation for coping with a wide range o f health concerns including physical and psychological symptoms o f stress, chronic pain, anxiety, psoriasis, and fibromyalgia (Bernhard & Kabat-Zinn, 1988; Kabat-Zinn et al., 1988; Kabat-Zinn, et al., 1985; KabatZinn, Lipworth, Burney & Sellers, 1987; Kaplan, Goldenberg, & Galvin-Nadeau, 1993). M u c h o f the critique o f Kabat-Zinn's earlier work has focused on the small sample sizes and lack o f control groups (Astin, 1997). In more recent studies these limitations have  65  been addressed and continue to show similar results. For example, a study using a matched control design with a group o f 22 participants examined the effectiveness o f mindfulness meditation programs i n psychiatric patients with generalized anxiety disorder, panic disorders, and agoraphobia, and found that M B S R can effectively reduce symptoms o f anxiety and panic and help maintain such changes (Kabat-Zinn et al., 1992). Another area o f inquiry used mindfulness-based interventions with patients managing chronic pain (Kabat-Zinn, 1982; Kabat-Zinn, et al., 1985; Kabat-Zinn et al., 1987). This research showed significant reductions in pain measures ( M c G i l l - Melzack Pain Rating Index), negative body image, inhibition o f everyday activity by pain, mood disturbance and psychological symptomatology including anxiety, depression and hostility. Kabat-Zinn notes that the central and underestimated therapeutic importance o f mindfulness meditation is attentional regulation that is common to other psychological interventions used for chronic pain relief (biofeedback, hypnosis, visualization). These studies suggest that the systematic cultivation o f one's capacity for detached observation of sensory experience (proprioception) can enhance whatever the patient's previous coping strategies had been and reduce the level o f distress related to chronic pain. M a x i m i z i n g dimensions o f human consciousness for achieving well-being, even i n the midst o f suffering, may be possible through meditative practices (Kabat-Zinn). To this end, further inquiry into understanding the underlying psychobiological mechanisms o f meditation and the self-regulation o f pain are required. W i t h respect to adherence to the meditation practice, Kabat Z i n n et al. (1987) reported that more than half o f the participants in studies regarding chronic pain continued to meditate regularly (that is, at least three times per week for at least 15  66  minutes) after six months and one year. Four years after completing the program, 30% o f participants indicated they maintained that level o f formal practice, with an additional 20% being sporadic meditators (e.g. two times per week for at least 15 minutes) over the four post-intervention years. A few qualitative studies were located in this review o f the literature. Brennan and Stevens (1998) explored the perceptions and experiences o f cancer patients and the role o f meditation as a complement to cancer treatment. The authors identify a grounded theory approach, although they present only selected themes. Unfortunately, the specific type o f meditation used by patients in this study is not identified. Nevertheless, some o f the themes identified are relevant to end o f life concerns and are supported by other research on mindfulness. For example, the themes o f gaining control, and perceiving a positive difference in their lives is corroborated in Astin's (1997) and Shapiro's (1998) work. Astin conducted a randomized experimental inquiry with sense o f control as a variable and found overall increases in the Sense o f Control Index, compared with a control group. These findings suggest that mindfulness meditation's emphasis on accepting and trusting one's present-moment cognitive, affective, and bodily experiences (rather than trying to alter them) may have "positive carryover effects in how one relates to or copes with life experiences in general"(p. 104). Some research exists regarding potential negative effects o f intensive meditation practice in retreat settings (7-14 day retreats). Craven (1989) cautions that meditation is contraindicated for clients with histories o f psychotic episodes, dissociative disorders, or those at risk for increased social withdrawal. One reason for caution is that intensive meditation has 'destabilizing' effects (Wilber, 1986). Although little research has been  67  done in this area, one qualitative study provided insight into these concerns. Vanderkooi (1997) conducted a descriptive, qualitative study into the experiences o f extreme mental states in Western meditators, and the experiences o f teachers guiding such students. Twelve experienced and sanctioned meditation teachers from Theravada, Zen, and Tibetan traditions and four college-educated meditators who had experienced major psychological difficulties during extended meditation retreats were interviewed using semi-structured interviews. Three vignettes were presented in Vanderkooi's (1997) study to illustrate the kinds o f experiences and motivations conveyed by these meditators. A l l three cases resulted in psychotic episodes requiring hospitalization during or following a 7 to 14-day intensive retreat. Psychosis was understood by meditation teachers as "a problem o f over identifying with non-ordinary states o f consciousness and being unable to disidentify and let go" (p. 40). O f note, is that one person had a prior history o f mental illness, one was subsequently diagnosed with schizophrenia, and the third self-identifies with borderline personality. The teachers interviewed in Vanderkooi's study estimate the occurrence o f major psychological difficulties to be far less than one percent. N o other research was found to determine the prevalence o f psychotic episodes associated with intense meditation practice or any similar negative outcomes. The teachers in this study also identified signs to assist meditation instructors when 'extreme non-ordinary states' might foreshadow a psychotic break. These indicators include: a student's obsession with non-ordinary states o f consciousness; more negative, fearful and bizarre states; being emotionally disconnected; feeling more rage, self-pity; and, experiencing fewer moments o f sadness and clarity than those who are not  68  prone. Vanderkooi (1997) suggests that most meditators who practice meditation informally w i l l discontinue their practice when frustrated or having negative experiences. It is clear that further inquiry into these kinds o f experiences is necessary to better understand negative experiences associated with intensive meditation practices. Critical examination o f cultural constructions and interpretations of'negative' outcomes would also provide a better understanding o f these non-ordinary states and apparent 'spiritual crises' that have recently been addressed as health concerns. The outcome literature on meditation clearly indicates positive effects o f meditation far outweigh the negative results presented in Vanderkooi's study. Nevertheless, this qualitative study provides insight into the experiences o f a small number o f people and contributes to a broader understanding o f meditation and its effects.  Limitations and Missing Voices Criticisms and limitations o f earlier inquiries into meditation focus on methodological concerns and the contradictory findings regarding outcome effects (Bogart, 1991; Murphy & Donovan, 1999). Murphy and Donovan account for the apparent inconsistencies in physiological effects o f meditation in various ways. For example, much o f the early research did not take into consideration differences o f sex, age, or socio-cultural background, and participants were frequently college students with no previous meditation experience. Further, much o f the inquiry into meditation has been fragmented into components lacking a clear conceptual framework to guide the inquiry.  69  Empirical investigation into meditation is almost exclusively dominated by quantitative research designs. Although conventional quantitative designs including randomized clinical trials contribute to our understanding o f the effects and outcomes o f meditation, new forms o f inquiry into the complexity and ambiguity o f direct perception and its meaning are needed. Even though most existing research into this phenomenon falls exclusively within a scientific-modernist discourse, contesting voices can be found. Busby (1996) is one such voice who maintains that alternative mind-body approaches such as meditation reflect alternative knowledges and consequently influence the mechanism o f healing in very different ways. Busby does not directly address the implications for inquiry but infers that approaches for investigating alternative knowledges require a critical examination o f conventional inquiry approaches. Margolin, Avants, and Kleber (1998) concur that alternative therapeutic approaches possess theoretical bases that are seemingly antithetical to a quantitative, biomedical framework and that methodological considerations must be accounted for in bodymind inquiry. The experience o f mindfulness and its role in accessing the experience o f living/dying may best be  What was marked formerly by the firm and rigid shapes o f a Eurocentric geometry is now the fluid, shape-shifting image o f chemical flux and transformation, as margins move to the center, the center moves to the margins, and the whole is reconstituted...The whole concept o f center and margins is being transfigured by methods, methodologies, research practices, and epistemologies scarcely dreamed o f a generation ago. (Denzin and Lincoln, 2000, p.1063)  explored using qualitative and aesthetic forms o f inquiry. The challenge remains o f embodying Buddhist meditation and its theoretical frameworks within existing approaches to inquiry. This inquiry is a study o f mindfulness, using mindfulness as the path or method. Addressing complex human experiences o f momentto-moment awareness requires new ways  70  S T R A N D T H R E E  ~ P A T H O F  INQUIRY  Zazen, hands cupped in universal mudra thumbs touching. Curiously aware o f breathing and sensations o f awareness Muffled swishes o f robes soft thumps of bare feet on wooden floors, as meditators find their seats and settle into silence. Sitting upright in dawn's early darkness, Shadows cast on rice-papered windows fading into clear light as daylight awakens....  PATH  So one might as well know that the principle enemy in life is fear. To write only has meaning i f the gesture o f writing makes fear retreat. A s always, it is double: we must be afraid and not afraid o f writing for the sake o f writing, and at the same time we make fear retreat. (Helene Cixous, 1997, p. 26)  The path o f inquiry addresses how this study and its fruition were constructed. Questions asked vis-a-vis the path include: what analytical and interpretive approaches were used and why? What decisions were made and what was my thinking in choosing one path over another? Were there surprises along the way and what challenges did I meet? What were the strengths and limitations in proceeding in this way? H o w was the path guided by the inquiry question? Although responding to such questions may seem straightforward, it does not feel so. This strand was written after completing the fruition section and yet it is read first. In part, this conventional sequencing suggests that the path was predetermined, like a detailed topographical map, and as inquirer I only had to interpret the lines and squiggles in order to find my way. However, as qualitative inquirers share, the interpretive process is rarely straightforward; the path is neither clear nor well-trodden and the end is often not foreseen at the outset. O f course this is not always the case. Inquiry designs suggest a particular structure and process that are congruent with the inquiry question. For example, grounded theory directs one towards a 'basic social process' and determines what is created and what is left out. I knew this intellectually, but came to realize the role and significance o f structure while experiencing a space without structure and then later intentionally  72  creating the structure o f koans. In part, the topic and question o f this inquiry seemed to ]6  necessitate an iterative process o f structure and no structure. The experience o f resting in ambiguity and confusion, o f not knowing what the dissertation would look like seemed an important step. After all, the glimpses o f fear and confusion evoked in these spaces o f uncertainty seemed integral to an inquiry into dying and mindfulness. More importantly, experiencing the 'double' suggested above by Cixous (1997) called forth an opportunity to tarry in space(s) o f knowing the path and not knowing—for the sake o f inquiry, as it was happening.... I wondered how the content and process o f the study could be integrated—where boundaries could be open-ended.... I came to view the topic and path as inseparable, that is, i n examining mindfulness and the experience o f living/dying, I sought to engage in this process mindfully and with an awareness o f living/dying as it relates to conducting this work. Even so, the study was guided by particular assumptions, intentions, and Varela et al.'s (1991) notion o f openended reflexivity as path. Eventually a structure o f koans was chosen that henceforth shaped how the fruition was written and conceptualized. In other words, the structure became the content, the medium was the message, and form became path.... What follows is an account o f how this inquiry has manifested. A t the outset, I was aware o f the many possible approaches and interpretations I could use i n constructing this narrative. There is a dominant assumption that a truth exists regarding how an inquiry comes to be and that it can be accurately recounted. I resist this assumption, knowing that interpretations and constructions are ongoing and multi-  The structure of koans will be addressed later but in brief, koans are stories or cases that are designed as a meditation tool in Zen practice. Koans are developed to engage the learner's mind and assist in going past conceptual reality. This structure was adopted here as a procedure for exploring new ways of thinking and languaging existential issues related to living/dying and meditation. 1 6  73  faceted, while at the same time recognizing the academic demand for consonance and coherent accountability. This tension is seen throughout the dissertation and is broached by juxtaposing different voices while maintaining an overall organizing principle. The voices o f participants are integrated with author/ities from published texts and author/ized by comments, critiques and musings from reflexive/reflective fieldwritings. Throughout, this tension is permeated by the following assumptions and intentions . 17  Underlying assumptions guiding the inquiry: 1) Interpretation is a practice that can only be learned through doing and is never complete.... 2) W e can never finally determine what things mean. However, we can open up spaces that show meanings as partial, open to questions and always changing.... 3) Every narrative has embedded i n it multiple narratives: background narratives, absent narratives and future narratives that must be inferred or 'read' by the reader.... 4) There is no text independent o f a reader. Interpretation is inextricably linked to the interaction o f reader and text.... 5) A text can convince and persuade through rhetorical power while simultaneously holding a view o f its partial, impermanent, nature....  Underlying intentions in the path o f inquiry: The analysis and writing were interlaced and not intended to necessarily discover new elements but rather: o  To heighten awareness about the experience o f mindfulness meditation in relation to living/dying from an interpretive location i n Buddhist philosophy/psychology and to do this within the social/cultural/disciplinary context o f nursing....  I'd like to acknowledge Dr. Carl Leggo for his contribution to my thinking in this area during a course on Narrative Inquiry. 17  74  o  To explore a complex picture that invites the reader into multiple dimensions o f mindfulness...while at the same time recognizing reader-text interpretations that are fluid, always partial, contestable....; there are always other narratives, other interpretations....  o  To dialogue with and contribute to the ongoing constituting o f nursing through the creation o f new cultural scripts for interpreting living/dying....  Diabook Entry ~ Monday, September 25, 2000 / was tired yesterday and didn't want to write. Found myself sitting on the rooftop with the expansive view of San Francisco. Up there in the early morning sun I read David Chadwick's account of the life and teachings of Suzuki-Roshi who founded SF Zen Center. What is a little surprising, and yet it ought not to be, is how the book brings out the seeming 'foibles' and human weaknesses of Suzuki. It explains how he was a master teacher and then again how from time to time he lost his temper or had some unfinished issues (like his reaction to his old English teacher Miss Ransom) and how his student Graeham drifted away because of it. Suzuki is shown as a committed practitioner, wise, and yet political and a very human man. I find myself wanting him to be otherwise, wanting him to be something out of the ordinary (which he was) and not have any weaknesses or faults. Why? Because to have weaknesses or faults means the Way is not fool-proof (interesting expression). Trungpa said, don't be afraid to be a fool [What are the contrasting discourses here?] Seeing the patterns and stories of my mind. Trying not to grasp but to appreciate them for what they are, stories, and let them go without holding on to the momentary narrative as being too real or static. Beginning to wonder about the inquiry what form it will take. Is this 'data'? Am I thinking and analyzing deeply enough? What is it I am doing? Recognizing and letting it go. It has been interesting and helpful to read David Chadwick's book. The history and development of Zen Center provides a context and sense of the historical lineage of this place. There is a simplicity and straightforwardness here. The binding element is zazen, the practice of mindfulness. There is very little emphasis on intellectual understanding of the dharma it seems—. However, the practice period begins this Saturday and includes study and practice, so maybe that will change....  75  Mindful, Open-Ended Reflexivity Although a growing body o f quantitative research exists on physical and psychological outcomes o f meditation, little is known about mindfulness and its meaning for those living with life-threatening illness or caring for those who are dying. In addition, Buddhist interpretive lenses have not been integrated into current meditation inquiries. Therefore, a qualitative approach using mindful, open-ended reflexivity (Varela et al. 1991) was chosen to guide this study.  Reflexive Approaches Reflection and Reflexivity Reflexivity and reflection are integral to qualitative inquiry and are understood in a variety o f ways. In this inquiry, the concepts of'reflection' and 'reflexivity' were distinguished. The importance o f this distinction lies in their underlying ontological assumptions. For example, within the notion of'reflection' is an assumption o f something 'out there' that can be reflected back upon, as a mirror reflects back whatever is in front o f it. Likewise, inquirers may locate themselves in a position that assumes they are distinctly separate from and can reflect back on the 'data,' field experiences, and/or themselves. In comparison, 'reflexivity' involves recognizing that an account o f reality does not mirror reality but rather, "creates or constitutes as real in the first place whatever it describes" (Emerson, Fretz, & Shaw, 1995, p. 215). This emphasis on the social and relational construction o f reality through language is part o f a postmodern critique o f  76  research that has culminated in what Marcus and Fisher (1986) call a 'crisis o f representation', that is, a crisis resulting from disrupting the belief in an underlying reality independent o f the representations that strive to contain it. If there is no underlying, independent reality that can be apprehended, where then, is the ground? In response, postmodern thought challenges the assumption o f a singular shared reality and supports notions o f different g/rounds or realities that are continuously shaped and constituted relationally. Reality constructed by representations and therefore o f multiple perspectives where representations become reality and where reality is always, necessarily, represented....for Baudrillard (1988) this is a condition of'hyperreality', the condition where meanings become signifiers in a constant reflexivity o f signs and an endless multiplicity o f meanings. The 'truth' o f cultural activities and objects lies therefore not in how closely they represent reality but rather in their referentiality, their relationship to other signifiers. (Usher & Edwards, 1994, p. 14)  It is in this view o f reality, constructed through languaged representations, where reflexivity is clearly distinguished from reflection. This view is also congruent with Buddhist notions o f interdependence and relationality. These ideas are complex and run counter to the representational discourses in much o f the Nursing literature in which I have been educated. A n d yet, a view o f reality that is continuously constituted with each moment o f perception speaks to my experience and non-formal education in meditation. Consequently, as I encountered these notions with participants and in Buddhist texts, and found them to intuitively 'ring true,' I have tried to both understand and make them my own, so to speak, through an ontological emphasis that arises again and again in the fruition writing(s).  77  Mindful, Open-Ended Reflexivity The ability to be aware o f how we are perceiving and then interpreting through language is an important aspect o f qualitative inquiry that is currently undeveloped in the literature. In the current notions o f reflexivity the ability to be aware o f how we are actually perceiving the data is not yet accounted for or recognized. A s a result.. .the interpretation process that is going on even before the step o f identifying what the belief is.. .rather the actual perceiving and then constructing o f fieldnotes remains unexplored. (Marcus, 1998)  Links between the practical application o f mindfulness practice and reflexivity within inquiry can be seen in Marcus's observation. Varela et al. (1991) have called the combination o f mindfulness and reflexivity— mindful, open-ended reflection that I have adapted to mindful, open-ended reflexivity. T o illustrate how reflexivity and mindfulness can be connected, I offer an example drawn from a nursing text: I was at the point o f discouragement about my interviewing skills when I became aware that I was mentally classifying interviews as either 'good' or 'bad', depending on my emotional response to the subjects. (Burns and Grove, 1993, p. 567) Reflexivity in this example is demonstrated through the inquirer's awareness o f the emotional experience o f 'feeling discouraged' and what was going on in the mind. The inquirer observed a pattern o f classifying based on judgements o f 'good' or 'bad' related to his/her emotional responses. However, in order to consider this 'mindful' reflexivity in a Buddhist sense, Varela et al. (1991) suggest that the process must include not only an awareness o f the discursive contents o f mind, but awareness o f the lived aspect o f reflexivity as experience itself. Reflexivity is not seen as an abstract mental activity, but  78  is a full-bodied experience where body-mind are brought together in the present moment.  18  Varela and his colleagues call this mindful, open-ended reflection where  reflexivity leaves open the possibility o f something new. What we are suggesting is a change in the nature o f reflection from an abstract, disembodied activity to an embodied (mindful), open-ended reflection. B y embodied, we mean reflection in which body and mind have been brought together. What this formulation intends to convey is that reflection is not just on experience, but reflection is a form o f experience itself—and that reflective form o f experience can be performed with mindfulness/awareness. When reflection is done in that way, it can cut the chain o f habitual thought patterns and preconceptions such that it can be an open-ended reflection, open to possibilities other than those contained in one's current representations o f the life space. We call this form o f reflection mindful, open-ended reflection. (Varela et al., p. 27)  Through cultivating open-ended reflexivity, inquirers may also begin to address Marcus' (1998) concern about awareness o f what is going on in our experience even before the step o f identifying our beliefs that shape what become fieldnotes or journal memos. Just as critical thinking and appreciation o f aesthetics can be cultivated, Buddhist teachers maintain that it is possible to learn to notice what is going on externally, internally, and the interaction between the two (and the illusion o f this dichotomy) (Epstein, 1995; Trungpa, 1975; Welwood, 1996). The notion o f mindful, open-ended reflexivity has been the path for all aspects o f this inquiry. H o w this approach was specifically used i n analyzing and writing w i l l be addressed in an upcoming discussion on 'Approaches to Interpretation.'  In their text, The Embodied Mind, Varela et al. (1991) examine reflective dimensions of human experience from cognitive science and Buddhist traditions of meditative psychology and philosophy. 1 8  79  INQUIRY DESIGN Specific details o f the inquiry including data generation, inviting participants, accessing the field, approaches to interpretation, and ensuring ethical inquiry are explored.  Locating the site(s) and negotiating access Zen Hospice Project (ZHP) located in San Francisco, California and the San Francisco Zen Center ( S F Z C ) were the physical sites o f the fieldwork. These facilities are located across the street from one another and provided an ideal opportunity to both cultivate a mindfulness meditation practice in a retreat-like environment and experience how mindfulness manifested in hospice care. Zen Hospice Project offered a range o f programs including residential care, an extensive volunteer program, and training. The hospice program was founded in 1987 as a branch o f S F Z C , and became an independent, non-profit corporation in 1992. Each year over 200 people facing death from various illnesses are attended by 100 volunteers contributing an estimated 20,000 hours o f service (Zenhospice, 2000). A l l staff and volunteers are either Buddhist practitioners, or individuals from other traditions who have a meditation practice and share a commitment to "bringing together spiritual insight and practical social action" (ZHP, Volunteer Training information sheet). I contacted Z H P staff by phone in A p r i l 2000 and followed up with email communications to request permission to participate in the Volunteer Training Program and use Zen hospice as a site for this inquiry. Z H P was an ideal location for several  80  reasons. First, their established practice o f mindfulness meditation and a non-modernist understanding o f living and dying within palliative care was unique. N o comparable situation existed (or exists) in Canada. Participating in the day-to-day activities afforded an opportunity to better understand on multiple levels how a non-modernist perception o f death and dying, and meditation practice were embodied, and shaped the experiences o f providing care. Second, although historically the residents o f Z H P were people who had neither engaged in meditation practice nor were necessarily interested in this area, the hospice staff, as members o f a larger Zen community, could facilitate contacting people who might be interested in participating in the study. A n d finally, Dr. Betty Davies, my co-supervisor is on faculty at the University o f California in San Francisco ( U C S F ) and has many years o f experience in palliative care inquiry. Having a link with faculty at U C S F may have provided reassurance for Z H P staff in accepting my proposal to conduct a study in this sensitive domain o f end-of-life. With relative ease, my proposal was forwarded to the Executive Director from the Volunteer Coordinator and within two months permission was granted to conduct the inquiry and arrangements were set for my participation in the Volunteer Training. In the interim, I investigated living at S F Z C for the duration o f my fieldwork. Although a 5-6 month stay was not possible, arrangements were made to participate in a six-week Guest Student Program with the possibility o f an extension. This is indeed what happened and I spent the first ten weeks living in S F Z C focusing on mindfulness training while volunteering in the office at Z H P for three hours per day until the Volunteer Training began. The timing was ideal with Zen Hospice Volunteer Training beginning  81  approximately six weeks after my arrival i n San Francisco. Negotiating access was a multi-layered process that continued once I arrived; however, the initial steps were relatively straightforward. In part, I attribute this to my 'insider' status as a meditator and member o f an established Buddhist community and as a practicing nurse. After confirmation o f participation was received, ethical approval from the University o f British Columbia Ethical Review Committee was sought. The fieldwork had two overlapping phases. The first focused on immersion in the culture and practice o f Zen. This phase emphasized developing a meditation practice as "intellectual understanding o f the meditative processes is dependant on an adequate base o f personal experience" (Walsh, 1982, p. 82). Therefore, inquirers in this domain are urged to cultivate personal meditation experience throughout their studies. The Guest Student program provided an introduction to Zen practice and an opportunity to establish meditation as an integral part o f everyday life. Although I had previous experience with Tibetan Buddhist practices, Zen was a new tradition. The daily schedule was rigorous and included sitting meditation practice (zazen), chanting (service), study, and work. A s a Guest student I also attended semi-weekly  Guest Student Schedule M o n d a y to F r i d a y  Saturday  5:00 am wake-up bell 5:25 zazen (sitting meditation) 5:55 kinkin (walking meditation) 6:05 zazen 6:40 service 7:05 soji (monastery cleaning) 7:20 breakfast 9:00 work meeting 12:30 end worklunch 1:30 work 3:00 end work tea with a practice leader (once per week) or informal study 5:40 zazen 6:20 service 6:35 dinner  6:10 wake-up bell 6:30 zazen 7:10 service 7:40 soji 7:55 zendo breakfast 8:40 break or 8:45 zazen instruction 9:25 zazen 10:15 lecture 11:00 tea &discussion 12:00 lunch 1:30 pm afternoon off Sunday 7:30 breakfast 6:00 pm dinner (optional)  82  lectures, had individual meetings with teachers, and audited two courses on Zen and Psychotherapy and Contemporary American Koans. The first ten weeks focused primarily on developing relationships and entering into the world o f Zen practice. The second phase began once I had completed the hospice Volunteer Training, after I had moved from S F Z C and began to do volunteer hospice work three to four days per week. A s volunteers, we worked in pairs with a salaried care attendant, along with a nurse and physician who visited each week as needed. A l l the basic care (bathing, feeding, meal preparations, laundry, errands) and attending to the needs and wishes o f the residents were accomplished by volunteers. A journal or diabook was kept throughout.  83  Diabook Entry ~  N o v e m b e r 9, 2 0 0 0  Working with Izney was a true gift on Friday. She is gentle and soft and her sing-song voice is soothing as she tells Malcolm what she is about to do, "We're gonna' turn you towards Anne now Malcolm....Okay....here we go Malcolm....slow and gentle now....thas' it....good" she says encouragingly with her American accent. Izney wears loud, outrageous clothes that are skin-tight and accentuate her full body; her shiny black hair is flattened against her head with four inches at the tips dyed bright red. Ironically, these outward clothing statements belie a quiet, somewhat conservative person who quietly and light-heartedly engages with each resident. As I write the experience of what is happening, it becomes enriched and fleshed out. In part, I am recounting what happened as reportage and at the same time there is a construction and analysis of what transpired interwoven into the narration that I construct. I can also feel that the process of constructing this narrative will affect how I interact with Izney and the others about whom I spend time thinking and developing a storya story that is my experience and musing about and with them. These stories become the history and context in which further actions, experiences and stories will take place. I can also see how the narratives and experiences that I read in the volunteer journal also shape my experience of being at Zen Hospice. For example, I read someone's entry about Izney and immediately felt a resonance with what they had written. In turn, I felt I too could say, or think about her in a similar way that is, through appreciation. I am aware that the recognition of appreciation is a 'cultural' norm at hospice. I want to remain attuned to how this is created...and introduced...or constructed. For starters, the training initiated this attitude that is fostered in many ways. In reading Alveeson and Skoldberg (2000) I want to pay heed to their caution that: ...even ideologically and politically aware researchers risk being steered by their own text production, where influences from prevailing, free-floating discourses can gain the upper hand and play their own fragmented game with the intentionally referential, supposedly politically aware, text. Any ambition to determine 'how things are' or 'how best to interpret a phenomenon' in this situation may then be regarded as illusory and doomed to failure (p. 9). (I interpret this to mean that the narrative about Izney that I read will influence and shape other narratives that I construct and I ought to be aware of that and not blithely accept my new narrative as 'true'. ...or something like that.)  84  Inviting Participants Participants included two groups: 1) volunteer caregivers, hospice staff, health professionals, and 2) community members living with H I V - A I D S . Criteria and snowball sampling (Creswell, 1998) were used in inviting participation. I waited eight weeks before initiating any requests in order to become a familiar and known member o f the hospice team. Criterion sampling focuses on participants with experience o f the phenomena o f study and I approached five caregivers I knew and asked i f they would be interested in participating in taped conversations about their experiences. In all cases people were assured that their participation was without obligation and purely voluntary. Another two participants were recommended and two others offered to participate during casual conversations. To avoid any subtle coercion, I requested those who had recommended potential participants to first contact them and receive permission for me to follow-up. Both o f the recommended participants were known to me and were aware o f the study prior to being contacted. Inclusion qualities for participants involved: a) willingness and ability to talk about experiences o f mindfulness and its relationship to the experience o f living/dying or caring for adults who were dying; b) an ability to communicate in English; and c) a regular meditation practice for at least one year. Based on Kabat-Zinn's (1985) studies, regular meditation practice is defined as follows: regular practice is formal or informal meditation, three or more times per week for 15 minutes or longer. Formal meditation is understood as mindfulness practice sitting in a chair or on a meditation cushion; informal practice includes intentional application o f mindfulness to any activity such as walking, washing residents, or listening.  85  The rationale for suggesting at least one year o f meditation practice experience was twofold. For most beginners, meditation practice is often approached as a skill that is applied in developing some degree o f mental 'stability', that is, the mind is able to stay with an object o f meditation for increasing lengths o f time. Then the technique is surpassed and one develops "an approach to reality through the technique, a kind o f feeling in relation to the present moment" (Trungpa, 1969, p. 74). The assumption here was that a year o f practice would provide a deeper experience and understanding o f mindfulness that could be articulated. There is no projected timeline for 'progression' as meditation is a highly individual path (Trungpa); however, one year o f regular practice provided a baseline to work with. Second, most current research on meditation uses participants with only a few months o f experience (Astin, 1997; Kabat-Zinn). Therefore, this study would offer an understanding o f meditation from more established practitioners. One exception was a participant who had been practicing regularly for just over six months. However, because he had offered to participate and was one o f the few people living with a life-threatening illness with a regular practice, I appreciatively accepted his offer. Interestingly, I did not notice a significant difference in either the content or way in which he articulated his experiences. Perhaps this was because he had 'dabbled' in meditation before. O r possibly, living with the inevitability o f death added poignancy to his awareness? H i s insights reflected those o f someone who has a good understanding o f his own mind and way o f being in the world. Identifying people living with life-threatening illness who met the criteria for the study was challenging. After a couple o f months, I read a newsletter announcing a b i -  86  weekly meditation group for those living with H I V - A I D S . After contacting the group facilitator and explaining my intentions, I began sitting practice with this group. The group was small (five regular members) and we often went to a cafe after each sitting. One member, Bruce, offered to participate during our initial discussion about the study while a second member, Stan, was recommended but was too sick to approach. Going through the facilitator, Stan was eventually contacted and he was also enthusiastic in his offer to share his experiences. In sum, nine people participated in taped in-depth conversations. O f these, seven were volunteers, staff, or health care professionals and two were people living with H I V A I D S . Demographic information was gathered with characteristics o f inquiry participants presented in Table 1.  87  Table 1. Inquiry Participant Characteristics  Age  Volunteers, Health care & hospice staff 49  People living with H I V - A I D S  M  35-61 4  42-48 2  F  3  (X) range  Sex  # o f years o f meditation (X) 16 range 6 - 2 8 years  6 months - 8 years  # o f years providing care at ZHP (X)  5  range  1-13 years  Buddhist tradition Theravaden  19  Vajrayana (Tibetan) Zen  1 3 3  2  There are three major traditions of Buddhism: Theravadin (Sri Lanka, Thailand, Burma, Korea), Mahayana (Japanese Zen, Chinese Chan and Indo-Tibetan ), and Vajrayana (Tibetan Buddhism). All three traditions have growing numbers of adherents in North America and differ somewhat in their doctrines and practices. Nevertheless, the basic tenets and practices such as mindfulness are shared by all traditions. 1 9  88  Generating Data Approaches to generating data included reflexive participation in volunteer caregiving ( Z H P ) and as a Guest student ( S F Z C ) , field writings, ongoing Buddhist study and practice, as well as in-depth taped conversations.  Reflexive participation Participant observation is often used i n qualitative inquiry and suggests a special form o f observation in which inquirers immerse themselves in a setting so they can experience the milieu i n which study participants reside. Emerson et al. (1995) go even further in claiming that inquirers (ethnographers) must get close to the activities o f everyday life and "take up positions in the midst o f the key sites and scenes o f other's (sic) lives i n order to observe and understand them"(p. 2). Participant observation, as it is employed by these authors, infers a clear separation between the observer and those whom s/he is observing. However, having located this inquiry in-between Buddhist and modernist nursing discourses, such definitive distinctions did not apply. That is, rather than a clear distinction between researcher and researched, there was an assumed doubling o f separation and non-separation. A s such, I engaged i n reflexive  participation  or mindfully attending to experiences. This does not mean to imply that I located myself as inseparable from others, but rather i n an iterative process that assumed both separation and inseparability where one was sometimes located in separateness or inseparability and sometimes in-between. Either way, the view was one o f doubling . 20  2 0  The notion o f doubling' is explored in greater detail in the Fruition Strand but is used in a similar  manner as that of Cixous (1997) in the opening quotation.  89  A s with participant observation, reflexive participation was a form o f data generation used to contextualize my experience o f living/dying and mindfully caring for people i n the end-of-life i n order to be better able to 'hear' those living through this experience. Attending a 40-hour volunteer training and engaging in hospice service over a five-month period provided experience o f the ordinary routines and conditions o f mindfully caring for those who were dying. Approximately 250 hours o f fieldwork were conducted as a member o f the interdisciplinary team at Z H P . After I returned to Vancouver, I continued to volunteer weekly at a free-standing hospice. Fieldwriting(s) took the form o f stories, free association writing, prose poetry, and haiku. Initially, I carried a small notebook and pencil in my pocket to take notes during shifts, but soon abandoned this practice. In part, there was little time for writing, but also it felt inappropriate and somewhat voyeuristic. Instead, I often went to a local cafe afterwards and jotted notes or waited until I returned home where I wrote impressions and contemplation from the day's experience. I struggled with my dual roles as caregiver and inquirer and found my allegiance ultimately lay in being primarily a caregiver. Perhaps this was because I more closely identified with being a nurse while a new identity as 'inquirer' was being constructed. I was also aware o f my discomfort in the role as inquirer. I attributed this to background vestiges o f 'research' as maintaining an observer position and 'taking' something from people in the form o f observations or their stories. The irony was in aspiring to conceptualize inquiry differently, and yet holding these conflicting views. Some strategies used i n dealing with this discomfort were to avoid predetermined 'goals' for fieldwriting where I was situated in an observer/separate position. This meant  90  abandoning plans to record: a) observations o f other caregivers and health professionals in their provision o f service, b) my experience providing mindful care, and c) observations o f the volunteer training program and monthly support meetings. Instead, fieldwriting(s) were spontaneous articulations o f whatever seemed interesting and in the forefront o f my awareness. This left me free to simply be with residents without a 'research agenda.' This was an important step in feeling my way into being engaged with residents as a caregiver/inquirer without needing to separate myself as 'objective' watcher. O f course, I did have an inquiry agenda but it became a more integrated, subtle focus rather than a cultivated position. This process also evoked questioning about what inquiry is and what constitutes 'data.' I began querying the process o f generating data itself. What was going on when 1 selected particular aspects o f my experience to follow through in a train o f thought? What happened when I imposed constraints on what I wrote by using the inquiry question that subsequently shaped what and how I thought about experience? What was I leaving out and why? When I first began fieldwriting in San Francisco I wrote descriptively about what I was experiencing. Then came an analytical process o f asking, 'how does this dimension o f experience relate to the overall inquiry questions'? Analyzing and trying to make those links to the bigger picture seemed premature and forced. B y holding the inquiry questions too closely, the data seemed to become narrow and predetermined. Instead, I chose to write free-form and spontaneously about whatever came to mind. Often this took the form o f a story or prose poetry without concern for how it might 'fit i n ' .  91  Haiku was also explored attempting to use the traditional three lines o f 5-7-5 syllables . A s haiku is seen as a form o f meditation and a path o f awareness (Strand, 21  1997), the congruence o f content and process was appealing, hence I explored its use as a form o f data generation. A s I began to read and write haiku, it became clear that this poetic form is deceptively difficult and, like any discipline, requires practice and guidance. A well written haiku is able to open a direct experience that the reader may interpret open-endedly. I worried that my lack o f experience and knowledge would be an obstacle and significant limitation i f I chose to use it as a main form o f data generation. Nevertheless, I played with haiku and would like to pursue this area in future inquiries into awareness and non-discursive experience.  Collected Entries ~ D i a b o o k  N o v e m b e r 2000- J a n u a r y , 2001  " d i d I g e t my h u g ? " s p l a s h i n g warmth a n d l i g h t e n i n g o v e r w a l l s and f l o o r s  massaging gently, f l a c c i d , sagging, soft boundaries melting  sitting quietly listening, feeling, curious delights'  muscle  watching  I'd like to thank Dr. Davies for pointing out how the haikus that followed the 5-7-5 syllables seemed to read more easily than those that deviatedfromthe form. 21  92  k i t c h e n  t a b l e  c o m f o r t i n g w a t c h i n g  t a l k  s i l e n c e  f o r  t h e  mouse  a n g r y  a n d  s p i t e f u l  h e l p l e s s words  s u f f o c a t i n g  s p i t  i n s i d e  t h o u g h t s no  o u t a n d  f l o a t i n g  l o n g e r  h o l d i n g  t r a n s p a r e n t l y  p i n k  t o  harm  o u t  f r e e l y o n  c l e a r  b o u g a i n v i l l e a  shadows  c a s t  a u t u m n ' s  on  m o r n i n g  t a b l e  t o p  l i g h t s i n g l e s o a r s  b i r d t h r o u g h  w i t h o u t  s t r e e t  n o i s e  i l l u s i o n s momentary  o f  f l o a t s  a  f l u t t e r s . t h e  t r a c e ,  e v e n i n g  s k y  gone  t h r o u g h  i n s i d e - o u t s i d e  change  Audiotaped Conversations Kvale (1996) traces the etymology o f conversation as 'wandering together with' (p. 4) and perhaps better illustrates the kind o f inter/views that we engaged i n . Participants were invited to talk about meditation and how their practice shaped their experience and understanding o f living-and-dying. In-depth, semi-structured  93  conversations lasting between one to two hours were tape-recorded and transcribed. The interviews were held at an agreed upon location, usually in participants' homes or at Z H P . Efforts were made to create a relaxed environment to help foster interactive and meaningful conversations. In preparation for the first conversation, I developed a list o f questions and a demographic sheet as prompts to initiate conversation (see Appendix A ) . The list was too long and rendered what was intended to be a conversation into an interview o f questions and answers. Subsequently, I had the questions at hand but learned to trust in the situation and allow the conversation to flow and be directed by the participant. In using a conversational approach, there were times when my interjections seemed to steer the conversation away from an area the participant may have been taking us. U p o n examining these transcripts closely, this seemed to occur i f I was not listening attentively or, conversely, when I was following their wave o f thought and felt impelled to affirm, challenge, or seek clarification. In using a conversational rather than interviewing style, the intention was to avoid talking "about" things exclusively but rather to move into a dynamic space by constructing together... stories with a life o f their own....and opening new insights. This occurred occasionally and was accompanied by feelings o f "wandering together' or being turned around in a new space. When this occurred, there was a sense o f excitement, as i f something had happened, and was followed by mutual expressions o f heartfelt appreciation. Even so, my comments were at times reactive and in future I would explore follow-up questions using the participants' phrasing and ordering as suggested by Hollway and Jefferson (2000), to further invite  94  participants to articulate. A s these authors caution, i f the inquirer's perspective is interjected too soon, the participants "gestalt that is emerging...is destroyed" (p. 32). Unlike the goal o f achieving saturation or until new findings consistently replicate earlier ones (Sandelowski, Davis, & Harris, 1989), the number o f conversations originally proposed was eight and was loosely based on deciding i f sufficient 'richness' existed to respond to the inquiry question. For this reason, having only two participants from the second group did not seem problematic as our conversations were dense and full.  Engaging with Texts ~ Practical Considerations  Audiotaped Conversations Some technical difficulties were encountered in recording conversations. One participant expressed discomfort with the tape-recorder placed in full view because it made him feel self-conscious. This same participant said later that he felt intimidated by all o f the 'equipment' and papers and had envisioned a more casual tete-a-tete. In the following conversations, I put the recorder to one side but was unable to discretely check i f the recording light was working properly and on one occasion missed a malfunction for approximately half an hour. Immediately following each conversation notes or memos were written and in this situation more extensive notes were written.  95  Within a day or two of the conversation, I listened to the tapes to ensure the quality of the recording and additional thoughts and impressions were added to the diabook reflections. Shortly thereafter, the tapes were transcribed. Transcribing the conversations was challenging because o f the long pauses, thoughtful tones, and playfulness o f participants and their difficulties in talking about mindfulness "with language that is subject and object oriented" (Sophia ~ a participant).  I questioned the im/possibility of transcribing 'verbatim' with each deliberation o f where to insert periods and semicolons while at the same time, attempting to translate an openendedness imbued through participants' voices. Clearly, transcribing was re-  The consequence of this insight was an appreciation of the non-modernist notion that the text has no author,that is, that with every reading and re-reading, and with every reader there is translation, interpretation, and transformation that is occurring. The idea of a fixed text with a particular meaning was an illusion. As this realization dawned, I also saw my relationship with the texts change. What was originally highly identified with each participant, became something different. The text began to have a life of its own and although each text had a history and context that contained the participant and the experience of the conversation, this history began to expand with each reading and re-reading. The process was no longer one of seeking and finding, but clearly became a messy process of constituting and re-constituting There are ethical implications here of whose text, whose voices become appropriated and whose reconstruction is read and re-read it is always in progress, partial, and contingent  inscribing and became a significant interpretive endeavor.  Participants also varied in the degree to which they spoke in full sentences. In many cases thoughts were completed through nods or eye contact that were lost on audiotapes. In re-reading the transcripts and listening to the tapes, it was evident that much was left out in the process of translating spoken, embodied language within a  96  shared space o f conversation into Aramaic symbols on a page. Initially I hesitated in numbering the lines on the transcripts as the mere presence o f numbers also altered what was a personal conversation into an object o f analysis. However, as the practical implications o f working without line numbers arose, and as a shift in the relationship with this 'data' emerged, I reluctantly added numbers. I was surprised by this transformation in what was an experience o f 'wandering together' into a scripted 'text.' Conversing included perceptions, interpretations and feelings embedded in the voice(s) and conversational rhythm within a shared time and place. However, once the emphasis shifted to the words and verbal responses alone, much o f the conversational experience was lost. Attempts were made to minimize the loss by re-reading my post-conversation notes and in some cases adding a descriptive introduction to set the context o f the conversation. Even so, the emphasis became the record o f what was verbally spoken.... In contrast, what was said... and unsaid, seemed to rest i n the context o f the conversations that was lost in 'verbatim' transcriptions o f the spoken words. Once again this reinforced the partial, contingent quality o f all interpretations. Nevertheless, I 'transcribed' pauses with  spaces  to visually and  rhythmically invoke the cadence o f the speaker's voice and included other verbal responses such as sighs and laughter. Some words like "ah" or " u m " and partial sentences were edited in situations where they obstructed and seemed to convey a different message in print than that in the spoken exchange. Additions or changes were marked by parentheses to alert the reader o f changes to the original transcription.  97  Diabook E n t r y ~ December 18, 2000  Warren is declining. He now no longer goes down the stairs but spends most of the day in his chair. He's wearing 'diapers' and seems sad and depressed. Little wonder. Ifeel a special connection with Warren. Maybe because he moved into hospice as we started our training... and maybe it's because I identify with him . He's only 56 years old and was a veterinary surgeon for years. He taught at the University and seems like an ordinary guy with a great sense of humour and a gentle, almost passive demeanor. Warren laughs and cries simultaneously. It's hard to assess what is happening with him because of his brain tumor. Does he understand andfollow what is happening? ...what is going on in his mind as he meticulously opens up an envelope with slow, studied precision? My sense is that he usually does understand. He responds appropriately whenever I ask him questions ....or he simply doesn't respond verbally. Interestingly, I usually interpret his silence as a choice to not respond (hmmm....). The staff and Cecelia, the nurse, have decided that Warren should not get up much anymore...and that we shouldfeed him too. I was taken aback on hearing this and thought, "they really don't know him very well". Why do I, who have only volunteered for a matter of weeks, think I understand Warren and the progression of his disease better than they who have years of experience? Is this my 'hanging on' and not wanting to accept that Warren is declining? Is this the resistance and denial that often happens when we want things to be other than (what) they are? Perhaps...but it is also feeling a connection and empathizing how I might feel if it was me in his place. Even though Warren fell last week he still wants to walk to the shower. Instead of insisting that he have a bedbath...Izney and I supported Warren as he walked with his walker. Fleetwood Mac was playing on his CD player as he inched down the hall in his diapers and T-shirt. We walked with him slowly, ever so slowly, as he put one foot in front of the other. Izney would remind him softly in her Black American sing-song voice, "OK Warren, move yo' leg for—ward goo—oood, you done good". Izney is kind and gentle with all the residents. She has infinite patience and good humour. One day she jokingly scolded Ms. William by saying, "Now Ms. William, don 'tyou get involved in that hospice gossip ". Arms around Warren and encouraging him along, Izney croons gently... "Lock those knees now Warren.... how you doing"? It's as if his mind is willing but his legs won't respond....but as he stood with his walker Warren started to bend his knees, moving his legs up and down in time with the tunes floating out from his room. He had an elfish grin as he bogeyed; somehow appreciating the fun and ludicrousness of the moment. "No fancy stuff Warren " Izney warns as she smiles encouraging him to put his left foot forward. The whole process took a long time and Izney never appeared hurried or impatient. She left me to help Warren wash while she went to braid Ms. Williams' hair. The house is full of unbounded time and warmth. A great place to be dying.  98  Ensuring Ethical Inquiry Ethical approval was received from the University o f British Columbia's Behavioral Sciences Screening Committee. Although no formalized ethical process was required with the Z H P , all ethics forms and procedures received clearance from Z H P staff in their review o f the proposal. Informed consent was obtained from participants (see Appendix B ) and copies o f their transcripts were provided for those who were interested. Participants were given explanations o f the study and their right to not answer questions, request that portions o f the tape be erased, or withdraw at any time. Even though participants were informed o f the topics for discussion, I was aware that talking about their experience o f living/dying may cause undue distress for some. This did not seem to arise and my ongoing connection and contacts with participants allowed me to make this assessment. Ongoing consent was a subtle process. A situation arose where I chose to pursue asking questions with a volunteer caregiver even though he had indirectly expressed fatigue. After pushing ahead with an additional question, I felt an immediate visceral response and realized that subtle coercion also includes choosing to ignore or misinterpret ambiguous statements. A s a budding inquirer, I sensed the need to attend very carefully to ethical practices that put the wishes o f participants first, with repeated requests for ongoing consent. A l l identifying indicators were removed to protect the identities o f participants. Having explained that pseudonyms would be used, I asked some participants i f they had a particular name they would like to use. Tapes and disks were numerically coded and kept in a small locked box with backup copies. A t the conclusion o f the project, all identifying  99  information w i l l be destroyed. The data w i l l be retained by me for future inquiry purposes (i.e., to answer inquiry questions that are beyond this project), subject to ethical approval according to standard procedures.  Approaches to Interpretation  Where did I go in the process o f writing the fruition section and how did I get there? What decisions were made and what was my thinking in choosing one path over another? Were there surprises along the way and what challenges did I meet? What are the strengths and limitations in proceeding in this way? Is the path related to the end-inview and was the path guided by the inquiry question?  Narratives are fashionings o f language which vary immensely in their degree o f structuredness and o f adherence to prescribed standards o f form—which seek to make sense o f and be adequate to experience, as it transpires over the course o f what, for simplicity's sake, we can call time. (Freeman, 1998, p. 465)  In the broadest sense, this inquiry can be viewed as a form o f narrative analysis. However, what began as an empirical 'narrative inquiry' has become more akin to a philosophical exploration or rhetorical project inspired by the 'data' and ongoing experience in the domain o f hospice and Buddhist meditation. H o w that transition occurred is addressed in the following discussion o f approaches to analysis and interpretation and structuring the fruition piece using a koan form.  Preliminary approaches in analysis and interpretation  100  Interpretive approaches seem to differ depending on the inquirer's perspectives on language and its relationship to experience. Here, discourse was seen as a linguistic process through which reality and identities were shaped. Language was not merely a vehicle to communicate concepts but was seen as performative, shaping realities in and through its utterances. A great deal o f attention was paid initially to the relationship between experience and language. The first challenge arose as analysis and interpretation were seen as interlaced endeavors, while the direct link between experience and text was questioned. Emphasis shifted from the accounts o f people's experience(s) represented within transcribed conversational texts, to notions o f lived 'textuality'. A s Frow and Morris (cited in Denzin, 1997) describe: The worlds we study are created through the texts we write. For example, . . . . [someone] dying o f A I D S . . . . W e do not study lived experience, rather, we examine lived textuality. (p. 33, parenthesis added) Lived texts are representations that are themselves embodied representations o f experience....Lived textuality transforms lived experience....Real-life experiences are shaped by prior textual representations.... The direct link between experience and text can no longer be presumed. (Denzin, p. 33) Several weeks were spent reading and thinking about the nature o f language and the challenges o f 'thinking about' pre or non-conceptual experience. H o w do contemporary writers use language to disrupt the hegemony o f representational discourse(s) and bring us to the limits o f language? The texts and generated 'data' were understood not as carriers o f fixed meaning that can be recounted, but as sites o f ongoing negotiation o f meaning and possibility. A t the same time, there were terms and phrases used during the conversations that assumed some shared understanding o f Buddhist philosophy and practice. The question arose, to what degree is this inquiry an  101  interpretation o f meaning that is never fixed but embedded in a context o f Buddhadharma that calls for 'translating' some o f the assumed understandings in our conversations? In non-modern texts, as in the conversations, the narratives were often discursive, self-reflexive, and resistant to all-encompassing explanations. Therefore, analysis required an approach that was messy, multilevel, and multimodal (Denzin, 1997).  Strategies o f Mindful Reflexivity Mindful reflexivity was advanced through several strategies including regular meditation practice, journaling/diabook writing, and critically questioning. Journaling or free association writing was done as a way o f exploring and thinking 'out loud', rather than a means o f reporting thoughts, feelings and impressions. The intent was to cultivate awareness and develop insights into the sites o f interpretation. Through writing and rewriting I've come to see on an experiential level the multiple voices and multiple selves within the text(s); seeing the changing tone and locations o f the varied authorial selves makes this clear. A l s o , I've felt the struggle between a desire to be consistent, coherent, and constant....(a modernist voice).. .while at the same time, knowing that the production o f a seamless story is not at all reflective o f the inquiry process or o f life itself. The modernist narrative o f the academy and Nursing as a discipline, strongly encourages a unified, coherent self that is authoring, and inferring author(ity) throughout an inquiry. I live i n multiple worlds with multiple possible worlds and make choices along the way. In writing and re-writing these pages, I experienced being in shifting ideological sites. A t times, the contradictions felt  102  uncomfortable and problematic while at other times opposing positions seemed 'contradictory but true.'  Steps along the path Although presented in a linear fashion, these movements were like a dance, with steps forward, backward, along with occasional leaps. In general, the approach to analysis / interpretation included: a) reading and gaining a sense o f the transcripts and what 'called forth'... b) beholding the texts in a space o f perceiving before interpreting... c) engaging in questioning relevant to the inquiry questions... d) identifying and dialogue with themes... e) constructing koan(s) and developing commentaries reflexively drawing connections with literature, insights from other texts, and proposing possible reinterpretations...  a l Noticing what 'addresses' or 'calls forth' The first step was to read the transcripts and note any images, ideas or thoughts that arose and to later dialogue with these ideas, thinking more deeply and freely. B y attending to images and visuals, non-cognitive processes shaping the interpretive process could be accessed. Following the reading, a spontaneous, prose poem was written to engage what initially caught my attention. A brief'overall story' was crafted to give form to this first 'sense' o f the narrative. The intention o f the first step was to develop a sense o f the whole before fragmenting the narratives.  103  b) Finding a way to 'behold' the conversations in a space o f perceiving before interpreting Rogers et al., (1999) claim that in qualitative inquiry we must begin to recognize not only what is said in the texts, but also what is 'unsaid.' These authors use Wallace Steven's (1946) poem, The Snow Man, to explain how as inquirers what we perceive and interpret in any situation includes more than what may be immediately present. Therefore, as we transition in-between perceiving and interpreting, we can explore the experience o f dwelling in the midst o f perceiving without interpretation, that is, "perceiving without thinking of anything '(p. 78, italics added). 1  The Snow M a n One must have a mind o f winter to regard the frost and the boughs of the pine-trees crusted with snow; and have been cold a long time to behold the junipers shagged with ice, the spruces rough in the distant glitter o f the January sun; and not to think o f any misery in the sound o f the wind, in the sound o f a few leaves, which is the sound o f the land full o f the same wind that is blowing in the same bare place for the listener, who listens in the snow, and, nothing himself, beholds nothing that is not there and the nothing that is. (Stevens cited in Rogers et al., p. 77) I agreed that an important interpretive approach was to "sharpen our perception to avoid ascribing meaning or overwriting our data (nothing that is not there)," while at the same time, avoiding "overlooking or ignoring the meaning o f what is absent (the nothing that  104  is)" (p. 78). Recognizing the nothing that is always present was a challenge along the path. Since I too assumed that an interplay between the 'said' and the 'unsaid' added valuable understanding to what is 'said', I cultivated a regular meditation practice to help appreciate the presence o f the 'unsaid' while trying to avoid the aforementioned traps o f ascribing meaning or ignoring completely the absent. Anderson (1998) encourages incorporating intuitive processes such as meditation and alternative states o f consciousness as aspects o f analysis and although not always successful, the process o f paying attention to silences and gaps is subtle and requires further exploration in qualitative inquiry.  c) Questioning the data vis-a-vis the inquiry questions To develop a more detailed sense o f how participants responded to the inquiry question, 1 began 'content analysis.' Using coloured pens the transcripts were coded based on: a) history o f mindfulness practice (why, when, how); b) how was mindfulness conceptualized; c) perceived benefits; d) perceived limitations; e) how meditation shaped experience; f) how dying was conceptualized. The decision to engage in this kind o f analysis was made, I believe, because it was consistent with all o f my previous experience in conducting qualitative inquiry. However, it became clear early on that this process was neither effective nor helpful in its micro level o f analysis. I found my attention constantly wandering with a feeling o f heaviness and drudgery as I returned to the 'task' o f coding. The vitality o f the texts was lost and I soon abandoned this step. Gaining a sense o f the aforementioned questions was more easily attained through simply  105  reading and re-reading the texts without dissecting them. Moreover, this line o f questioning, although useful in the beginning, seemed to be a side-step.  d) Identifying and dialoguing with themes Themes began to be noted. W i t h a 'slow reading' o f transcripts, a process o f dialogue occurred with themes, ideas, or phrases that grabbed my attention or 'stopped my mind.' I paid attention to ideas or phrases that caused me to pause, where I couldn't assume to understand. Whenever the internal dialogue was interrupted in this way, I took note and began to think aloud through writing. Dialogue included questioning, comments, and linking ideas with other texts. In this way, themes were constituted. Over time, themes were collapsed into five themes: meditation and dying as parallel processes; seeing differently; realizing change and impermanence; groundless and open space(s); and an expanding sense o f inter/dependence.  e) Constructing koan(s) The structure o f koans using a conventional format o f K O A N case, C O M M E N T A R Y , and V E R S E was chosen. Koans are traditional meditation tools used in Zen that present a perplexing story or case for contemplation. The koan case was constructed from participant quotes selected intuitively by their ability to confound. This was followed by a commentary deconstructing and re-constructing the koan using a Buddhist lens, weaving theoretic understandings, literature, participant voices, and musings from fieldwriting(s). A n d finally, a verse that expresses a poetic sense o f the koan provided yet another interpretive form. Using a koan structure allowed both an  106  Eastern approach o f privileging concepts by intuition, that is, beginning with what intrigued and interrupted, and a Western privileging o f rational thought in commentary interpretations.  Koans Traditionally koan (Chinese: kung-an) is translated as 'publicly posted' referring to unanswerable questions or stories that, with deep pondering, lead to an 'awakening' beyond binaries (Corless, 1989). Koans are designed to engage the learner's mind and assist in freeing one's inherent potential to see directly beyond dualities o f 'this' and 'that', 'me' and ' y o u ' , 'past' and 'future'. Cases or stories known to lead to such insights were posted publicly with the hope o f benefiting others. Perhaps some o f the best known one-line koans in the West are:  "What is the sound o f one hand clapping?" "Where is One?" "What is your original face?"  Most koans are formed from baffling stories o f Zen masters and are used today by meditation students to assist in going past conceptual thinking and opening one's heartmind to a new understanding beyond understanding. M e l Weitsman describes the fruition of koan practice as seeing yourself as you are and everything around you just as it is (cited in Wenger, 1994). Koans are not questions as such but are more akin to conundrums. Corless (1989) also differentiates koans from riddles, although like riddles, koans present a problem that appears confusing and muddles the mind. However, unlike  107  riddles with logical answers that eventually resolve the confusion posed by the question, koans are problems wherein, "the feeling o f problemness has to be turned back on itself. Whereas a riddle is solved when the answer is found, a koan is solved when the question disappears" (Corless, p. 232). In the vital space o f the koan, meditators engage their question with a concentrated introspection far beyond the reach o f intellect. According to Austin (1998), the koan is " . . . a p r o c e d u r e for exploring life's deepest existential issues" ( p. 112). Eventually a koan may be realized rather than solved through direct experience and insight that cuts through layers o f unconscious and preconscious mental processes; realization shines through between meaning and non-meaning. Unlike most Western traditions o f scholarship that focus on conceptual mind, Eastern scholarship, exemplified in Zen koans, illuminates unconditioned, non-conceptual awareness (Welwood, 2000). Although there are hundreds o f recorded koans, Roshi Philip Kapleau (1989) claims that the best koan is, " the perplexing inquiry that arises naturally out o f one's own life experience and cannot be put aside until resolved" (p. 294). It is in this spirit that the koan arising from conversations and field notes was created. The koan form was adopted here, not as a learning tool that takes the reader (or writer) to extremes o f mind where insight ensues ; rather, the structure was adopted as a procedure for exploring new ways 22  of thinking and languaging the existential issues related to living/dying and meditation. The metonymic texture o f koans provides a space in which both conceptual and nonconceptual approaches to these inquiry problems could be explored.  22  Daisetz Suzuki held that, "To solve a koan one must be standing at an extremity, with no possibility of  choice confronting one" (1965, xxi).  108  To illustrate the general koan structure, the following examples from Michael Wenger  23  were received during a course on Contemporary American Koans at the San  Francisco Zen Center from October-December 2000.  The Shallow Meaning is Enough KOAN CASE Maezumi Roshi (teacher) was holding dharma dialogue in the meditation hall. A student came forward and asked, "Roshi, I want to contemplate the deep meaning o f life." Laughing, Roshi replied, "For you, the shallow meaning is enough." COMMENTARY Many people are like this student and seek the profound and exalted and shun the common and surface. This is perhaps quite natural but isn't the whole pool shallow and deep, wide and narrow? What is important? Just a particular prize location? M a e z u m i Roshi points to our pride. VERSE If you look for the deep you miss the shallow If you settle for the shallow you miss the mysteries o f the Deep Perhaps Basho's frog is to the point SPLASH!  Michael Wenger, Ph.D. is the Director of Buddhist studies at the San Francisco Zen Center in California who became a teacher/guide throughout my fieldwork in San Francisco. Wenger's (1994) text entitled, 33 Fingers: A Collection of modem American koans is a good resource of contemporary koans. 2 3  109  Don't Lose Your Critical Intelligence  KOAN CASE Khandro Rinpoche was giving a set o f teachings and a woman asked her: "What should we do with anger? H o w should we deal with anger?" Khandro sharply replied: "Anger is always a waste o f time." The woman said, "But what about things that are wrong? What about things that deserve anger?" A n d Khandro Rinpoche replied again very sharply, "I didn't tell you to lose your critical intelligence!" COMMENTARY Khandro Rinpoche is one o f the few female Rinpoches in the world o f Tibetan Buddhism. Born in India in 1967, she is a teacher in both the Kagyu and N y i n g m a traditions. A t Dharma Centers in the West, lectures, classes, and workshops that talk about anger often generate lots o f interest. Expressing anger or suppressing anger are two popular modes but Khandro Rinpoche points us in a different direction. D o you push people away, do you deny what you feel? Perhaps there is another way. Don't lose your critical intelligence! VERSE B o i l i n g vats o f oil Burning as Dry Ice What to do? Sometimes a thunderstorm leads to blue skies But don't cling to the weather report. Clearly observe! (Michael Wenger, 2000)  11  Although six koans were created, only one — Meditation  and Dying,  has become  the fruition o f the inquiry. This koan was selected because it directly addresses the broader questions underlying the inquiry and provided a starting place o f perplexity. A s the commentary  unfolded, aspects of the other koans became organically integrated and  the aforementioned themes and analysis also manifested within the commentary.  11  STRAND FOUR ~ FRUITION  Let us not talk about death, Let us talk...with/in open-endedness forming and dissolution, trans/forming, per/forming, constantly dissolving becoming anew abiding in spaces between thoughts.  Let us talk nursing as witnessing mindful o f empty spaces and places of self/no-self o f birth, old age, sickness and death. Mindful o f basic impermanence of living and dying, abiding in spaces of ceaseless transitioning  FRUITION  Things are not always as they seem, nor are they otherwise (Lankavatara Sutra) When phenomena are seen to paradoxically be and not be, the logical mind is often disconcerted and protests. There is a natural tendency to respond by seeking terra firma. Resting in unstable ground is difficult and may lead to attempts to construct meaning out o f what is beyond cognitive mind— beyond conventional comprehension. Some traditions such as Tibetan Buddhism and Western modernism approach such insubstantiality through reason and the dialectics o f logic. Other traditions, including Zen Buddhism, avoid what is considered excessively conceptualizing that which is nonconceptual and use heuristics such as silence, koans, and non-directive meditation practices to exhaust the logical into spacious clarity o f mind, unobstructed by concept (Austin, 1998). Given that this inquiry is an academic project embedded within language(d) texts, an emphasis on silence or the logically absurd is left for future endeavors. So, I proceed in a manner located somewhere in-between these two traditions, that is, between a Tibetan Buddhist approach using reason and logic and a Zen approach o f non-conceptual heuristics. In Buddhist fashion, a middle way applying the structure o f koan, commentary, and verse are used in this Fruitional dis/play.  113  KOAN CASE  Stan has been living with A I D S for over twenty years and has practiced Zen meditation for almost a decade. Over the last few years his eyesight has drastically diminished and he uses a cane more often than not. Despite a recent diagnosis o f lymphoma, he remains light-hearted and continues to attend regular meditation meetings at a Zen center. Dying is interesting, he explained, i f you look at it from a Buddhist view, there's death every mind moment. So, it's just compressing it or expanding it and time is the duality....Meditation is like dying, he continued. First you start with a lot o f discursive stuff and a lot o f fast activity. Then you slow down and settle; eventually your body starts disappearing at the edges. Next your mind goes, and that's what happens in death 2 3  COMMENTARY Stan's comparison that parallels meditation and dying points to an interpretation o f dying that goes beyond conventional Western perspectives o f locating death in the body within linear time. Rather than situating death at the end o f a life-line, death is constructed as a momentary experience, occurring every mind-moment. This, according to Sogyal Rinpoche (1993) is the revolutionary contribution o f Buddhism to the West, summarized in his statement that "life and death are in the mind and nowhere else" (p. 46). A s an underlying view threaded throughout my conversations with inquiry participants, this primordial aspect o f mind and its role in living/dying provided the context o f our discussions. A n attitude o f curiosity and interest pervaded our conversations regarding how [the] mind functions and, by extension, how the interplay o f life and death intertwine within momentary awareness and at the end o f life. Although fear and resistance were expressed during our discussions, death and dying also evoked  This case is a combination of quotationsfromtwo different participants. They are combined to more fully demonstrate a perspective of the relationship between meditation and dying expressed by several participants.  23  114  curiosity and interest as this koan case demonstrates. Before examining the central theme of parallel processes between meditation and dying, the notion o f death and dying as interesting w i l l lay the unstable g/round for these comments.  Dying as interesting  The term 'interest' comes from the Latin word inter esse, which means to be in the midst o f or in- between . To be interesting is to be neither fixed nor finite, but 24  (-inter)  between (esse ~ to be) being. Therefore, dying that is interpreted as interesting is not a finite end but is situated in the midst of—or one could say, in a liminal  space  in-between  being and whatever/wherever follows The earliest use of the term liminal or liminality  is attributed to anthropologist von  Gennep (1908, cited in Turner, 1982) who used the term to identify a quality o f transition in rituals where novitiates were neither in their former social category nor in a subsequent post-ritual group. V o n Gennep's use o f liminality infers a bounded space o f transitioning between these states o f being whereas liminality is used somewhat differently in this inquiry vis-a-vis living/dying. Here, oppositional states o f living followed by dying are merged with an emphasis on the inseparability  o f living/dying in a liminal space o f  interplay. These notions are threaded throughout the dissertation and w i l l take shape as the commentary unfolds Dying was also perceived as interesting for meditation practitioners at Zen  24  Hawkins, J . M . & Allen, R. (Eds.). (1991). The Oxford Encyclopedic English Dictionary. New York:  Oxford University Press.  115  Hospice, with hospice seen as an in-between space wherein social conventions continued and yet were simultaneously suspended so that transitioning both at the end-of-life and from moment-to-moment could occur freely and fully. In the best of all worlds that is what it [hospice] is...it's an inbetween space there is a time in which people are moving into their dying ....helping people actively explore this phase of their life...which is their dying...and it is a different phase. And there is a need to know this phase of life and to experience this phase of life...and if we pretend that it isn't happening or that it's just like every other phase, then I think we are really coming up short. S o it is an in-between phase...a liminal s p a c e (Gary, participant) 25  Hospice is seen as both a physical and mental space or as Seale (1998) describes, "an institutional construction o f liminal space" and "a separate state o f mind" (p. 120). What follows is a commentary or contemplation on a question arising from this koan: 'If living/dying occur in the interesting spaces of transition(ing), how might we understand d y i n g and meditation as parallel processes?' The commentary begins with  the g/round o f how mind is re-interpreted within this inquiry, followed by thoughts on the path o f mind as 'doubling' or 'interplay', and culminates with a fruition o f meditation and dying as parallel processes  H o w was mind interpreted?  All quotations from participants are inserted using right justification.  116  Re/cognizing mind Sogyal Rinpoche (1993) in his text The Tibetan  Book  of Living  and Dying  begins  a discussion on the nature o f mind with a story about a young frog who has lived in a dark well all his life and is visited by an old frog who has seen the ocean. In describing the ocean to the younger frog, the older frog explains that there is no comparison in the size and depth o f the well with that o f the great ocean. "The ocean is gigantic and bigger beyond your imagination", says the older frog. Insisting on seeing for himself, the younger amphibian sets out from the well towards the coast. When he sees the ocean, it is such a shock that his head explodes into pieces. Dramatic perhaps, but the underlying message is that most o f us are firmly ensconced in our ideas o f reality and have difficulty conceiving other dimensions. In particular, participants situated in Buddhist views and practice, within a modernist society, articulated other ways o f conceiving mind and its relationship with living/dying.  Situating M i n d Although Nursing has a long tradition o f philosophical inquiry into what it means to be human and engage with others in illness and death, the nature o f mind and its functions are ' w e l l ' steeped in Western perspectives. However, inquiry participants situated mind otherwise, assuming not only cognitive functions but emotional qualities that inferred mind-heart within a concept o f mind. For example, a participant placed her hand at her heart, as do many Tibetan Buddhist teachers, when referring to mind. In pointing to non-Western interpretations assumed by participants, mind or mind-heart is situated as follows....  117  In Western traditions o f thought since the Greeks, the understanding o f mind has been approached through the means o f abstract, theoretical reasoning (Verala et al., 1991). Although psychoanalytic theory comes close in turning away from reason as a means o f seeking the truth about [the] mind, even so, Varela et al. suggest that: whether an individual is commenting on a free association .....having an ordinary waking conversation or dealing with the highly convoluted symbolic language o f dreams, that person is knowing the mind and commenting on it i n an after-the-fact fashion, (p. 20) In other words, even psychoanalysis remains in the realm o f abstraction. That is, when approaching mind, the tendency is to examine its contents o f thoughts, symbolic referents, and feelings which is to explore its projections o f ideation and emotion. Rarely do we explore 'that' in which all o f the contents o f mind arise (Lief, 2001). W e are often caught in the activity o f mind unable to access a boundless awareness within which all is displayed. In contrast, Buddhist teachings and meditations are aimed at training the mind by looking into its nature and functioning through direct experience. One way in which awareness and the discursive content o f mind are examined is through bare attention, "the clear and single-minded awareness o f what actually happens to us and in us at the successive moments o f perception" (Thera, 1962, p. 30). Attention is understood as 26  'bare' because it relates directly with that which is perceived through the six senses without reacting, critiquing, or self-referencing with judgements o f liking or disliking. In other words, direct perception, including direct awareness o f thought, is privileged over the dualism o f thinking 'about' or discursiveness. Although the primary approach for  The practice of meditation ( Sanskrit: Samadhi) is never taught independently in Buddhism but is always in relation to (and requires) ethical view (shila) and penetrating insight (prajna) (Lief, 2001).  2 6  118  understanding mind is through this process o f raw sensory experience without conceptual commentary, theoretical models and descriptions o f mind also abound. Participants varied in their interest and appreciation o f the theoretical aspects o f mind, be it Buddhist or otherwise, yet all participants were drawn to the practice o f meditation and it was this direct experience o f mind that appeared to sustain their interest in meditation and hospice care. A participant sums this up in her comment, " we come here because we're interested in our minds. A n d we all have minds....whether we are in the bed or not". (Lauren)  Zen isn't about a big ideological system, and it's not about believing something. Over and over it was said, 'find out for yourself; don't believe what I say. This is my experience and you have to go by your experience'. (Camilla) Even so, Dzongsar Rinpoche (2001) suggests that cultivating a conceptual understanding o f mind and its functioning is also important. Through examining the limits o f thought and language using logic and conventional reasoning, we can better understand our experience and gain confidence in that understanding. A s discussed earlier however, an emphasis on conceptual understanding is not shared by all Buddhist traditions. In certain Zen schools for example, the risks o f getting caught in conceptualizations are too great when compare with the simplicity o f the practice o f insight through attention to unfolding experience as it is. Nevertheless, what inquiry participants assumed and Buddhism offers, was both a reflexive conceptual understanding o f mind, concurrent with a way to examine mind directly v i a nonconceptual meditative experience. It is this combination o f methods linked with a conceptual framework for understanding human experience that provides alternative  119  interpretations (and experience) that can broaden current nursing perspectives and practice. Constituting mind as doubling Within Buddhist thought, one's state o f mind is seen as the most significant element in our experience o f pain, pleasure, happiness, and suffering (Dalai Lama, 2000). O f course, adequate material resources and freedom from oppression and injustice are also important factors that must not be minimized. Yet, material wealth or social and political freedoms alone do not guarantee happiness or an end to suffering. Recent events like the bombing o f the World Trade Center in N e w Y o r k City and retaliatory measures in Afghanistan and around the world clearly demonstrate the repetition o f history with geopolitical changes while the driving forces o f fear, hatred and delusion remain essentially unexamined. Shakyamuni Buddha taught 2500 years ago that in order to permanently relieve suffering, we must necessarily turn inward into the recesses o f our own mind (Thera, 1962); this advice remains timely. A s the primary object o f investigation, [the] mind and consciousness are explored through various theoretical schemas in different schools and traditions o f Buddhism  . In  addressing mind in relation to living/dying, I have turned to Theravaden and Mahayana perspectives on consciousness and awareness. Sogyal Rinpoche (1993) and others (Lief, 2001; Dalai Lama, 2000; Levine, 1989; Lati Rinbochay & Hopkins, 1979; Freemantle & Trungpa, 1975) have written and taught extensively on mind in living/dying from a Buddhist view. During my fieldwork, I attended a lecture given by Sogyal Rinpoche on this topic and found his perspective on the nature o f mind helpful in interpreting  2 7  See Kalupahana (1992), A History of Buddhist Philosophy, for a detailed discussion.  120  descriptions o f awareness provided by participants ". Keeping in mind however, an old 2  Zen saying that "as soon as you talk about a thing, you miss the mark" (Austin, 1998, p. 295), two aspects o f mind and their interplay are offered as one o f many possible interpretations o f awareness that lays a g/round for exploring living/dying as a metonymic phenomenon.... The analogies o f sky and clouds are traditionally used in Buddhist texts when referring to the phenomenon o f mind. The first aspect o f mind, known as sem (Tibetan), is often translated as 'conventional' or 'ordinary' mind (Sogyal. 1993; Trungpa, 1981). Likened to the formation o f clouds, ordinary mind functions through thinking, conceptualizing, reducing experience to ideas, and expressing emotion. It is within this awareness that we engage in reflection, analysis, and initiate paying attention. A s participants spoke o f practicing meditation and attending to what was happening through formal and informal meditation, it appears that sem mind is what they were engaging with. For example, Michael a hospice volunteer, shared a story about being with a resident:  Richard [a resident] started taking off his shirt right in the middle of the hospice and I realized that he just wanted to change his shirt, so somebody went and got him a new shirt. He was trying to do the buttons and he was having so much difficulty doing the buttons...and I was just standing there with my hand on his back, and I could just see the impatience in me arise. I could just watch myself. I was getting impatient and I wanted to help him....and I could just reach over and do it for him...but I just stopped. I didn't do it....I was just watching that impatience arise. And then after awhile I asked, "Hey Richard, can I help you with that?"... "maybe I'll just do one", and he was okay with that. Experiences like that have been really helpful; just to watch them and not necessarily react to them....to make space around the feelings or emotions that come up. And it doesn't feel like a separating practice either. It's not that I'm  watching myself so much that I'm not present. There is a very subtle 'Conversations on Death' was an educational series organized by Zen Hospice Project during Fall 2000 to Spring, 2001. During this series, Sogyal Rinpoche presented an evening seminar on Death and Dying. 2 8  121  quality to it, that I can still be with somebody and still know what's going on.  Michael demonstrates how ordinary mind is aware o f what is happening during successive moments o f perception. It is important to note the subtle quality o f attending to one's experience without being separated from the broader environment or fixating on ' s e l f A s Michael recounted, there is a simultaneous awareness o f what is happening within and around him that includes the person and environment he is in. This aspect o f awareness that goes beyond and yet includes oneself seems important as it mitigates selfconsciousness or fixing awareness on ' s e l f as separate from one's environment. According to Zen teacher Dogen Zenji, " T o study Buddhism is to study ourselves. To study ourselves is to forget ourselves" (Suzuki, 1970, p. 79). Studying ourselves begins with examining our ordinary mind that is said to exist only in dichotomies where a separation o f subject and object occurs. Trungpa (1981) describes ordinary mind as: ...that which can associate with an 'other'—with any 'something', that is perceived as different from the perceiver. (p. 23) That which possesses discriminating awareness, that which possesses a sense o f duality—which grasps or rejects something external—that is mind (p. 23). A second aspect o f mind is rigpa  (Tibetan) that is more challenging to articulate  and is described as direct, non-dualistic, ineffable awareness that is the nature o f mind (Dalai Lama, 2000). Analogies o f boundless sky and unobstructed space are often used to depict the nature of mind or rigpa.  L i k e space, it is said that rigpa  without causation and accommodates everything. Rigpa  is ever present, clear,  is described as ungraspable by  thought and therefore by sent mind, insubstantial without taste, touch, sound, or smell. The best we can say is that mind is continuous, unceasing, and luminous (Dalai Lama).  122  Rigpa is primordial, pure, pristine awareness that is at once intelligent, cognizant, radiant, and always awake. (Sogyal 1993, p. 47) Just like the boundless sky, rigpa awareness is always accessible despite the fog of discursiveness that may obscure it. Although rigpa is beyond dualistic thought, it goes without saying- so to speak, that we can experience our life-world directly, unmediated by thought processes. One way to relate with primordial awareness is through our longing that is also difficult to articulate. Many people seem to experience a yearning that is always present and arises more evidently at different times. Such longing is deeply felt but difficult to identify. Although we pursue many activities and avenues in attempts to fulfill this yearning, it usually remains. In writing this section o f the dissertation it became clear that my interest in the topics o f metonymy, dying, and meditation are manifestations o f this yearning that seeks fulfillment through inquiry into these illusive experiences. According to Buddhist thought, such longing is linked with a desire to connect fully and directly in our lives. Even though we have glimpses o f such awareness in moments o f openness, we quickly lose track and return to our habitual patterns o f attention. Despite its non-conceptuality, the echoes o f pure awareness (rigpa) can be pointed to just as a finger may point to the moon. However, as the pointing finger must not be mistaken for the moon, we are cautioned in transcribing experience to avoid reducing the linguistic sign to a transmission o f information and meaning (Paz, 1969). Instead, we can view these articulations as pointers towards that which is ungraspable by thought.  123  Manuel's story is instructive in illustrating how these two aspects o f sem and rigpa  mind interplay in a 'doubling' in everyday and hospice experience pointing to that  which is un/graspable....:  Existential Questioning: Manuel has been a hospice volunteer for approximately eight years and has practiced meditation for almost nine years. In our conversation, we discussed the effects of meditation in his life and Manuel recounted the following: I've had experiences ....where I'm talking with someone, just normally about work related things and they may be someone that I may not particularly like. There might not be any particular dispute, but I may not care for their apparent way of being. Without wanting it to happen, I just see their eyes as a human.. just like me! Then I don't know what to do because I'm ready to fall apart.. .Sometimes it's just frightening to have their humanness come through so plainly.. All of that [other] stuff just falls away like my notion of who they are and why I don't like them.. And I'm 'me' relative to this person...so then if they're not that way anymore? One interpretation o f this story is that it illustrates how everyday experiences such as this are an interplay or doubling of'ordinary-and-non-conceptual' awareness—a metonymic moment. Most o f us can identify with what ordinary consciousness feels like; we're in it. Ordinary sem  functions through awareness o f emotional mental contents  (Manuel disliking his co-worker), thoughts (his mental critique and analysis) and feelings (his fear, surprise, doubt). A t the same time, infused throughout and inseparable from this awareness was another awareness—a sudden shift—experiencing a falling away o f preconceptions and a direct experience as i f seeing for the first time. Manuel does not describe or is unable to articulate this shifting experience except to say, "Without wanting it to happen, I just see their eyes as human . . . " , and goes on to identify the subsequent experience o f fear and uncertainty as he lets go o f his previously fixed beliefs —"[it] just  124  falls away." Simultaneously in this space, a new open-ended awareness arose as Manuel was left questioning existentially  "so then i f they are not that way anymore?.. .[who  am I?]" This brief moment o f awareness revealed to Manuel an underlying sense o f groundlessness—his experience was shifting and opening up»—things were not as they seemed and yet.... He sensed an interdependence and relatedness with his co-worker that changed how he experienced and thought about himself and 'other'. Not only did he see their shared humanity, but Manuel saw how his construction o f himself was directly linked to his narrative o f 'other'. A s he stated, " I ' m me relative  to this  person"-- his  identities o f self and other were interdependent and temporary. In that brief pause, Manuel seemed to experience a metonymy o f shared connectedness with his co-worker concurrent with a dissolution o f their identifying narratives. There was a gap, and he was resting t/here. In de-constructing Manuel's momentary experience, it seems larger than life; however, similar experiences and insights happen to many o f us in everyday activities and in meditation. Sogyal (1994) suggests that as we do not have a context in which to understand these moments, they often transpire without much notice even though they "may  be the most revealing experiences o f our lives, i f only we understood them" (p. 51).  One framework offered here is to interpret such momentary disruptions as experiences o f meeting one's mind or mind-heart. The mind-moment o f doubling exemplified in Manuel's story revealed a flow o f experience that had been obscured by a priori  perceptions o f not particularly liking his  co-worker (or alternatively, it could have been a hospice resident, etc.). In stark contrast,  125  the sudden interruption o f awareness exposed his tenuous 'hold' on a presumed reality and solid ground that resulted in fear. From a Buddhist view, Manuel's experience is significant because it allowed him to see life unfolding as it is. That is, the three marks o f phenomena were evident: first, realizing how perceptions are constantly changing; next, that we do not exist as we think we do; and third, that our experience is usually tinged by dissatisfaction or suffering. Attending to moment-to-moment experience as it unfolds provides glimpses into the nature o f mind and existential concerns (Sogyal, 1993) such as: who am I, who dies, and where is death?  Where is death?  Situating death-and-birth  Non-Existential Questioning Manuel's experience also suggests a moment in which a cycle o f death and birth unfolded. Suddenly his co-worker was no longer who he had been just moments before and neither was Manuel. This loss and change evoked what Manuel described as fear and a sensation o f "falling apart." W h y fear? Was this fear o f groundlessness and no longer being certain? Was this fear o f change and the unknown? Was this fear o f death, death o f the 'selves' that he had taken for granted? Manuel suggested that the unsettling o f what had been previously known and assumed to be real was the source o f his fear and then wondered i f this momentary experience was indeed 'naked awareness'—direct, non-conceptual experience? In understanding mind as a doubling o f ordinary (sem) and non-conceptual (rigpa) awareness, was this a flash into the interplay o f mind? A n d as is often the case (Epstein,  126  1995), did Manual quickly identify with the contents o f his mind—his reaction o f fear, and thereby obscure the open-ended quality o f non-conceptual mind? According to Buddhist thought, this is a probable explanation that can be tested through one's own experience where reactivity and closing often occurs when we believe in or identify with the solidity o f our projections. A s Stan shared regarding habitual patterns o f belief that we reify: It doesn't matter what you do, but whatever you do, if you do it a lot, you get pretty good at it. And if it's holding on to anger, or if it's learning to appreciate beauty, it doesn't matter...if you practice, pretty soon you get good at it; it just becomes engrained. And I think that's the essence of meditation practice [to see habits of mind clearly].  L i n k i n g back to Manuel's story with his co-worker, he attributed its occurrence and his awareness o f it to meditation practice. That is, he was developing new habits o f awareness and attending to the subtle perceptions and emotional terrain that arise every moment. Meditation practice allows us to first recognize these moments o f interruption and then through remaining open, to abide momentarily and for prolonged periods, in liminal space without identifying with anything. A s one participant remarked, mindfulness... alters, at least temporarily, the habitual pattern of seeing with an agenda  and this opens up the possibility of all kinds of things that can happen that could not have happened before.  S o mindfulness allows me to be aware of my fear and becoming intimate with it. And then I can use it productively for being with somebody else...it provides meeting places with individuals we may be serving.... (Gary) In the open g/round o f awareness, we can be receptive to whatever thoughts and emotions arise. Just as the sky absorbs storms and its plethora o f cloud formations, we can learn to accommodate all manner o f mental contents whether it is fear o f death,  127  anger, compassion, bliss, or despair. A l s o , as the quotation above suggests, being receptive to our life experiences without manipulation also provides meeting places for others. More on this later. According to the Tibetan  Book  of the Dead  (Freemantle & Trungpa, 1975), there  is also a momentary experience o f complete freedom and openness at death; however, without training in recognizing or being familiar with this groundlessness, we quickly resume our mind's habitual patterns such as fear or grasping which, it is said, propels us into further confusion and suffering. Therefore, death within this tradition, whether moment-to-moment or physical death, is viewed as a special moment o f potential wakefulness wherein we can meet our mind directly.  Doubling o f life-and-death Re-cognizing mind as a play o f ordinary and non-conceptual awareness avoids materializing sem and rigpa  as ultimately separate aspects o f mind. M i n d can be seen as a  process o f doubling that includes the content and functioning o f ordinary thinking within ineffable awareness, while simultaneously generating something new. A s a generative process o f life and death in a mind-moment, the birth o f new beginnings arises. In the story o f Manuel, he was going along 'as usual' when suddenly his train o f thoughts and perceptions was disrupted and he was momentarily open, pliant, and receptive. Death was located in that momentary release and letting go. With the dissolution o f previously held views, an open space o f possibility arose for Manuel as he saw his co-worker and himself as i f for the first time—in this moment. In Zen, this space is known as 'beginner's m i n d ' and is considered an open state o f mind that can be fostered (Suzuki, 1970). Within this  128  perspective, life and death are not situated as binary opposites in linear time but are located i n the in-between spaces o f awareness i n each mind-moment. Rather than a bounded space between two illusory extremes such as birth and death, liminality is in this inseparability o f birth-and-death that embraces and goes beyond these apparent oppositions into new possibilities. Like Manuel, we wander into and out o f these spaces where predetermined narratives o f the world are suddenly seen as translucent. Sometimes when these disruptions are subtle, we pause briefly but usually carry on with our familiar behaviours without noticing the fluidity o f experience. However, as one participant stated, some disruptions are not so subtle, such as a life-threatening diagnosis o f lymphoma that "is like being whacked in the side o f the head with a two-by four"; it gets your full attention—"it's a wake-up call". The challenge seems to be in attending to our more subtle disruptions in everyday life and learning how to stay awake and abide in these spaces. To this end, paying attention to the constantly shifting, unfolding play o f awareness was the meditation practice that participants engaged in. My sense is that we can't really accompany someone in territory if we haven't really explored it ourselves Mindfulness practice is one tool, and it's not the only one, but it's one very good tool in making that exploration....that allows us to be present with another human being in their sickness.... (Gary)  129  Examining the play o f mind Inquiry participants used mindfulness meditation as an approach for understanding their minds and experience(s). A s in most Buddhist meditation practices, experiences o f the everyday became their ground. Systematic examination was done through formal mindfulness practice in environments like the meditation hall (zendo) in San Francisco's Zen Center where attention began with gross objects o f awareness such as bodily sensations and breathing, and eventually moved to more subtle objects such as thoughts and awareness itself. Or, awareness was cultivated through everyday activities (meditation in action) practiced through service at Zen Hospice. Either way, the examination was a process o f inspecting one's experience closely, whether it was the sensation o f air entering or exiting the nostrils, or the sensations and movements o f being with and turning a bedridden resident. Carefully and gently, without judgement or critique, one attended to, (1) the contents o f mind: perceptions, interpretative narratives about sensations, imaginings, and (2) awareness itself as interplay. Although this description insinuates a duality o f someone or some aspect o f mind being aware o f something,  this is theoretically inaccurate albeit experientially true for  many beginning meditators (Wallace, 1999). That is, there is a sense o f 'I am placing my awareness', and (I am) aware when [my] mind wanders. This separation is not necessarily problematic but is merely an illusion that becomes transparent with extended attention and clarity. With practice, one soon realizes that mindfulness is not something that we do, but is somewhere that we relax into (Trungpa, 1981). A common misunderstanding o f mindfulness is that 'it' is a process o f vigilantly paying attention and being careful.  130  Although this is somewhat accurate in the beginning, i f taken too literally it can lead to self-consciousness and a sense of'tip-toeing' around. Instead, mindfulness was viewed in this inquiry as a space o f awareness that is constantly present and available. Mindfulness is translated from the Tibetan word trangpa  which means  recollection or memory (Trungpa, 1981). According to Trungpa, this is not a memory o f something  in particular, but is like an overall memory o f or feeling about something. For  example, with the experience o f deja v u there is a vivid memory that something happened, o f thatness,  but not necessarily the specific details of the event. Or, i f you had  a fight with your father many years ago, you can recall that something happened and the experience o f the happening but not necessarily the details. It is this experience o f 'happening' that is going on all the time that we can tap into; this, is mindfulness. The idea is that mindfulness is not a process o f application in terms o f growing yourself, but a process o f undoing yourself. There is a sudden sharp jerk, a gap o f undoing, ceasing to act. When you cease to act, the mindfulness enters into your system o f being. That seems to be the basic meaning o f recollection. There is something in the past, not as memory but experience (Trungpa, 1981, p. 7).  A s described earlier however, when approaching mind, the tendency is to identify with and react to mental contents o f ideation, sense perceptions, and emotional experience. This process o f examining mind's projections and patterning is more akin to introspection or phenomenology. For Immanuel Kant, for example, phenomenology was the study o f that which can actually be experienced (phenomena) rather than the unknowable 'things-in-themselves' which he called houmena  (Payne, 1996). In  comparison, through mindfulness or bare attention one can cultivate awareness o f phenomena o f experience (mental contents) while unmediated awareness addresses that  131  which is 'unknowable' in the sense that it is beyond concept— primordial awareness.  zy  Such non-conceptual awareness can be pointed to, according to Smith (2002), by attending to stillness which is always t/here. Such stillness has been referred to earlier as non-conceptual awareness or rigpa  (Sogyal, 1993) and elsewhere as pure consciousness  (Shear & Jevning, 1999) and natural pristine awareness (Varela, 1997). A l l terms defer to a stillness o f awareness without discursive thought—simply perceiving as is....things-inthemselves. During a recent meditation workshop for people working in end-of-life care, Rodney Smith (2002) used the term 'stillness' sporadically as he suddenly stopped midstream throughout the weekend workshop and asked, " D o you feel the stillness?" Or following an experiential exercise where we were guided through a visualization o f our own dying with its heightened level o f emotion, he gently directed our attention to momentary experience asking again, "Where is the stillness in this moment?". In turning our attention beyond the contents o f our thinking or emotions, there was a fleeting opening into content-less awareness. Stillness awareness or rigpa  is timeless and always  accessible in the stillness o f each moment, i n the stillness within action, and in the stillness o f death. A l l stillness; the same and yet different....  Who is reading and experiencing this right now? Where are you?  Where is....  Wallace (1999) provides a clear explanation of how this process functions using the nine stages of samatha. Epstein (1995), a psychiatrist, claims that the transformational potential of meditation lies in the separation of direct, sensory experience from conceptual and emotional reactions.  2 9  132  Stillness Still illness ill nestle listen listless still(born)  stillness.  Meditation and dying as parallel processes  Meditation is like dying, first you start with a lot of discursive stuff and a lot of fast activity. Then you slow down and settle; eventually your body starts disappearing at the edges. Next your mind goes, and that's what happens in death. (Stan)  Stan's comments have a ring o f intimacy as i f he knows dying—there is a familiarity and confidence in his tone that seems to come from experience. Perhaps it is not surprising given the almost twenty years he has been living with A I D S and during that time, he has seen many friends grow sick and die. Complex loss including social death, identity death, and sexual death, are major issues in H I V / A I D S (Hall, 2001). So, has Stan's familiarity with dying and death developed over time with multiple losses? Perhaps, but i f we consider Sogyal Rinpoche's (1993) assertion that "life and death are located in the mind" (p. 46), then it is also reasonable to link, as do several participants, meditation as a way o f becoming familiar with death through their parallel processes. The degree to which meditation practice has shaped the participants' sense o f intimacy with dying and whether such familiarity has an impact on levels o f death anxiety and denial are interesting questions for further inquiries. What is contemplated here, however, is how meditation and dying are conceptualized and experienced as parallel experiences; the processes are configured as three interdependent themes o f turning  inwardly  outward,  letting  go, and  dissolving.  134  Turning Inwardly Outward For many dying residents at Zen Hospice, a turning inward occurred as they began to lose interest in engaging with others and spent more time sleeping and disengaging socially. From biomedical perspectives, this process has been called a terminal  drop  in cognitive and behavioural functioning (Aiken, 2001; Samaral, 1995)  which manifests in decreasing sensorimotor abilities, cognitive organization, and social interaction. Lieberman (1965) suggests that decreased functioning in the last weeks or months o f life is attributed to physiological changes and psychological factors such as feelings o f chaos and approaching doom so that an individual becomes less w i l l i n g or able to exert themselves as they once did. From a physiological perspective, signs o f impending and imminent death also infer a turning inward as the dying person experiences diminished body movements and an inability to move, difficulty speaking and swallowing, blurred vision, and loss o f reflexes (Samaral). Notably, all o f these indicators have a quality o f dread as they are described in the literature rather than the aforementioned 'interest' that characterized dying earlier. A s a parallel process in meditation, turning inward infers attending  to  experience  as it is. However, as with many terms, the word 'inward' is understood differently in the Buddhist context o f this inquiry. Conventionally, i n Western understanding o f the self, we understand 'inward' as relating to feelings, thoughts, and imaginings and 'outward' as oriented to the physical world outside o f oneself. However, in meditation practice inward is viewed in a radically different sense. Shear and Jevning (1999) explain,  135  [In meditation]... even awareness o f one's own most private, internal thoughts and feelings is still external to one's awareness itself, for they still appear to one's awareness, in front o f one's mind's eye', so to speak, and 'inward' referred to here is intended to indicate a complete reversal o f attention away from thoughts and feelings as much as from external objects, back into awareness itself, (p. 191) Shear and Jevning's (1999) description illustrates once again the emphasis on non-conceptual awareness as a vital aspect o f meditative awareness, but may also mislead in creating a false dichotomy through reifying the concepts o f mental contents and awareness and presenting them as objective phenomena to be turned away from. inwardly  outward  Turning  in the context of this inquiry does not mean turning away from  thoughts and feelings as suggested above, but rather implies turning one's lens o f awareness into and through feelings and thoughts completely— without solidifying or holding on. Turning inwardly outward is attending to whatever is arising and passing away in the flow o f experience as it is happening without holding o n — 'bare attention'. Attention is in-between inward and outward. One participant's description o f meditating illustrates this: Seeing the arising and passing away of sensation....there was nothing before and there was nothing after, it was just [the] arising of an object, and consciousness of it, and then it was gone. (Michael)  Michael, a volunteer hospice caregiver, describes the impermanent quality o f directly experiencing successive moments o f perception and subsequently shares how shifting inbetween direct experience and thinking about experience manifested in his meditation: I was watching the rising and falling of my abdomen and after awhile there was motion and some kind of structure to it. Then, after a while all of the structure gave away and what was left was all of these sensations arising and passing away. And then as soon as I tried to note 'rising' and 'falling', put a word on 'it', it got flat There was no more of that really fine quality of experience.  136  My explanation is that once there was a word attached to it, my mind thought it knew it, so it flattened the experience completely. When the words were not there, the experience was so rich; there was all of this sensation going on ...it was just pure awareness of what was going on at the time. And then as soon as I put words on it, all of that went down to...(clasps his hands together).  Silence(s) One way to reorient one's awareness inwardly (outward) in a Buddhist and conventional sense is to settle the mind through stillness and silence. In many contemplative traditions, silence is a heuristic that assists in turning one's gaze inward; a quiet environment supports this process. Despite intuitively knowing this, when I first arrived at San Francisco Zen Center, the emphasis on silence felt somehow threatening and solemn. That is, functional talking—speaking mindfully and only when necessary, was practiced during working hours . Complete silence was maintained during specific 30  times and in the dining hall for the first ten minutes o f the evening meal. Silence provided a context for attending to both the active contents o f mind and the inward stillness o f awareness while bringing this awareness into everyday activities. Experientially, sitting with strangers without connecting verbally or through eye contact was oddly anxiety provoking. Initially, the silence felt claustrophobic and heavy; I felt awkward  quietly  we would eat our meals with each swallow reverberating throughout the hall (or so it seemed). Then, after ten minutes a bell was rung and talking was permitted. Usually after a brief pause o f additional silence, I impulsively escaped into conversation, back into the  Functional talking was strictly enforced in the kitchen where mindfulness was practiced in a heightened manner. In the offices where staff were dealing with the public and where the nature of the work required verbal communication, talking was more frequent. Monastic rules required silence in the morning which began with sitting meditation at 0525 hours until breakfast at 0720. 3 0  137  familiar world o f speech where the terrain was comfortable and the discourse less edgy. Why is silence so often unsettling? This experience o f silence was different from that experienced in other social situations such as standing in an elevator or on a bus. These everyday silences on the elevator or bus I signify as closed  silence/  closed  awareness.  Such silences are an  expected social norm that have a different intention, experiential quality, and outcome than that at Zen center. In an elevator for example, the intention o f silence is often to close-in awareness by not engaging and not noticing—or at least pretending not to be aware o f others in the elevator. We cast our gaze downwards and wander off in thought, or stare upwards at the lights indicating the floors. In general, this silence is comfortable and contained as we sink into our own cocoon—avoiding too much attention to others and vice versa. The outcome is one o f mutually agreed upon avoidance and invisibility. However, in Zen practice at the hospice or in the San Francisco Zen Center, the intention is more akin to the silence nurses might bring into a room with a sick patient and their family, that is, to practice staying open and attentive. What I am signifying as open  silence  / open  awareness  in this situation means attending to all perceptual  experience in the simplicity o f ' n o w . ' The meditative element in these situations lies in first, recognizing one's discomfort (or whatever arises) and then not sliding away into 'trains o f thought'—thereby limiting one's immediate ongoing awareness. With practice, one soon recognizes the transparent, transient nature o f thought itself within broader awareness  31  so that the allure o f thoughts and images no longer closes off one's  awareness into abstraction. The outcome o f this kind o f awareness, based on practice and  The idea of meditation as trying to rid one's mind of thought and cultivating a blank slate, so to speak, may be incorrectly inferred here from this discussion.  31  138  interactions with long-term meditation practitioners, corresponds with Wallace's (1999) descriptions o f the effects o f samatha meditation that include: an increased capacity for concentration, cheerfulness and lightness o f mind, increased mental and physical pliancy, and fewer and less intense afflictive emotions such as anger, craving, and fear.  32  In  particular, participants described changes i n responding to intense emotional episodes o f anger, depression, and despair as an outcome o f their meditation practice. You can go there, into that territory of feeling despair and hopelessness.. ..and everybody has to - it's just part of the process. But it's a matter of how deep you go in there and how long you stay, and whether you have enough mental focus to be able to pull yourself back out again... (Stan)  Empirical studies on the effects of mindfulness also support Wallace's descriptions (see Astin, 1997; Kornfield, 1979; Shapiro, Schwartz & Bonner, 1998). Wallace (1999) defines shamatha as quiescence and a form'of attentional training that is not bound to any religious or philosophical tradition and is found in many contemplative traditions throughout history. Shamatha is intended to quieten the mind and work with either excitation or laxity. In order to cultivate this kind of attentional stability, the mental factors of mindfulness and introspection are required. Mindfulness is understood here as the faculty of placing and sustaining one's mind on an object of attention. Introspection in a Buddhist sense is a repeated scanning of the state of one's body and mind. Together, examining one's state of mind as it subtly changes and sustaining attention or the object of awareness constitute the practice of shamatha. Although Wallace's work is not empirical research, his perspective is supported by outcome research as cited above.  139  Inter/play of silence Returning to the silence o f the dining hall at SF Zen Center, sitting in silence provided glimpses into the fluctuations between opening and closing silence/awareness. A s the weeks passed, a familiarity with transitioning in-between opening and closing became increasingly evident and spontaneous. This awareness carried over into the work at hospice as the following field writing illustrates:  Shifting Between Worlds Paying attention as we shift and move between worlds. Rather than losing our seats, getting thrown off, flustered, and lost. Instead, cultivating sensitivity of the transitioning.... as we walk into Zen Hospice from a frantic drive through morning traffic as we meet fear in glazed eyes as we open the fridge to prepare Lois' lunch as we glove to pick up feces floating in the shower at a resident's foot as we don't know what to say, as we synchronize our breathing, as our tender hearts ..open... Staying connected with the flow of experience and seeing what happens as we move in-between into somewhere (a)new....  Experiences o f closing awareness were observed as attention wandered off into thoughts while opening awareness was simply staying with constantly changing feelings,  140  sensations, and thoughts—pleasant and unpleasant.  jJ  The affective qualities o f heaviness  and angst did not necessarily go away, but a concurrent awareness o f open-ended stillness around these phenomena made them less claustrophobic and more workable. This sense of workability, with whatever was happening, was echoed by participants who spoke about gaining a sense o f control over their minds and their responses to what was happening in their lives: We can control whether we're going to go into being in despair all the time or being angry and resentful....maybe it sounds very simple, it is simple and sometimes simple things are very profound. You know, you don't need to go through the histrionics, I mean we do, but like I said ...when you've learned how to focus your mind a little bit more, then...the histrionics are a little shallower and they don't last as long...you don't need to wallow in it...you learn that. (Stan)  Caregivers at Zen Hospice advocated a turning  inward  towards their own fear,  suffering and histrionics, as Stan suggested, and how resting with these experiences without holding on or pushing away allowed for new insights to arise. Through awareness practice, one learns to see where turning away from experience into the safety of narrative distraction only solidifies experience and how one can also gently lean into and become familiar with whatever is arising, dwelling, and passing away. Turning away from one's experience may happen because our mind lacks practice in attending to immediate experience, or because the experience is too threatening, too unpleasant, or because habitually we deny certain experiences (Epstein, 1995; KabatZinn, 1985). Fear o f death has been identified by Western philosophers, theologians, and  Glimpses of open silence / awareness were neither steady nor continuous but moved back and forth as awareness floated into the safety of thinking and back into momentary awareness of awareness~to and fro, into and out of stillness and silence until a bell rang indicating that the periods of silence were ending. Flickers of awareness included: moments of heaviness, shifting perception, the colors of silence, the hard edge of shyness, the cool breeze of a laugh, and the fly in my soup, etc.  141  psychotherapists as the most pervasive emotion we turn away from and that this denial motivates our lives and actions (Becker, 1974; Olson, 1962). Buddhism suggests that fear and death are also opportunities for awakening by turning inward. That is, such moments are powerful doorways through which we can realize that fear and death are not solid obstacles but merely transparent projections o f our own mind. This is not to suggest a cavalier attitude towards fear and suffering; quite the opposite, such an attitude suggests that all experience is workable. B y attending to the finely woven and uniquely patterned unfolding o f momentary experience, we can learn to let go into the flow o f each outbreath....  Great is the matter of birth and death, Quickly passing, gone, gone, Awake, each one awake, Don't waste this life.  Zen  Saying  142  L e t t i n g go Nobody wants to suffer and Buddhism re/cognizes the inherent suffering embedded in the experience o f impermanence. Because things change, there is inevitable suffering as tragic events take away that which we cherish or, on the contrary, we suffer when we don't get what we want. Buddhism asserts that because offixed ideas about how reality is or ought to be, there w i l l always be dissatisfaction; this is part o f the human condition and the im/possibility o f sustained happiness. From this view, such suffering is a form o f conditioning that can be interrupted by learning to let go.  Meditation is like dying, first you start with a lot of discursive stuff and a lot of fast activity. Then you slow down and settle; eventually your body starts disappearing at the edges. Next your mind goes and, and that's what happens in death. (Stan)  Letting go o f fixed mind A s many beginning meditators attest, the first realization when turning one's attention inward is how compulsively distracted and easily carried away by thoughts and sensory stimuli one's mind is. Our minds are typically busy with discursive thinking or conversely, they may be dull and sleepy. Without practice or training, it is difficult to sustain awareness avoiding either excitation as Stan's comment above suggests, or laxity where attention becomes slack, without precision or vividness (Wallace, 1999; Jevning & Shear, 1999). However, with meditation practice, [the] mind begins to slow down and settle as the second line in Stan's quotation states. A s this settling process occurs, one sits with awareness knowing that we cannot know what w i l l arise in the next moment o f awareness or with the next breath. Mindfulness is learning to sit i n that awareness without judgement, without speculating - simply being open and receptive to whatever is  143  arising in the unknown space o f the next moment, and the next. Experientially, one's sense o f speediness or dullness dissipates as [the] mind settles into vast, open awareness. A s one attends to whatever arises without engaging or holding on, one is suspended momentarily while moving into an unknown with each breath. L i k e meditation, death is also stepping into an unknown o f what is/is not while transitioning from what we call life into what we call death. In Buddhist texts, internal narratives and speculations about what is happening or might happen are forms o f turning away from direct experience and thereby holding on to conceptualizations o f what is. Not only are we "missing our life in the present moment" (participant Camilla) by continuously engaging in conceptual mind, but attachment to such discursiveness also generates suffering and fear as anxieties about what may happen tend to dominate and further separate us from our immediate situation. A s participants shared, meditation is practicing letting go o f discursiveness while staying connected with embodied experience as it unfolds unceasingly with each breath. This process applies to all aspects o f experience, including dying and death.  ...it relates to death, dying and illness....you go along everyday.... And if you get ill, you experience your illness. If you are close to death, if you're at hospice getting ready to die, so then ...that's that....this is how I would like to do it. Take each day as it is. (Camilla)  A s awareness begins to settle one also sees patterns o f thought, feelings, and themes that constitute one's experience and sense o f an experience?*. Instead o f holding tightly to the dominant concept o f a unified, essential self, we begin to experience self as a composite o f thoughts and sensations arising moment-to-moment as solid identities  144  come into question. The grip o f T am essentially' this or that loosens as meditation practitioners begin to see through and let go o f mental fixations on identity, social roles, conventions, and what was previously perceived as important. ...somehow the energy of meditation together...I don't know what that is, but I think that it definitely helps, being in the same environment with other people who are meditating, so even if we're not physically communicating at that moment....it's a calming and nurturing feeling...we're all working on being present, we're all just working on being right where we are...and who we are...and not...not putting on our everyday masks, not dealing with all the other things in the world...that really aren't so important (Bruce) When bringing awareness to the moment fully, or even partially, we see more easily what some participants called our 'masks' or personas. These textured masks are interpreted as tightly woven images and stories about who we are and how we see the world that simultaneously express and conceal what is integral to our sense o f being in the world. While attending people who are dying, one can sometimes see the mask falling away even i f only momentarily. Often masks o f 'able-bodied person', 'entrepreneur', or 'cancer survivor' are replaced by new masks of, 'dying', 'hospice resident', or narratives of illness as suggested by Arthur Frank (1997). There were times however, when residents and caregivers were without masks as their sense o f coherence was disrupted and they opened into groundlessness. There is little in Western culture or Western psychology to prepare people for dealing with such moments o f identity loss (Wellwood, 2000). These experiences—momentary or prolonged, in-between the dissolution o f one textured  mask and the construction o f  another, have been described in the literature as 'narrative wreckages' (Frank, 1995) and 'chaos' (Samarel, 1995) while Zen teacher Shunryo Suzuki (1970) calls such moments without scripts—'beginner's mind.'  145  A comparison o f Arthur Frank's (1997) and Shunryo Suzuki's (1970) perspectives on the experience o f groundlessness illustrates differing interpretations o f the role and benefits o f letting go o f narratives and provides alternative views on conceptual mind as a point o f reference in situations o f potential loss o f identity. To begin, Frank identifies 'deep illness' as situations where illness is always present and defines one's life and invokes suffering that medicine alone cannot address. In order to survive such suffering, Frank promotes using the power o f conceptual mind to narrate stories that allow us to take control o f our reality through narrating what is meaningful. Our stories are never isolated however, and, according to Frank, they exist only in relation to narratives asserted by others. Or, to put the matter a bit differently, meaningful stories are needed in order to transform what is formless, raw experience, into a coherent and meaningful interpretation that is simultaneously shaped within the texts o f institutional, cultural, and other people's stories. Thus far there is congruence between Frank's view and Suzuki's Buddhist ontology. In Frank's (1997) work with chronic illness, he identified a typology o f three illness narratives: restitution, chaos, and quest narratives, with the crucial difference between them being the form o f agency the narrative affords the ill person. For example, in the restitution narrative, the storyline is one o f becoming i l l , then focusing on getting better, and eventually becoming healthy again. The restitution narrative is described by Frank as the culturally preferred narrative in the West as it affords the greatest sense o f independence and individuality. Frank's sense o f the transparency and possibility o f reshaping one's narrative is also shared within Buddhism (see Batchelor, 1997).  146  The differences between Frank (1997) and Suzuki's (1970) positions now come to the fore. The difference seems, in part, to be Frank's concession to our desire for order and coherence and "the wish that our lives would be as orderly as the books we read" (Freeman, 1998, p. 30). Freeman suggests that narratives are not woven into the fabric o f life itself but are an imposition in an attempt "to give form to what is essentially formless and perhaps meaningless" (p. 28). Although Freeman does not go so far as to say that the possibility o f meaninglessness is untenable from a Western perspective, this seems to be the crux o f the matter. Even so, the point o f departure between Frank (1997) and Suzuki (1970) rests in the centrality and importance given by Frank to the self-stories for people living with 'deep illness': The tragedy is not death, but having the self-story end before life is over. It is a tragedy i f having nothing else to say means that these people have no further use for themselves; i f they have lost any language in which they can remain available to themselves (Frank, 1995, p. 96).  It is in the interpretation o f tragedy and the reliance upon language in order to remain available to oneself where meditators i n this inquiry, and Buddhist practitioners in general, differ from Frank's (1997) understanding o f self and death. A s in Buddhism, Frank views the end o f the self-story as a form o f death; however, unlike Buddhism, he emphasizes re-storying and re-constructing meaningful narratives as the primary approach to disrupted life narratives. This approach is consistent with other research that looks at the importance o f meaning-making (Coward, 1994). Although useful for some, such perspectives are culturally embedded and would not necessarily be relevant or helpful for Buddhist practitioners who may see the unraveling o f one's self-story as a  147  realization o f self-lessness and therefore as an experience o f liberation rather than tragedy. Yet, what o f Frank's (1997) concern with losing any language in which to remain available to ourselves? A s in other instances where gaps arise—such as gaps o f existential anxiety where the world as we know it falls away— an habitual Western response, as exemplified in Frank's approach, is to fill the void through attempts in constructing narratives to forge an authentic, languaged response to reality. Perhaps such narration is eventually necessary; in contrast, a Buddhist view does not encourage  filling  such ontological gaps, but suggests ways for entering more deeply and letting go even further into such groundless spaces (Wellwood, 2000). One could say that a Buddhist approach does not deny or oppose the languaging o f our lives, but also does not fear the display, that is, the spaces in-between and surrounding the words that also shape meaning.... In this way, the importance attached to a meaningful self-story by Frank (1997) is juxtaposed with Suzuki's (1970) 'beginner's mind' where the dissolution o f a predetermined self is seen as liberation from suffering rather than Frank's notion o f tragedy. According to Suzuki, " i n the beginner's mind there are many possibilities; in the expert's mind there are few" (p. 21). 'Beginner's mind' was a favorite expression o f the thirteenth century Zen master Dogen-zenji and implies that the mind o f the beginner is free, unfettered by preconceptions, ready to accept and doubt, and is open to all possibilities. Therefore, i n Zen practice, the beginner's mind is cultivated i n all stages o f life i n order to see clearly and directly, beyond pre-determined stories about what is or ought to be. Instead, one practices simply resting with whatever arises....seeing what  148  happens.. .being curious what the next moment w i l l bring.... Not identifying with thoughts but seeing thoughts as thoughts... meeting each moment without expectation. Such is the flavour o f meditation practice. Whereas Western therapies are geared towards personality and therefore aimed at knowing and having a meaningful self-story (Wellwood, 2000), participants in this inquiry, and Buddhism in general, assumes otherwise. That is, there is an assumption that not having a solid story-line and not being certain o f our identity is both natural and to be anticipated as contexts change, sometimes radically and unexpectedly, and assumed realities are cracked open as they inevitably w i l l be. Letting go o f where we have been and resting in awareness that we cannot know what is next is a re-aligning, so to speak, away from the narrative itself towards an ongoing awareness o f ongoing narrating....  149  Letting go o f time  Time past and time future A l l o w but a little consciousness. To be conscious is not to be in time But only in time can the moment in the rose garden, The moment in the arbour where the rain beat, The moment in the draughty church at smokefall Be remembered; involved with past and future. Only through time time is conquered. T.S. Eliot (p. 44, 1944/1976)  Time is a complex construct that is necessary, as T.S. Eliot eloquently states, i n order to re-mind ourselves o f cherished moments o f the past. After all, where is the fullness o f life without dreams o f the future or memories o f the past? A n d yet Eliot (1976) teases, "to be conscious is not to be in time" wherein the poet introduces a notion o f 'without time' and the possibility o f situating between time and timelessness. Eliot invokes a metonymy in the midst o f time-and-timelessness where, "only through time time is conquered." Conquering time in Eliot's poem and in the context o f this inquiry does not signify destroying time or ridding ourselves o f temporality, but is rather interpreted here as turning towards or leaning into while letting go o f time. Letting go, as inscribed earlier, allows fixed concepts to soften and melt as formations simultaneously arise from moment-to-moment as contexts require. Therefore, letting go is a process o f abiding with whatever arises and passes away instead o f pushing away or holding onto fixed ground. B y interpreting time as a complex construction, one can see how 'letting go o f time' is linked with the previous notion o f 'letting go o f fixed mind' where 'time' is a fixed concept. That being said, the metonymy o f time/timelessness holds a particular  150  significance in this inquiry where a sense o f time is not only an abstraction but a dynamic experience. In part, the significance o f time is due to the special role it plays in dying and death where we may experience time as: 1) a linear resource that eventually runs out and/or a circular process o f transitioning moments, 2) a privileging o f present time or 'nowness', and 3) the disappearance o f time through nondual meditative experience. In what ways can we understand time and its relationship to dying and meditation processes within a Buddhist context? A n d how might we interpret Stan's comment:  Dying is interesting...if you look at it from a Buddhist view, there's death every mind-moment. So, it's just compressing it or expanding it, and time is the duality  Time is constituted in this inquiry as an embodied experience and mental construction. Feeling the spaciousness o f 'free time' or the taut constriction o f 'running out' o f time, the symmetry o f 'being timely' or the paradox o f going beyond time are some ways in which this phenomenon manifests in our lives. Rather than a mental construction alone, Austin (1998) refers to "doing-time" (p. 562) as an internal sense o f time that then becomes interpreted as our time. For example, our sense o f time shifts and changes depending on internal and external circumstances. O n vacation, as we vacate our normal routines, we leave home and enter a new environment without familiar structures and forms. Time seems to expand as its usual slicing into significant units is reduced: we eat when we feel like it, go to sleep without concern for morning fatigue, and read leisurely in the mid-day sun. Similarly, in many hospice situations conventional determinants o f time are reduced and time is tailored to the wishes o f the dying person. Consequently, perceptions o f time begin to shift and conventional realities are more  151  readily interrupted. Attending to these subtle disruptions as not only institutional flexibility but as states o f mind was cultivated by participants through mindfulness in the sense used by Trungpa (1981), namely that mindfulness is not something we do, but is something we can relax into. One's personal sense of'doing-time' is also embedded in societal and cultural conceptions o f time that Geertz (1973) suggests have "an unbreakable internal link" with what it is to be a person (p. 389), that is, a person in time. What I am suggesting here is that just as meditators practicing mindfulness may constitute 'person' in-between relative (self) and ultimate (no-self) perspectives, constructions and experiences o f time can also be located in such liminal spaces. Linear time In modernist societies for example, time is conventionally imagined as linear or what Freeman (1998) calls historical time. Broadly conceived, historical time is irreversible, unrepeatable, and an evolutionary line with moments in time like beads strung on a cord from birth until death. Within this linear trajectory is a division o f time into past, present, and future and a sense o f personhood that is "individualized" (p. 34) or a separate entity that moves from birth, old age, and into death. Linear time emphasizes a sense o f material reality where time is a resource that eventually runs out. This configuration dominates biomedical views where time is measured sequentially and death is an absolute end o f human existence. D r . Sherwin Nuland, a clinical professor o f surgery at Yale University and author o f How  We Die (1994) reflects this perspective: "I  have no evidence whatsoever that anything happens after death other than that the body  152  decomposes" (p. 44). Materialist ideology such as this clearly separates living from dying and one must ask how viewing ourselves as finite entities that cease to exist with death might shape our perception and experience o f living and dying? In response, Gadamer (1996) suggests that such division is a false dichotomy as we cannot imagine our own death and this impossibility leaves angst and fear i n its wake. He links this impossibility to our notions o f time where "a man's very ability to envisage his own future lends to it such a tangible presence that he cannot grasp the thought o f its actually coming to an end" (p. 65). This impossibility was shared by one participant:  It's hard to imagine a time when I'm not going to be here because there's no one here to imagine me not being here....except maybe you!...but I don't know what that feels like. It doesn't work on an intellectual level. (Manuel)  Death as a separate phenomenon quickly moves into a place beyond intellect where the limits o f thought are evident and the binary o f life then death becomes problematic. In the preface o f his Pulitzer Prize winning book The Denial  of Death,  Ernest Becker (1974)  states what is echoed by many Western thinkers that the finality o f death haunts us like nothing else, "it is a mainspring o f human activity—activity designed largely to avoid the fatality o f death, to overcome it by denying that it has the final destiny o f man" (p. ix). However in our efforts to repress death's inevitability so as to focus on our living, there is a paradoxical outcome that science and secular society seem to ignore. A s Freud (1957) stated in speaking about the days before World War I:  153  ... .we were o f course prepared to maintain that death was the necessary outcome o f life, that everyone owes nature a debt and must expect to pay the debt—in short, that death was natural, undeniable and unavoidable. In reality, however, we were accustomed to behave as i f it were otherwise. We showed an unmistakable tendency to put death on one side, to eliminate it from life. We tried to hush it up.... But this attitude o f ours toward death has a powerful effect on our lives. Life is impoverished, it loses in interest, when the highest stake in the game o f living, life itself, may not be risked. It becomes as shallow and empty, as, let us say, an American flirtation, in which it is understood from the first that nothing is to happen, as contrasted with a Continental love-affair in which both partners must constantly bear its serious consequences in mind. (p. 289)  Within materialist ideology, time is a valuable resource to be measured and managed with efficiency, whereas the necessity o f interdependence in living/dying as metonymic phenomena that is ambiguous and uncertain is overlooked. Without fully re/cognizing death and its inseparability from life, life remains impoverished and 'loses in interest'. That being said, the dichotomy o f life then death remains a universal principle in Western medicine and nursing, with a linear trajectory o f our life-time eventually running out  full stop.  Cyclical time In contrast, the wheel o f life or cyclic existence of samsara  (Pali) is configured in  Buddhism and is translated as "always moving" (p. 312, Corless 1989), implying that life and death continue in an indefinite cycle unless specific steps are taken to interrupt the cycle or go beyond the spiral o f time. Time becomes linked with a circular image where birth and death refer to constructions, deconstructions and reconstructions o f the sense o f self rather than the dissolution o f the physical bodymind. Even so, physical death is also seen as a transformation or re-cycling o f the bodymind (addressed in the following section re: dissolution).  154  The materiality o f time comes into question when the experience o f ' s e l f becomes less solid and fixed through meditation practice. Epstein (1995) uses spatial metaphors to describe how beginning meditators initially perceive themselves as separate beings dwelling in space and time. A s described earlier in Manuel's existential story, the solidity o f self begins to destabilize and as this occurs in meditative experience, metaphors shift from spatial representations o f self to temporal metaphors, that is, self as constantly changing. Shifting from an inner 'deep me' within space and time, self is perceived as a changing, "ever-evolving organization" (p. 142) o f patterns arising moment-to-moment in ever-present 'nowness'. A s one participant pithily expressed,  ...we all understand that everything is changing, we can intellectually grasp this, however when we turn the lens of mindfulness on ourselves we begin to understand that we also are this change... not just that things are changing...but we are change.... (Gary). In viewing ourselves as ceaseless patterns o f change, who or what dies? H o w does this experience o f self change one's perception and experience o f death? According to participants, as we see more deeply into impermanence, we start to see the pervasive inevitability o f change and that, according to one participant, diminishes fear. After all, i f we are change, then death is presumably another form o f change about which, it seems, we cannot know, except to say that it is transition. Buddhist thought supports this view through the doctrine of anatta  (no-self) where the belief in an inherent, essential T gives  rise to fear o f death simply because there is a sense o f someone who can be threatened by annihilation. However, upon closer examination o f this someone, an individual cannot be  155  found except in the form o f constantly changing patterns o f perceptual awareness in thoughts, feelings, sensations, emotions.  34  Rather than the finality o f death—full stop, there is a quality o f open, uncertain, movement. In a Buddhist context, death is not the end or final condition but is "one moment i n a larger journey o f transition" (Welwood, 2000, p. 151). A s one participant laughed, "impermanence is the only permanence there is". Lauren, a participant and nurse for twenty years, remarked how even after participating in many deaths, she continues to be affected emotionally in her work. What is different now is that the sense of tragedy surrounding death is no longer there; it is simply death— ordinary and profound. Present Time Mindfulness permits continual relinquishment into directly experiencing this moment.  Meditation is just focusing my mind, training myself, practicing being in the moment. And that's enough! (Stan) Why, you may ask, would we want to privilege the present? H o w is it that being in the moment is experienced as beneficial? For two participants living with H I V - A I D S , the tangible certainty o f death makes living ' n o w ' quite poignant. There is, after all, no other moment, only imaginings o f past and future conjured up in the present. So-called living in the past or future is either planning or strategizing for the future or re-thinking  This type of analysis is conducted formally in Buddhist meditation traditions and is known as analytic meditation (see MacPherson, 2000).  34  156  what has already occurred. This is not to suggest that thinking is in itself problematic or that thinking cannot also be experienced fully in the present. A s Tarthang T u l k u (1974) instructs: It's possible to make thought itself meditation.... H o w do we go into that state? The moment you try to separate your self from thought, you are dealing with a duality, a subject-object relationship. Y o u lose the state o f awareness because you reject your experience and become separate from it.. .But i f our awareness is in the center o f thought, the thought itself dissolves.... A t the beginning...stay in the thoughts. Just be there.... Y o u become the center o f the thought. But there is not really any center—the center becomes balance. There's no "being," no "subject-object relationships" : none o f these categories exists. Yet at the same time, there is...complete openness.... So we kind o f crack each thought, like cracking nuts. If we can do this, any thought becomes meditation ( p p . 9-10)  Judith L i e f (2001) speaks o f an experiential place where past and future meet. In attending to the breath at the place where breathing-in becomes breathing-out, there is a gap where L i e f suggests past and future breaths meet. A gap. Placing your attention on the sensations o f breathing, what happens as your breathing is neither in-coming nor outgoing but is mingling in-between. Is there an experience o f momentary presence? Is there a momentary suspension—a stillness in-between breaths? Again, it seems that direct experience rather than conceptualizing what is happening can be cultivated as a habit o f perception. Without this kind o f direct perception, participants described conceptually mediated experience as only seeing what they expect to see, taking things for granted, and experiencing as i f on automatic pilot. L i v i n g in abstraction had a subtly numbing quality— feeling distant or buffered. Michael, a meditator for nine years, described this quality as "flat" and contrasted it with a highly  157  nuance(d) quality o f direct sensual experiences. Directly perceiving one's life unmediated by discursive distraction was experienced as dynamic, v i v i d , and raw: You  start to appreciate beauty in places where you never saw it before.... a flower can be just amazing,..and you see things differently (Stan)  Appreciation, beauty, and the inexplicable mysteries o f human life and death became not just philosophical speculations, but aspects o f participants' experiences. Some attributed being i n the moment to a freshness and 'seeing for the first time' or seeing things differently i n a practical sense too: ...we see things that we didn't see before...we begin to notice, for example when there is a lot of chaos in the room-physically in the room,and is the commode sitting in the middle of the room? And is that commode in the eye-line of the person lying in the bed? Is that what he or she is seeing all day? Maybe it's a convenient location for the caregiver, maybe it's a terrible location for the person who's lying in the bed. (Gary) In the context o f living/dying, training one's attention to letting go o f thoughts o f past and future, and abiding i n present experience leads to unmediated experience. Disciplined meditators can directly perceive subtle impermanence and selflessness that puts them in touch with unique moments o f reality as it is (Sogyal, 1993). Unmediated moments o f sadness, despair, beauty, and delight allow one to see the fluidity o f human experience that becomes both a threat  in its raw, nakedness and a relief  m knowing that it  too is impermanent, changing, and passes away. Meditation seems to help in being more open in ever-changing experience —come what may.  158  Dissolution Following the first two processes o f turning inwardly outward and letting go, the third configuration is the dissolution o f bodymind at the end o f life and within meditation. Dissolution as envisaged in this third process signifies a liminality that manifests as loosening, melting, disappearing and transitioning  Meditation is like dying.... first you start with a lot of discursive stuff and a lot of fast activity. Then you slow down and settle; eventually your body starts disappearing at the edges. Next your mind goes, and that's what happens in death.... (Stan)  Martin's Dissolution Story Sun streaming through an open window smoky plum walls stunning white orchid, eight blossoms on arced stem. Wooden Buddha in full lotus, thumbs touching, arms resting gently in his lap. Thick glasses rest on Suzuki's Zen Mind, Beginner's Mind growing bulkier as Martin wanes. Witch Hazel astringent, G o l d Bond lotion, Vaseline and Gekkeikan sake. Small seedling o f potted pine adorned with colourful bobbles, Red box o f Cheez-its, salted cashews, bags o f chocolate-mint wafers and chips. Left-over fortune-cookie prophecy, "you are about to change your line o f work." O l d poet snoring mouth agape, a gap long periods o f silence long stretches o f breathlessness.  159  11  Y o u moaned and groaned too loudly so they hushed you into slumber into unbidden places where we can't accompany or witness. Y o u journey there alone. Maybe it's your way, from years o f drugs and booze going places, staying still. Still here. iii Arggh Momentarily awake, pale gray-blue eyes washed out by morphine. Pin-point pupils, beady eyes peering into space. Y o u didn't want this, but are at the mercy o f night guardians, well meaning, yet inattentive... or unable to see?  " G o o d morning Martin". Y o u startle, eyes flitting, seeking recognition, hands grasping invisible objects in space.  " H i , how are you" you whisper through dentureless jaws. About to respond, but you're gone drifting rudderless eyes rolling upward and away.  A r e you able to be present for the journey? Y o u moaned and groaned too loudly, so they took away the/ir pain and hushed you into slumber where we cannot go or witness, you journey there alone  iv Walking softly into Martin's room after lunch, the autumn air feels thin and cool. The room is quiet in a protected corner o f hospice. Sounds filter in from the neighbours. Muted sounds of joy and muffled laughter floats by as a child blows watery soap through a plastic ring. Squealing, the child delights as each blow forms bubbles sailing upward out o f sight, pulled effortlessly toward the sun.  Afternoon light shines through semi-closed blinds casting striped shadows across the bed where your emaciated body lies propped up on pillows. Y o u r rheumy gaze is fixed; one eye is neatly patched with white gauze while the other looks directly ahead drawing me into its vortex o f darkness without bounds.  " O h Martin", she says softly, gently caressing your head. " H e ' s gone". W i t h a twinge o f sadness she asks you, " D i d you just leave?" It seems important to her that you not die alone, and although someone was sitting here all morning, you slipped away just before we arrived. "Maybe you waited until we were gone, eh Martin?" she asks hoping it was your doing. " W e l l , journey o n . . . " and she bends down touching the crown o f your head while whispering something in your ear.  Pulling up a chair I stay with you as she gets things ready to bath the body and looks for clothes you would have wanted to wear. Cradling your hands I notice they are still warm. A s the minutes pass your heat evaporates and your colour fades into pale tones o f yellow and gray.  161  Except room,  for  the house  the computer's is quiet. Silence  Martin,  re/living  the experience  images,  memories,  andfeelings  through  by slowing  the window have finally and  allow  down  my mind  going  needed  to wander,  after thinking  offarmers  two o 'clock.  this long  spell  of tires from  the computer  of imagining catches  of dry. I enjoy  of the maligning  of rain  at this time of a passing hums  evoking  has multiple-layers  of branches  and firefighters  The swish back;  sway  re-visiting  of remembering,  This recollecting swirls  in the other  of imagining,  into mindscapes  into the gentle  and subtle  of the fridge  to this process  deeper  of yesterday.  of rain  much  I think  is conducive  and leaning  the drizzle come,  It's  hum and the soft gurgling  woven  Looking  my eye. The these  by many  out rains  wet, dark, urban  days dwellers.  year....  car on the road  brings  me  softly.  Martin's absence is felt. H i s body, now a corpse, remains a form we know as Martin and yet Martin is gone. He no longer breathes, his warmth is gone—he is utterly still. Absolutely s t i l l . . . . a stillness that is vast and deep. I wonder i f this silence and profoundly spacious stillness is the presence o f death?  Is this where death abides,  where the immateriality that was once Martin is now dispersing like perfume hanging in the air though its vector has since disappeared? Such stillness is unusual and yet not unfamiliar; its pervasiveness evokes a shudder and feels somehow trustworthy... Tara, his nurse, returns into the room and smiles. Quietly and attentively we bathe Martin's body soaking in the open silence and stillness as it flows through and between us. This final act o f caring brings intimacy and relaxation into the stillness. Quietly and with lightness we move through and into the curious edges o f this inevitability that is death.  162  Dissolution o f elements ...when you first see pain it's like this solid object—the mind doesn't really see. It's just seeing the surface of it and calls it 'pain'—the word. Obviously you're putting something into the structure that's making it solid. But as soon as you start looking into it you see there is liquid, and sharpness, and vibrations, and there were all of these qualities....And when you start to look into that, it all just sort of breaks apart and there's nothing left of it anymore...there's just the elements. It really was something.... (Michael) Aristotle divided the contents o f the universe into the four basic elements o f earth, water, fire, and air. According to Stephen Hawking  (1988/98)  in A Brief History of Time,  this division o f the universe is still used in cosmology today. Michael's quote reflects his Buddhist lens that also constitutes the world into the same four elements. Interestingly, in deconstructing the solidity o f pain into its basic elements, Michael demonstrates both material-cwd-experiential elemental qualities that are not seen in Western interpretations. More specifically, Michael points to the qualities o f elements where the earth/textural element manifests as s h a r p n e s s ; the water/cohesion element manifests as fluidity; and the air/vibration element manifests in sensations o f movement. Thera (1962)  suggests that by closely examining experiences into these elemental qualities, the  actuality o f phenomena becomes apparent; just as Michael realized, the 'idea' o f pain did not exist in his direct experience even though a varied display o f sensations arising and passing away were noted. According to Michael and Buddhist theory, this constant unfolding o f sensation was interpreted as an interplay o f elements— the constituents o f experience.  163  Inner and Outer Manifestations o f Elements Tibetan Buddhist teachers present an elaborate system o f subtle psychophysiology based on the elements  35  and add a fifth element o f space/consciousness. In Tibetan texts,  the elements are divided into the gross outer elements such as those identified by Michael that include sense perceptions, and the more subtle inner elements o f thoughts, mind states, and emotions. For example (see Table 2), the inner elements o f earth /texture are said to manifest as arrogance, pride, equanimity, and generosity; vrater/cohesion element manifests as anger, aggression, clarity, and wisdom; fire /temperature element manifests as desire, compassion and discriminating insight; air /vibration element manifests as paranoia, envy, accomplishing action; and space/consciousness element manifests as dullness, confusion, ignorance, and wisdom. Interested readers are directed to accessible texts by Freemantle and Trungpa (1975), Lati Rinbochay and Hopkins (1979) and Thinley (1998) for more elaborate discussions. Outer- sense perceptions Sharpness, heaviness, pressure, etc. Eye- colours & shapes Fluidity, sense o f Water - cohesion continuity, etc. Ear - sounds Burning, chills, warmth, Fire - temperature etc. Nose - odours Movement, shakiness, A i r - vibration stretching, etc. Tongue- tastes Awareness, concepts Space - consciousness Mind Table 2 Inner and Outer Manifestations o f Elements  Element Earth - texture  Inner — mental states, emotions Arrogance, pride, equanimity, generosity Anger, aggression, clarity, wisdom Desire, compassion, discriminating insight Paranoia, envy, accomplishing actions Dullness, confusion, ignorance, wisdom  This discussion of the elements draws from both Theravaden and Tibetan Vajrayana perspectives (Goldstein, 1987;Thera, 1962; Thinley, 1998).  3 5  164  A basic understanding o f the elements as an interpretive frame for experience becomes relevant when exploring the bodymind experience o f dissolution in meditation and dying. What seems important to remember is that elements from a Buddhist view are primarily states o f consciousness that dissolve from gross to more subtle levels o f awareness. Dissolution and formation occur in the constant display o f ordinary phenomena, as Michael alluded, but occur more obviously, for example, when falling asleep (Varela, 1997), or while moving into subtle levels o f awareness i n meditation or with changing levels o f consciousness when dying (Sogyal, 1993):  ...you slow down and settle; eventually your body starts disappearing at the edges. Next your mind goes, and that's what happens in death... (Stan) What is o f interest here is how we might interpret Stan's experience o f "disappearing at the edges" as a parallel process o f dissolution in meditation and living/dying from a Buddhist view. I construct an interpretation by exploring dissolution in a general sense and then within a context o f meditative experience, followed by dissolution as a process o f dying. Despite this linear approach, the discussion o f this section continues to be situated in the midst o f liminal spaces where dissolution seems to occur, that is, in gaps o f interruption, in melting separations o f self/other, and in the transitioning of dying. While processes o f turning  inwardly  outward  and letting  go  addressed bodymind from the aspects o f awareness and conceptual mind, the process o f dissolution  also includes these and more specifically identifies the elemental qualities o f  the body i n the phenomenon of bodymind.  165  A s suggested earlier, the dissolving sequence flows from gross elements (earth) and levels o f consciousness (sense perceptions) to the more subtle elements (air and space) and states o f consciousness (emotions, non-conceptual mind). Therefore, as gross elements disappear we lose sensations o f smell, taste, tactile feel, hearing, and sight while the inner elements o f thinking, mental states, and emotions also begin to dissolve. In everyday experience, the transitioning o f consciousness while falling asleep may be a useful reference point for readers in relating with these processes. For advanced meditators, the dissolution process is identified as absorption  samadhi  or  (Sanskrit). External absorption is a common experience amongst thinkers,  hobbyists, artists, or anyone who becomes so engrossed in an activity that their sense perceptions no longer register as they do not hear a knock or are oblivious to sensations of hunger or thirst. Austin (1998) distinguishes external absorption as awareness "that expands outward in the direction o f merging with the object concentrated upon" (p. 475). In contrast, internal absorption is also a dissolving process o f sense perceptions through the meditation practice o f sitting quietly in an upright position without moving. While sitting silently for extended periods o f time i n meditation, a form o f sensorimotor deprivation occurs and the inclinations to move and act begin to fade so that one no longer has a sense o f a solid body positioned in space and you "begin to forget that you are, and no longer feel the impulse that you must keep doing 1998); and further, " Y o u don't let go of your  something" (Austin, 1998,  self. Y o u are let go of (p. 143). A deep  equanimity occurs. Although there is sensate loss as with external absorption, the significant difference with samadhi,  or meditative internal absorption, is the opening o f  intensified awareness. Whereas everyday absorption is described as a merging o f  166  awareness outward with an object o f awareness, internal absorption is the "disappearance o f the bodily s e l f (p. 142) and magnified awareness o f awareness, or as Austin states, "expansion o f clear awareness into ambient space" (p. 475).  Meditation is like dying.... first you start with a lot of discursive stuff and a lot of fast activity. Then you slow down and settle; eventually your body starts disappearing at the edges. Next your mind goes, and that's what happens in death.... (Stan) In this way, the dissolution o f elements provides one interpretation o f Stan's comments. To demonstrate how this perspective might be applied in everyday activities, Stan described an example o f working directly with his experience while receiving an M R I (magnetic resonance imaging) diagnostic test that is notoriously claustrophobic and uncomfortably loud. Despite being given ear plugs, the hour long procedure is usually very unpleasant. Stan described undergoing his last M R I and intentionally being aware o f his mind, being mindful o f breathing, and trying to be present with the noise. It seems that rather than struggling against the dread or the idea o f loudness, Stan adopted a stance o f simply staying with the nuances o f his experience as they were unfolding without judgement or wishing that things were otherwise. The outcome was that the noise did not bother him as much and that he found the overall experience less disturbing. In lieu o f distractions to take one's mind off what is happening, a meditative approach stays with the qualities o f temperature, texture, cohesion, vibration, and awareness as they unceasingly arise and pass away. In summary, the framework o f elements provides a way o f reconciling our ideas o f 'discomfort', 'fear' or 'dying' with our embodied experience. When experience is  167  examined directly without discursiveness, the concepts fall away and an ever more subtle unfolding o f one's bodymind is witnessed.  A n d what o f dying?  Dying envisaged as a process o f dissolution o f elements is described with intricate detail in the Bardo title, the Tibetan  Thotrol, Book  written by Padmasambhava around 750 A D .  of the Dead,  3 6  The English  was given to this ancient text by W . Y . Evans-Wentz,  an Oxford anthropologist, in his 1927 translation. Subsequent English translations use titles such as, Attaining  Liberation  in the Bardo  through  Hearing  (Freemantle &  Trungpa, 1975), that more clearly demonstrate the liminal and metonymic nature o f dying within a Tibetan Buddhist view. For example, bar means " i n between" and do means "suspended", with bardo  therefore inferring an in-between space often translated as  'transition' (Sogyal, 1993, p. 102,). Bardos  are seen as states o f mind or realities  characterized by deep uncertainty or groundlessness that may arise in everyday experiences and in the transition at the end o f life. Although written in 750 A D , the descriptions o f such mental states remain relevant. A s a basic part o f our psychological make-up, these in-between states o f mind are seen as spontaneously arising in everyday life. Another interpretation adopted here is to view  bardo  as a space o f metonymy in the  groundlessness in-between confusion-and-clarity, action-and-stillness, and living/dying. Bardos  in the Tibetan  Book  of the Dead  refer to several states of transitioning  between birth and death, from moment-to-moment, and in the transition o f dying.  3 6  The translation and spelling varies with Freemantle and Trungpa (1975) using Bardo Thotrol and Sogyal  (1993) using Bardo Todrol Chenmo.  168  .. .it is not only the interval o f suspension after we die but also suspension in the living situation; death happens i n the living situation as well. The bardo experience is part o f our basic psychological make-up. There are all kinds o f bardo experiences happening to us all the time, experiences o f paranoia and uncertainty in everyday life; it is like not being sure o f our ground, not knowing quite what we have asked for or what we are getting into. So, ... [it is] not only a message for those who are going to die and those who are already dead, but it is also a message for those who are already born; birth and death apply to everybody constantly, at this very moment (Freemantle & Trungpa, 1975, p. 2).  The Bardo  Thotrol  is unique to Tibetan Buddhism. Although all Buddhist 37  traditions situate dying as a gradual "development o f ever more subtle levels o f consciousness" (Sogyal, 1993, p. 256), Tibetan teachers have described specific stages o f dissolution for each element, or level o f consciousness, that is accompanied by particular physical signs, inner experiences, and visual appearances. For example, the text depicts what a dying person experiences as each element dissolves sequentially into finer levels of consciousness. In brief, at first a feeling o f heaviness overwhelms the dying person 38  as earth  elements  dissolve  into water  and a mirage vision arises; the energy level and  blood circulation decreases as the water  element  dissolves  into fire  and visions o f  cloudiness or smoke arise; we feel cool and are no longer aware o f what is going on around us as fire dissolves  into air  and appearances o f sparks arise in our mind's eye; the  last feeling o f contact with the physical world disappears as the air element space;  dissolves  into  finally, a sense o f white, red and then black light arises and the dying person is  unconscious. When the blackness dissolves into the mind o f rigpa  or clear light, then  death has occurred. Rather than death linked to exhalation, the appearance o f clear light indicates death and the departure o f consciousness (Freemantle & Trungpa, 1975; Lati  The detailed exposition of dissolution and the intermediate state is not shared by Theravaden or Zen traditions. There does not appear to be a conflict amongst traditions or practitioners as the basic principles of element dissolution are shared by all traditions but in varying degrees of specificity. 3 7  169  Rinbochay & Hopkins, 1979). This usually occurs three days after breathing has ceased and is the beginning o f the bardo or in-between transition . 39  What happens afterwards is understood differently by different schools o f Buddhism. For example, in Zen the focus is clearly on this current moment and whatever happens in the next moment or the moment after death w i l l be met with the same open, 'unknowing' mind that is cultivated in meditation. Camilla, a Zen priest I spoke with, exemplifies this perspective: I have no idea what is going to happen after I am dead. I haven't thought about it much and I don't think we can know that much about it. Maybe some people feel that they do, and that's fine, that's their belief, but ....I have to say... I don't know what's going to happen. It's not something that I particularly want to know. I'll find out when I get there (laughs). I'm just focusing on my life here, as long as it lasts. A n d when it's over, we'll see what happens then Buddha Shakyamuni did not teach what happens after death; nevertheless, Tibetan Buddhists use the Bardo Thotrol as a manual that is intended to be read aloud to the dying person and after their death as they are transitioning through the intermediate state between death and rebirth. Although the specifics o f this intermediate period are addressed differently in Zen and Tibetan Buddhism for example, the notion o f rebirth is shared by all Buddhist traditions. Rebirth is a commonly misunderstood concept in the West, where the implication is that someone w i l l literally 'come back' as another person, or parrot, or insect, etc. While from a Buddhist view there is no soul or tangible continuity that moves from one  See Lati Rinbochay and Hopkins, (1979) pps. 17-19 for detailed explanation. In January, a friend from the Shambhala Buddhist center in Vancouver died. As per his request, his body was brought to the meditation center and placed on dry ice for three days. During that time members of the Shambhala Buddhist community sat in meditation with his body around the clock. At the end of the three days, it is believed that the consciousness of the deceased had entered the bardo and at that time the body was taken for cremation. 3 8  3 9  170  life to another, T . R . Murti explains, "Rebirth does not mean the bodily transportation o f an individual essence from one place to another. It only means that a new series o f states arises, conditioned by the previous states" (cited i n Kapleau, 1989, p. 185). Therefore, just as the body decomposes into hydrogen, nitrogen, and various gases at a rate and manner determined by the condition o f the body at the time o f death, so too does psychic energy or consciousness transform into more subtle states that are determined by the condition (and conditioning) o f the mind at the time o f death. Analogies often used for rebirth are the transference o f a flame from one candle to another—are they the same flame? Yes-and-no? Or, another example used by Kapleau is how a billiard ball hits a second ball and thereby determines the direction o f the second ball. What is transferred from one ball (life) to the other is the momentum  of the ball (it's conditioning or karma)  and not a new movement that is reborn in the second ball. Limited as are all analogies, the question is not 'what is reborn' which is perhaps a misguided question, but rather the notion o f momentum in what is happening at every moment o f consciousness better conveys the notion o f rebirth.  40  Tibetan meditation masters suggest that the purpose o f developing awareness o f the dying process as laid-out i n the Bardo  Thotrol  is to familiarize ourselves with this  transitioning o f consciousness as part o f a natural psychophysical process. Through familiarity with groundless, in-between states o f mind, it is suggested that during the dying process at death, we w i l l be better able to recognize the nature o f [our] mind and be  See Sleeping, Dreaming, and Dying (Varela, 1997) for an in-depth discussion of this topic based on dialogues between the Dalai Lama and Western scientists during the fourth Mind and Life conference. The previous three Mind and Life Conferences addressed topics of cognitive science, neuroscience, and the relationship between emotions and health. Proceedings from all four conferences have been produced in published monographs.  4 0  171  liberated. Fundamentally, the Bardo  Thotrol  points to recognizing our own projections  and the dissolution o f the sense o f self as it arises in every moment until the moment o f death. W i t h extensive meditation practice in paying attention, the process o f dissolution becomes apparent. It is interesting to note how western science has extensive descriptions o f the physiological processes o f dying that correspond to the dissolution o f outer elements but is limited in knowledge concerning the transitioning from gross to more subtle states o f mind. For example, in the Medical  Care for  the Dying  (Victoria Hospice Society, 1993),  consciousness is defined as follows: " T o be fully conscious is to be aware o f one's self and the surrounding environment" and includes the aspects of: 1) mental content, i.e. the ability to discriminate among sensory inputs and internal mental processes; and 2) arousal or alertness to external and internal processes (p. 423). The possibility o f consciousness that transcends awareness o f self and environment is not yet considered. A l s o , the potential for people to be aware o f their dying process on more subtle levels as suggested by the Bardo  Thotrol  is also a possibility that warrants further inquiry. The transitioning  of consciousness from a Western view is limited in general to a progression from full conscious to "clouding" o f consciousness, to advanced confusion, delirium, stupor, and coma (p. 423). There is much to learn from ongoing dialogue between these traditions o f east and west.  172  * * * * Sophia's Dissolution Story  Getting close to the mystery of death, it happens to me in my meditation practice, especially in my concentrative practice where the fear of my own death comes up very strongly. You know, there is a Buddhist teaching about how death is really okay if we don't grasp at life, or anything.... And it is easy to say that-- that death is not a tragedy and it is a natural part of life, but try and apply it...and notice how much you freak out. (laughs)  So there's the Buddhist teaching of not grasping onto beliefs, and thoughts like, "this is my life, and I shouldn't be dying; I don't want this experience...." There are lots of beliefs and attachments in this idea that there is something wrong with death.  But, if I can have some experience where I'm free from grabbing after concepts, if I am able to really...I don't want to say 'live it', but at least live it sometimes, at least live in that space sometimes...and it's a deathless space really....where I am not attached to me being a certain way or having control if I can have at least a few moments of not holding on so tightly to everything... then maybe... I can be of help to someone else who is afraid...  173  Hospice care as meditation in action  Inquiry participants considered caregiving to be a significant aspect o f their meditation or spiritual practice. Whereas hospices, by definition, aspire to whole-person care for dying persons and their families, at Zen Hospice the intention was to also see caregiving as opening the mind-heart o f caregivers— who ultimately, were considered in/separable from those whom they served. A l l the while, with the exception o f silent meditation during shift changes, there was little talk o f spirituality or Buddhism at Zen Hospice and, as one training facilitator for volunteers suggested, " Y o u don't need to bring in bronze or porcelain Buddhas, bring in the living ones". Nevertheless, I wondered how care provided in a hospice steeped in mindfulness practice might be different, i f at all, from a conventional hospice. Whereas kindness and compassion are readily acknowledged as common denominators in hospice settings , what was unique to the caregivers at Zen hospice was first, their intention of service through being mindfully open and present, supported both institutionally and maintained individually through meditation practice, and second, that simple human kindness was embedded within particular ontological view(s) that guided their provision o f care.  Intentionality of service through being mindfully open and present  It seemed that for participants the emphasis was not on what they did but how they did it. A s one caregiver shared, Zen was not prescriptive but rather focused on cultivating motivations to act for the benefit o f others and to examine closely the  174  delusions and ensuing suffering embedded in cherishing the "self alone." Therefore, intention was paramount. How I work with my mind in relation to my work, it's definitely been a path quality. I set my motivation in the morning and my intention is very strong I mean, I'm a neurotic person like everybody else, I have aggression and ignorance and all that stuff. But when I go to work may whatever I do, first of all, may it not be harmful and then may it somehow serve the people around me. A n d , . . . . I think that's the most important part. (Lauren) The practice o f mindfulness included an intention o f opening into spaces where dualities o f self/other dissolved, separations o f work life/spiritual life faded, and the solid binaries o f living/dying vanished. The intention o f working with one's mind was an important notion amongst participants. There was an assumption o f some form o f learning or a "coming to know," developing insight into one's mind and its habits that extended into a better understanding and compassion for others. One o f the challenges appeared to be the deepening o f a view o f the constructed, interdependent nature o f ' s e l f integrated with an intention to serve others. Without such a view, one risked becoming self-focused and self-absorbed-—the antithesis o f mindfulness meditation practice. One participant described this pitfall o f self-absorption as "getting stuck at the personal-growth level". Chogyam Trungpa (1973) has called the process o f co-opting spiritual practices primarily for personal benefit as 'spiritual materialism.' In the same vein, Charles Taylor (2002) recounts that during the past fifty years there has been a shift away from organized religion towards spirituality and what he calls 'expressive individualism.' That is, individualism aimed at pursuing one's happiness through the consumption o f goods and services including spiritual practices. One may wonder how,  175  or if, similar tendencies toward spiritual materialism can be identified or prevented. One might also ask whether meditation is at risk o f becoming yet another 'tool' for relieving personal concerns alone? These questions w i l l be considered in more detail i n the upcoming discussion strand, however, as inquiry participants suggested, meditation was indeed a practice  that required cultivating a larger view beyond the self as well as  regularly re-connecting  with one's intention i n engaging and being engaged mindfully.  ...when I go to work may whatever I do, first of all, may it not be harmful and then may it somehow serve the people around me. A n d , . . . . I think that's the most important part. I don't think so much about myself when I'm working... I'm not interested in me 'doing something' and also I'm not interested in 'me being mindful'. But I'm definitely very present. Most of the time, I think I s e e what's going on; of course there's interpretation and questions and intuition - all kinds of other levels. But there is a certain sense that I'm not thinking about other places, or other things , I mean when I'm here, I'm here. And I try to do whatever I can to make it easy for the residents (Lauren)  C a r e g i v i n g with a Unique View  Caregiving in an environment like Zen Hospice was subtly unusual because questioning the substantiality o f conventional reality was encouraged and valued as part of meditation/caregiving practice. I realized how among these caregivers, their questioning o f how one comes to 'know,' as well as a genuine curiosity about how sensory perceptions arise and become transformed  into conceptual interpretations o f  oneself and the world was not merely an intellectual exercise. Rather, being actively interested in how it is that the mind shapes experiences o f suffering and joy for oneself and others was a reflexive way o f being for participants. This curiosity was practiced— not by talking, philosophizing, or doing things differently - but was practiced through the  176  simplicity o f paying attention to internal, external, and in-between layers o f experience; that is, simply noticing spaces within experience, without ambition or goal. Such curiosity into the nature o f mind was situated i n an ontology o f doubling, emphasizing a relationality o f reality that leads to compassion.  ...we start to see our commonalties...our common experiences as human beings as we begin to view our own experience...by turning the lens of mindfulness on ourselves. We start to see how we are created...if you will,.... as human beings...how our sense of self is created...and then we understand how that is common to other people with both joys and suffering as part of that experience. So, once again I think this cultivates compassion for the other.. (Gary) Human commonalties were seen as doubled with an awareness o f sites o f difference where identities o f ' s e l f and 'other' were constituted. In other words, we can be simultaneously the same and yet different and attending to such doubling takes practice... In this section I address queries o f how practicing awareness through mindfulness may have shaped participants' care. Where were the spaces o f action? H o w did they know what to do? A s with other aspects o f this inquiry, the realm o f action was not seen as a binary separate from inaction. ' D o i n g ' was situated i n a doubling o f action-and-stillness, i n the liminal o f in/separability where not doing was simultaneously doing.. .and yet  That  being said, participants described the simplicity o f simply doing what they were doing: making a sandwich, changing adult diapers, or cleaning lint traps. Although this may seem like merely word-play, it is an attempt to open up, or at least draw attention to a process o f closing down i f we interpret situations as fixed, solid, and monochrome. Participants seemed to hold multi-layered views containing doubled, co-existing realities. Things were neither as they seemed, nor were they otherwise. In articulating the practical  177  application o f meditation in hospice care, a challenge remains in providing specifics and direction without inferring solidity or immutable ground.  " A n d what o f doing?" she inquires, "Where is moving into the worlds o f action?" "After all", she points out, " Nursing is a practice profession, with an intentionality o f action " easing pain providing comfort promoting wellness supporting human functioning. "Where is the action in the midst o f this awareness?" she ponders...  Engaging a n d being engaged in caregiving actions  Synchronizing mind-and-body through integrating view-and-action was one way in which awareness and action were linked for participants. Based on field experiences and conversations, the following themes point to how the practice o f repeatedly bringing one's awareness partially or fully to the moment helped shape caregivers' actions: o  Cultivating un/knowing....  o  Discovering more possibilities and opening new dimensions o f self and other  o  Doubling: Seeing differently  o  Realizing impermanence....  o  Resting with groundlessness and open spaces....  178  Cultivating  un/knowing:  Engaging  and being  engaged  without  predetermined  agendas  Through the practice o f mindfulness, participants described how predetermined expectations about people or situations were less solid and less frequent which opened up possibilities that would not have otherwise appeared. Cultivating a 'beginner's m i n d ' was seen as a way to enhance both awareness and compassion. When caregivers were open, without fixed judgements and expectations— there was tenderness and kindness in the fullness o f their availability to residents and one another. L i v i n g from that place was said to communicate to people on various levels, even though such communication was usually not verbal. This capacity to engage and to be engaged without an agenda was described as 'presence' and it assumed a depth inversely related to separating self from other. ...if someone comes in with some kind of depth of presence, then they can be talking about football but something else gets communicated. Like some people can say, "I don't know why, but I always feel good when you're here". A n d it doesn't have to be on the personal level. ...there may be some other level of caregiving that happens when someone is living from a deeper place and comes here [to volunteer]. Like Manuel, he is such a literal kind of guy, mundane details, mice and um, breakfasts and blah-blahblah. But there is no way that people can miss what's really here, what's in the room with him. And maybe if you asked they couldn't tell you ... but on some other level.... (Sophia) Presence as an aspect o f caregiving w i l l be discussed later; however, a notion o f presence arising in a non-personal space was reflective o f participants' perspectives and ontological views. A presence of'non-(self)-presence' or opening into a shared space without distinctions o f 'I am here' and 'you are there' permeated my experience with caregivers.  179  Some participants conceptualized unknowing or being without predetermined agendas as an important element in connecting with others, one that allowed an intimacy in engagement to occur. For example, in entering a space o f uncertainty, "Sometimes not knowing is the most intimate. There is something about trusting that....and recognizing that that is pretty demanding." (participant- Desmond) The paradox o f engaging in situations without a script was seen as acting wholeheartedly based not on convictions o f certainty, but in trusting in the moment  trusting one's direct experience. Desmond  also shared that acting without an agenda was guided by the caregiver's: 1) overall intention, 2) personal skills, and 3) intimacy o f engagement. Trusting in a doubling o f direct experience with skills and established guidelines could be uniquely beneficial, even though actions were not always conventional.  and if I feel more intimately connected.... I can just sit there all choked up...and maybe start to cry... and hold your hand... and both of us just sit there and cry...and neither of us has a clue about what to do. A n d I think that's very powerful...and I think that can be very helpful too... (Desmond) Spontaneity was the container that arose from the particularity o f a situation and the intimacy o f engagement amongst those involved. Being fully present and trusting the authenticity o f one's intention and skills allowed new possibilities for responding to residents' needs.  Discovering  more  possibilities  and opening  new dimensions  of self-and-other  This second theme can be interpreted as an outcome o f the previous one i n which caregivers experienced openness free from fixed thoughts. Participants described how being busy with goals and plans could obscure what was actually happening. When fixated on goals, they often missed what was right and left o f the path they were walking  180  on. Although goals or plans were not seen as problematic per se, and were akin to the importance o f setting one's motivation, the caveat came in not ignoring the richness o f momentary experience, which is all we ever have. Within the context o f caregiving, the suggestion is that the abstraction of care plans ought not to be conflated with attending to immediate experiences with residents, and knowing the difference as it occurs. Synchronizing mind-and-body in open spaces o f momentary experience also seemed to provide insights into the in/separability between caregivers-and-residents. Some participants saw this relationality o f self-other as key to empathy and compassion in care. Camilla, a Zen priest, explained that when we realize we are not separate but inter/dependent with others, there is a natural tenderness that arises. Because being harsh to others means being harsh towards oneself, such aggression tends to wane. This attitude was said by participants to evolve naturally through practicing meditation and was certainly supported in my experiences with caregivers and staff who embodied relaxed kindness. Interestingly, this kindness was not 'sweet' but had an edge o f directness based in the sort o f logic explained by Camilla: since we are interdependent, working for the benefit o f others also benefits oneself. Maybe part of the practice is becoming the boat for other people, for others and for yourself too,.... and then realizing that they are for you as much as you are for them, you know, you'll carry them to the other shore as they will carry you too... .maybe not at the same time... .maybe that's the best way I can put it... (Manuel) That's one other thing how close I can get to people I meet here and how close and intimate we become in such a short time It's almost like my mother. It's like everybody is close, it's not like they are strangers and that is really interesting....they really are not strangers...they are me in there....in that body....they are just like me in there, exactly the same (sigh).... And it's still surprising to me that that will happen to me... Just like the first day of nursing school. (Lauren)  181  In this way, it was felt that meditation practice served caregiving while caregiving served meditation in a doubling or co-emergence.  Doubling: Seeing differently When mind-and-body were synchronized, participants noticed how they saw things differently. They described noticing the qualities o f space and spaciousness when sitting with residents. They noticed things that they had not seen before, or simply saw the familiar as i f for the first time. A s their perceptions opened, a sense o f vivid appreciation and beauty arose. One participant described this as noticing the beauty o f life that was constantly emerging. H e also equated the elegance o f a Japanese rock garden and Zendo (meditation hall) with a particular kind o f spacious aesthetic where letting go and deconstruction could occur. Creating a physical and mental environment that supported a similar aesthetic so that 'noticing,' and 'letting go' could happen seemed to be part o f caregiving at Zen Hospice. Simplicity and attention to details created opportunities to 'see' and 'feel' the flower-ness o f a flower in space or the easing inward and dissolving o f a resident who was dying. Preparing elegant, simple meals, having bright, clean rooms, fresh flowers, incense, paying attention to the vital, immaterial space, and catering to the wishes and whims o f residents as much as it was possible contributed to an expansive environment that could accommodate suffering and peace. Meditation appeared to cultivate the ability to both see what needed to get done and to do what was called for in supporting residents. However, as residents began to deteriorate and withdraw, there were fewer needs while 'doing' became more invisible as the lines between doing/non-doing began to blur. Learning how not to fill the gaps with  182  busyness while leaning into the stillness o f whatever activity they were doing was a meditative aspect o f 'doing'. Sometimes when I give someone a massage, I can be completely there. And there is nothing else going on except that massage and that person. I'm serving that person and I'm completely without activity....and I think that gets across to the person because they are completely there too. ...we will be just a unit...we will be just one with this activity (Camilla)  While attending residents who were actively dying, caregivers engaged a variety o f meditation practices i n accordance with their Buddhist traditions. These ranged from sitting quietly without 'doing' anything, synchronizing breathing with the resident, generating an aspiration that the person be free from suffering and its causes, or doing traditional Tibetan tonglen visualization. Tonglen is a practice o f breathing in the pain and suffering o f another in the form o f black smoke and breathing back peace and ease in the form o f white light. When asked i f there were tangible impacts in doing these practices, participants responded in Buddhist fashion with yes-and-no. One caregiver suggested that just as anxiety and agitation are tangible energies that are perceived when someone enters a room, likewise generating loving-kindness and equanimity creates soothing vibrations that can also be felt. Over the years, silently engaging in meditation practices while sitting with residents, this caregiver found that people responded and would tell her things unexpectedly or, as happened recently, would say, "thank-you for blessing me." Another participant wondered i f tonglen actually affected change or i f it was developed for the benefit o f the practitioner. Although he had not witnessed benefits for the recipients, he thought this practice might promote the development o f synapses in the practitioner's brain, thus creating new patterns or habits. In this way, when encountering suffering, one might reflexively go towards it rather than  183  turning away. He believed this was an important step in developing habits o f altruism. Whether there was a direct impact did not seem as important next to the possibility o f transforming even a small amount o f suffering for another person. Again, intention seemed paramount.  Real/izing Impermanence A s inscribed earlier in the commentary, meditation rendered cracks in participants' illusions o f their essentially formed 'beingness' and opened gaps in experiencing themselves as change(ing). When they brought awareness to an object and managed to stay with it long enough, they noticed that the phenomenon or object began to change; it wasn't what they thought it was. They could see the qualities o f impermanence and mindfulness from moment-to-moment. Or, as one participant said prophetically, the only permanence is impermanence. Such embodied realization o f transience was said to diminish fear and led to an understanding o f dying as no longer tragic but a natural transitioning into spaces o f unknowing. Death was seen by some as an opening for transformation that contributed to the view o f hospice care as meditation in action. W e start to see...more deeply...the truth of our experience...and as we do this, our fear diminishes, so.. .we start to see the truth of change... (Gary) ...there is so much mystique about death and that it's special and there is a special opportunity in dying...the whole energy of transformation and shedding the ego...shedding the layers of separation....ideally, it can happen in dying. Maybe it is more conducive to practice being so close to it, because it is like practice...dying is, the process of dying itself is like meditation.... (Sophia)  184  It may be that experiencing the parallels between meditation and dying cultivated a level o f comfort with dying that, for some, allowed them to be more courageous in talking with residents about their dying and death. Some participants maintained that they could speak from a place o f dealing with their own fears that helped them see openings with residents in which they could invite discussion about dying in a manner that was fearless and straight-forward. " A r e you interested i n what will happen during and after death? H o w is it for you? What do you believe in?....do you have any spiritual beliefs?....do you believe something happens when you die?" (Lauren) In contrast, fear of death and social taboos were also evident as some caregivers recounted situations o f closing off from residents and subtly not being available. What was unique, however, was the acknowledgment o f this turning away. Bringing their fears and hesitations into the light o f awareness was an aspect o f meditation/caregiving practice and in doing so, created openings for other possibilities.  Resting  in groundlessness  and open  space(s)  M a k i n g impermanence real, or real/izing the inevitability o f death allowed space for entering into the shaky ground o f fear. Fear manifested on many levels including the blatant example o f a new volunteer who refused to engage with a resident's fear o f dying on account o f her own discomfort. When this incident was shared, one participant interpreted this volunteer's action as a form o f abandonment while others saw the process of learning to engage and remain engaged in situations that are uncomfortable, emotionally intense, and frightening as a part o f the ongoing practice o f meditation in action that is supported through formal meditation practice.  185  More subtle aspects o f fear were identified including holding on to hopes, often subconsciously, that residents would get better and carrying this attitude into the room. Some caregivers felt that being mindfully present allowed them to let go o f both hoping and fearing about the situation and to be completely available to what is happening for residents. T o be without hope, in this sense, was to let go o f wishing things were otherwise and fearing what might be; entering a space without hope or fear allowed participants to be open to whatever was happening now. Participants queried whether we as caregivers, in general, are willing to situate ourselves in a place where there is no hope and accept that that is okay... .really okay. Are caregivers able to stay with and be engaged in groundlessness and transitioning? Can we open to and witness the suffering o f another when there is fear, struggle, resistance, or chaos arising? Participants saw the 'work' o f meditation/caregiving as subtly exploring these questions in order to recognize resistance, separation, fear, and practice abiding t/here with another. I was thinking of Aretha this morning, she was kind of scared. And I really think creating an atmosphere where we are not scared when she is scared; we are just there with her. A n d we don't necessarily do anything with the fear. W e don't say, 'no, no, no' but we don't say, ' Y E S , you're dying, dh how horrible' but we just kind of embrace that—then, it's much easier for people you know. And I think that in itself, to be mindful that somebody is afraid and not to reject it, not to sugar it over with something but also not to be freaked out. But to really be with that feeling and to embrace it and to feel from our heart and appreciate and love the person, that fearful....little body. Y o u know? Then, it seems that usually the person can....can relax. (Lauren)  Through mindfully being present, some created atmospheres where they were not afraid when the resident was. fearful.. .but were just there — not doing anything with the/ir fear. The practice was in being able to stay, opening to the experience and noticing  186  when they turned away and its resultant impact on others in the situation. The therapeutic use o f mindfulness seemed to be in becoming intimate with fear through direct experience that could provide meeting places for others who were afraid. The emphasis was not on perfecting performance in providing care, but rather on practicing to continuously open and be willing to shift, and be changed i n the process. Communicating one's humanness in the ups and downs o f this process was seen as an aspect o f compassion and letting go. For example, ordinary actions like resistance to walking into a new resident's room was considered a practice o f staying present in a space o f mutual vulnerability; staying open in the face o f turning away and making mistakes. Y/our humaness is not a problem.... And in a wonderful way, y/our humaness is an asset....all of it...And when that comes into the room, it's like magic...magical things happen....it's qualitatively different. (Desmond)  In sum, caregivers appeared to have a pragmatic approach in accepting a level o f empiricism while also recognizing that we cannot fully know. They were not paralyzed from action; rather, actions were tempered by 'knowing' that we 'cannot know fully' yet must act as best we can in the face o f such impossibility. Action and inaction were doubled in a view o f in/separability and our shared human fate. These kinds of thinking are what's become the lore and teachings around hospice care. Everything from...entering the room to be there fully, to trusting the intimacy and connection that goes along with not always knowing what you're doing.... Dying .... it opens hearts....  (Desmond)  187  VERSE Following the structure of koan collections, the commentary  which has ended for  now, is followed by a verse. But first to recollect the koan once again.... K o a n Case Stan has been living with A I D S for over twenty years and has practiced Zen meditation for almost a decade. Over the last few years his eyesight has drastically diminished and he uses a cane more often than not. Despite a recent diagnosis o f lymphoma, he remains light-hearted and continues to attend regular meditation meetings at a Zen center. Dying is interesting, he explained, i f you look at it from a Buddhist view, there's death every mind moment. So, it's just compressing it or expanding it and time is the duality.. ..Meditation is like dying, he continued. First you start with a lot o f discursive stuff and a lot o f fast activity. Then you slow down and settle; eventually your body starts disappearing at the edges. Next your mind goes, and that's what happens i n death  Verse  dying meditating , where are we in transitioning(s)? suddenly awakening into death, momentarily, into open skies o f life complex, yet simply what is, staying with, abiding arising and passing away... minds meeting in/separable in spaces o f unknowing abiding in thresholds where all possibilities await, at the edges  188  STRAND FIVE ~ DISCUSSION AND IMPLICATIONS  Child's Concept o f Death Warrior's die and are born. So do swallows die and are born. In this blue sky— sun shines, moon sets, anything could happen. Maybe the rhododendrons never die. Juniper should not die. I will die one day maybe without knowing.  Chogyam Trungpa  DISCUSSION The inquiry began with a question o f how mindfulness meditation practice shaped the experience o f living/dying for both caregivers and those living with life threatening illness. This fifth strand weaves a discussion o f how the Fruition is inter-connected within a larger project o f nursing inquiry and theorizing. In particular, interpretations o f presence/absence, un/knowing, and living/dying are discussed in relation to current nursing writing(s). Finally, implications for hospice care, nursing education, and future inquiry are explored.  Situating within a broader context of philosophy in nursing  In many ways, this inquiry is philosophical in nature as it configures how some people experience and understand self/other and reality within liminal spaces o f living/dying. Nursing has a long lineage o f philosophical thinkers who have struggled with ontological questions from diverse perspectives. Such diversity can be seen as a healthy sign o f debate or, as i n some cases in nursing, as problematic diversions. The clarion call for metanarratives or a single, agreed-upon truth in nursing, is still heard. K i k u c h i , Simmons, & Romyn (1996), from the Institute for Philosophical Nursing Research , call for agreement on a conception o f nursing truth which they feel is 42  necessary i f the discipline o f nursing is to flourish. They urge nurses to come to agreement about which kinds, measures, and expressions o f truth are appropriate i n nursing inquiry and in so doing, to begin conceptualizing a nursing truth i n which  The Institute is located at the University of Alberta, School of Nursing, Edmonton, Alberta, Canada.  190  knowledge can be organized. These nurse philosophers claim that without an adequate conception o f truth, nursing knowledge and development w i l l be scattered, resulting in the eventual demise o f the discipline. Clearly, K i k u c h i et al. value unity and congruence, and perceive the pursuit o f incommensurate positions as not only problematic, but ultimately leading to the "demise" o f the discipline:  What would the pursuit o f nursing truth entail? For one thing, it would require that we make up our minds about such basic matters as the nature o f reality, the nature o f human cognitive powers o f knowing, and the nature o f truth and knowledge. Either reality is knowable or it is not. Either humans can attain objective knowledge or they cannot. Either knowledge is a matter o f truth or it is not. Common sense would say that we cannot have it both ways. Yet it would seem that some nurse theorists must think otherwise when they claim that reality is unknowable, that attainment o f objective knowledge is impossible or that falsity and error are irrelevant matters in attainment o f knowledge. Surely, in their everyday lives, they do not find themselves operating under such beliefs (p. 152).  A s recognized scholars, Kikuchi et al.'s either/or perspective and 'common sense' approach is widely respected in nursing. Although I find oppositional thinking unsettling, it is in the disruption o f my own contrasting position where dialogue and debate are invited. This inquiry provides an alternative position(ing) and exemplifies how some people, in their everyday lives, live in spaces where reality is simultaneously un/knowable—where knowledge is a doubling o f relative/ultimate truth(s). For participants in this study, 'things are not always as they seem, nor are they otherwise' (Lankavatara Sutra), hence their 'common sense' suggests that we can, and do, have it both ways. This inquiry joins other voices i n maintaining a healthy diversity in nursing dialogue within a plurality o f reality(s) and truth(s) that co-exist.  191  Resonance and disjuncture in nursing theorizing  In preparing to write this strand, I re-read memos, quotes, and scribbles jotted down during moments o f inspiration. Interestingly, some notes seemed to be either written by someone else, as I no longer followed or gleaned what must have been stirring and fresh at the time; or conversely, I was drawn into the writing and wished I had gone further. Either way, I marveled at how ideas 'speak' to us at different times and how that 'calling forth' is heard across disciplines and philosophies. L i k e Indra's net, in/visible strands o f ideas are inter-connected and can be recognized despite differing disciplinary contexts. A n example o f these interconnections between nursing theorists and Zen Buddhism recently became apparent. This interconnectedness began arising while re-viewing some o f the early nursing theorists including Paterson and Zderad (1976), Benner and Wrubel (1989), and Parse (1987). These theorists, more philosophically attuned to the concerns o f this inquiry, grappled with existential questions o f what it is to be a person and how nurses can engage with others in their health, illness, and dying. M u c h o f their work resonates with my experience at Zen Hospice and the mindfulness lens used there. In particular, Paterson and Zderad (1976) were the first to emphasize the importance of'presence' and "existential awareness o f self and o f the other" (p. 3) in nursing literature. They introduced a mutual and transactional aspect o f human existence where transaction inferred an "aware knowing" (p. 122) o f one's effect in situations between persons. Although ' s e l f was described as relationally constituted, they maintained, as do most Western theorists, an emphasis on individuality rather than relationality. Even so, Paterson and Zderad also pointed to a 'doubling' o f sorts:  192  Existential experience... calls for a recognition o f each man as existing singularly in-his-situation and struggling and striving with his fellows for survival and becoming, for confirmation o f his existence and understanding o f its meaning. So, "all-at-once," while each man is unique; paradoxically, he is also like his fellows. H i s very uniqueness is a characteristic o f his commonality with all other men (p. 4). Their prescient theory, Humanistic  Nursing  (1976), proposed that nurses  consciously and intentionally approach nursing as an existential experience, suggesting existentialism as an "awareness o f self and otherness"(p. 4) and a doubling that recognizes human capacity for sameness-and-difference simultaneously. Although 43  awareness o f oneself and others transactionally is accentuated, the authors do not explore the phenomenon o f awareness per se, or how it is cultivated. The notion o f liminality is also introduced by Paterson and Zderad (1976), although not identified as such, in their focus on where  nursing happens rather that what  it is. "Nursing is an experience lived between human beings" (p. 3) "and [humanistic nursing] is concerned with 'the between' o f nurses and their others" (p. 44, parenthesis added). Drawing on Martin Buber's (1958) notion o f ' I - T h o u ' , 'the between' refers to a merging o f nurse/patient boundaries into a space o f authentic presence, while maintaining one's capacity to question. Interestingly, Martin Buber was well versed i n East A s i a n philosophy and translated one of the classic Taoist texts, Chuang  Tzu,  into German in  1910 (May, 1996). Although any direct influence is purely speculative, I wonder how Buber's contemplation o f Taoist and Zen nonduality shaped his configuring o f 'the between' that was later adapted into humanistic nursing theory:  See May Solveig Fagermoen (1999) for a discussion of the philosophies of humanism and caring; Fagermoen suggests that the roots of humanism have established nursing as an intrinsically moral practice guided by the motivation to act in the best interest for those in need of nursing care.  4 3  193  When I reflect on an act o f mine (no matter how simple or complex) that I can unhesitatingly label "nursing", I become aware o f it as goal-directed (nurturing) being with and doing for another. The intersubjective or interhuman element, "the between", runs through nursing interactions like an underground stream conveying the nutrients o f healing and growth. In everyday practice, we are usually so involved with the immediate demands o f our "being with and doing with" the patient that we do not focus on the overshadowed plane o f "the between". However, occasionally, i n beautiful moments, the interhuman currents are so strong that they flood our conscious awareness. Such rare and rewarding moments o f mutual presence remind us o f the elusive ever-present "between". (Paterson and Zderad, pp. 21-22)  This perspective resonates closely with the intention o f inquiry participants at Zen Hospice to serve through being mindfully open and present where mindfulness is everpresent—not something we do, but w/here we relax into. Likewise, Paterson and Zderad's sense o f appreciation and well-being arising from such awareness is shared by Zen Hospice participants. Paterson and Zderad (1976) emphasize the content of mind rather than an interplay o f conceptual and nonconceptual awareness. For example, i n developing humanistic nursing, it is said to be essential to explore and describe the intersubjective character o f in-between experiences. This is significant, the authors argue, in order to better understand how our interactions with others can have both humanizing and dehumanizing effects. The emphasis on description is contrasted by the focus o f participants in this inquiry who engage i n mindfulness  Do the orientations of duality and non-duality shape nursing practice in tangibly different ways? Or, does cultivating awareness of the "elusive ever-present between" simply render an environment of appreciation, allowing one to see things differently, softening the edges, and providing space to let go? Are the inquiry participants and Paterson & Zderad pointing in the same direction? For participants, it seemed the context of their hospice care was affected rather than the content.... and that context/content cannot be separated  practice, both formally and informally, i n cultivating awareness o f shifting conscious awareness. In doing so, it was believed that moments o f  194  non-discursive awareness would increasingly open. Or, to put it differently, the separation o f ' I am here' and 'you are there' would dissolve into ever-present awareness. Both approaches are complementary yet located differently; humanistic nursing emphasizes a duality o f articulation while mindfulness awareness engages nondual liminality. Even so, Paterson and Zderad (1976) were ahead o f their time. Humanistic Nursing was not widely accepted with its rejection o f determinism, reductionism, and modernist positivism ( K i m , 1999). In the academic milieu o f the early 1980s, nursing was attempting to legitimize its position as a discipline o f science privileging the natural sciences o f medicine over what became known as human sciences. However, a decade later, the mood had changed; nursing science's position on 'the person' (as a bio-psychosocial-spiritual being composed o f components continuously interacting with each other and the environment), was challenged by nurses integrating existentialist and phenomenological views. In particular, the work o f Benner and Wrubel (1989) contributed significantly to the discussions o f what it means to be a person, drawing primarily on Heidegger's (1962) work. Until then, Edmund Husserl (1859-1938), another German Philosopher (18591938) and founder o f been widely influential in constructions o f 'person' Oiler, 1982; Ornery, 1983). due, in part, to his Cartesian  Q. A r e you weaving a story to contextualize 'presence' in nursing theorizing? A . yes.... you could say so...  phenomenology, had nursing (Benner & Wrubel; Perhaps this was  Q.  Is this a metanarrative too? views that assumed  A  a stable, essentialized ego/self where mind, as a subjective consciousness, contained ideas  195  that corresponded, or not, to what 'factually' existed i n the world. Based on these assumptions, one can sympathize with K i k u c h i et al.'s (1996) convictions that humans can either "attain objective knowledge or they cannot" (p. 152). Husserl's views suggested a 'naive realism' and representational perspective that remains a powerful view in nursing as discussed earlier (see pgs. 8-11). However, this view was challenged by his student Martin Heidegger (1889-1976) , and subsequently adapted by nurse theorists 44  including Benner and Wrubel (1989) and Parse (1989). In brief, Heidegger (cited in Payne, 1997) challenged the view o f an essential ized self independently existing, by proposing self as arising through the act o f relating. According to Heidegger, a person becomes defined not as a transcendental ego as Husserl asserted, but as a self-interpreting being constituted through the process o f living. Further, when immersed in momentary happenings o f life, a particular kind o f knowing occurs that is nonreflective and beyond abstract, conceptual thought. A person has "an effortless and nonreflective understanding o f the self in the world" (Benner & Wrubel, 1989,  p. 41) where self and world are inextricably linked. A s you can see, these notions  correspond with the perspectives suggested in this inquiry with mindfulness as one way of accessing such nonreflective  experience.  Shortly after reading Benner and Wrubel (1989) with renewed interest, I was referred to Reinhard M a y ' s (\996j Heidegger's 45  on his work,  hidden  sources:  East  Asian  influences  that examines these influences and Heidegger's close association with Zen  Buddhism:  Refer to Varela, et al (1993) pp. 15-31, for an historical overview and critique of phenomenology in relation to non-western philosophical traditions. Husserl was a major influence on thinkers such as Merleau-Ponty and Sartre, who in turn have been major influences on nurse theorists. 1 would like to thank Dr. Ted Aoki for introducing me to May's (1996) text.  4 4  45  196  Heidegger's thinking definitely exhibits not insignificant similarities with East Asian thought. A n indication o f this comes, again, from Hsiao, who writes as follows: 'much o f what [Heidegger] has "brought to language" has...been said often in the same or a similar way in the thinking o f the Far East'. While these kinds o f thinking are gradually coming to the attention o f Heidegger Studies in Europe, they are rarely given further discussion. N o r has there been much response to the astonishing fact that the reception o f his thought in Japan has been for over sixty years as thorough as it has been comprehensive— a fact that can and should be taken as importantly indicative o f Heidegger's relations to East Asian thought (p. 5). .... Otto Poggeler has written that he [Heidegger] gladly acknowledged to visitors the closeness o f his thinking to the Taoist tradition and Zen Buddhism (p. 5).  Although Heideggerian thought and phenomenology have exerted considerable influence in nursing theorizing, East Asian inter-connections have not been made explicit. This is not surprising, since only recently have textual comparisons (May, 1996; Parkes, 1996) convincingly argued that Heidegger's formulations o f Being, Nothing, and the complex relations with/in language, were influenced by his readings o f Taoist and Zen texts and collaboration with some o f Japan's foremost philosophers during the 1920s. This revelation becomes important here for several reasons. First, the interpretation o f Heidegger (1962) and subsequently Benner and Wrubel (1989) and others, takes on a new spin and suggests the need for what M a y (1996) calls "transcultural thinking" that behooves us to devote ourselves "to non-Western thinking as thoroughly as to that o f our own tradition"( p. 57). It also points to a false binary between Eastern and Western thought and reminds us o f the in-between spaces o f hybridity and Indra's net o f inter-connectedness. A n d finally, it challenges the position o f the uniqueness o f disciplines in isolation from other sources o f knowledge. It is in these hybrid spaces, rather than in opposition, that the following discussion o f how re-  197  configurations o f presence/absence, living/dying, and knowing/ unknowing are situated within nursing.  Presence / Absence Although 'presence' is an important aspect o f nursing that has been addressed in nursing literature in recent years, it has not been studied extensively. Nevertheless, the capacity to bring one's awareness fully to a person who is dying and their family is a vital ability that is widely recognized in nursing texts (Gardner, 1992; Gilje, 1992; Osterman & Schwartz-Barcott, 1996). In addition, the importance of'presence' is reflected i n the recent Hospice Palliative Care Nursing Standards o f Practice (Canadian Palliative Care Association—CPCA Nursing Standards Committee, 2001 ) . nurses are held to the standard o f presence  CONNECTION  46  Specifically, palliative care  through demonstrating "a sense o f true  by continual, unconditional acceptance and tolerance" (p. 15, italics added).  Where does a reconfiguration o f presence as mindfulness awareness resonate and/or disrupt current notions o f presence in nursing? Resonance and dissonance with current literature A s suggested earlier, Paterson and Zderad (1976) catalyzed interest in the importance o f presence in nursing care. They saw nursing as a lived dialogue that involved 'doing with' and 'being with' the patient. Although this inquiry lends support to many o f the perspectives in Paterson and Zderad's work, there is also dissonance. For  C P C A (now Canadian Hospice Palliative Care Association) Nursing Standards are based on The Supportive Care Model (Davies & Oberle, 1990) that identifies six interwoven dimensions. These six dimensions form the basis for standards of care in clinical palliative care nursing and include: Valuing, Connecting, Empowering, Doing for, Finding Meaning, and Preserving Integrity. The second standard— Connecting states "The hospice palliative care nurse establishes a therapeutic connection (relationship) with the person and their family through making, sustaining and closing the relationship" (CPCA, 2001, p. 15). 4 6  198  example, in humanistic nursing, 'presence' involves knowing patients phenomenologically and co-experiencing their worlds (Minicucci, 1998) in the context o f their health care. The difference between such perspectives and the fruition o f this inquiry is both in degree and in kind. For example, in M i n i c u c c i ' s (1998)  / wonder what discursive space is being generated here? Moving towards a comparative analysis of how mindfulness as presence is similar to or different from other conceptualizations of 'presence' feels problematic. Why? Perhaps it is the emphasis on 'what it is"? What is the 'thing' of mindfulness presence? How is it the same and different? Although a useful discussion, and conventionally an expectation...there is a sense of falling into a closed space of defining and carving out territory with as much certainty as I can muster....  interpretation, the focus is on 'knowing' and having a shared sense o f experience. Moreover, nursing theories using holistic approaches see the nurse's role as learning about the meanings patients attach to certain experiences and how to facilitate, through dialogue, a re-construction o f meaning as the patient's life circumstances change. (Paterson & Zderad, 1976; Watson, 1985; Parse, 1987). While creating meaning and finding ways to understand chaotic, groundless experiences is known to be beneficial, it also aligns with the dominance o f epistemic knowledge and knowing in modernist,  This view does not reject knowing but questions the dominant view of valuing knowing over un/knowing. If we cannot know, how do we live well in these liminal spaces between nurse-and-patient, between nurse-and-families, between nurse-and-nurse?  Western traditions. The privileging o f knowing and meaning often ignores the role and importance o f unknowing—that is, resting directly in prereflective experience. Frank (2001) recognizes this hegemony o f meaning in situations that are unable to be spoken. He describes his fears o f health care professionals who would seek to explain (away) his suffering rather than encounter directly its groundless  199  incomprehensibility. A recent study by Davis, Wortman, Lehman, and Silver (2000) also suggests, contrary to previously held beliefs about grief, that finding meaning may not be a necessary element o f recovery for all mourners. Similarly, mindfulness awareness moves beyond an hegemony o f knowing, into spaces that equally acknowledge un/knowing, self/lessness and no/thingness. This leads to sites o f 'self/other' or, T-Thou' that include our in/separability while maintaining the ability to continue questioning. Although humanistic nursing points i n these directions, this inquiry lingers longer in these sites and spaces o f doubling. This lingering, or difference in degree, is one significant way in which presence is constituted differently. Other resonances and disjunctures are found in the work o f Benner (1984) who identified presence, or 'being with,' as one o f eight competencies held by expert nurses. Based on interviews with experienced, expert nurses, presence was considered therapeutic and healing for patients. Conceptualized as a quality, presence was demonstrated by touching, allowing venting o f feelings without verbal response, and face-to-face contact. Noteworthy, however, is how presence was seen to occur only when patients were stabilized, and nurses' attention could expand from the narrower physiological domain to the whole person. In this way, presence was constructed as an intervention akin to 'the therapeutic use o f s e l f (Fuller, 1991; Mohnkern, 1992; M i n i c u c c i , 1998) that could be engaged when a patient was no longer critically unstable and physiological concerns no longer took precedence. Benner (1984) does not emphasize a mutuality or interdependence between nurse and patients. Although not the intention, this omission minimizes the context o f a relational space and can lead to an instrumentalist view o f presence as embodied i n one's  200  ' s e l f as a therapeutic tool to be applied in nurse-patient encounters. M o c h and Schafer (1998), for example, caution nurses to attend carefully to cues from patients to avoid "forcing a presence encounter" (p. 165). Even though these authors cite Paterson's and Zderad's (1976) work in their definition o f presence, their remarks infer presence as something that can be forced upon another. In contrast, participants in this inquiry engaged presence not as something brought to a situation, but rather as a letting go into [the] presence that is always t/here.  From the Buddhist views of participants, the 'self and 'presence' are seen as metonymic; that is, the presence of self is beneficial through its absence, leaving unfettered awareness. More simply, an absence of self renders a space of presence with another. This space of absence/presenceseeing the presence in absence, is a reconfiguring that does not value presence as an entity over absence, as is found in most nursing literature....  Similar echoes o f openness and a commitment to stay in the moment with patients and families through the sometimes difficult process o f dying is found in mindfulness and notions of: 'I-Thou' (Paterson & Zderad, 1976), 'being-with' (Benner, 1984), 'shared vulnerability' (Pettigrew, 1990), 'holistic presence' (Easter, 2000), and 'healing presence' (Godkin, 2001). However, mindfulness differs both in how ' s e l f is constituted, and subsequently, its role and relation to presence. A reification o f presence is also noted in the typologies o f Osterman & SchwartzBarcott (1996) and Easter (2000) where mind and body are separated into: body-to-body (physical presence), mind-to-mind (therapeutic presence), and body-mind-spirit (holistic  201 \  presence). Easter's 'holistic presence' resonates most with mindfulness awareness in its integration o f mind-body-spirit and reciprocity between nurse and patient towards a "mindfulness and equanimity with self and other" (Watson, 1999, p. 155). Easter also identifies meditation as a technique for fostering holistic presence. Although holistic presence, as such, is not described in the literature, Easter moves away from inter subjectivity towards a more Eastern view o f transpersonal space in nurse-patient encounters.  47  Overall, an instrumentalist view o f presence as a tool or heuristic is questioned here. Whereas this inquiry emphasizes a dynamic space o f awareness between caregiver and resident and a doubling o f self/other, this engaged quality is not as evident when presence is 'applied' to situations. A s an intervention, nursing risks becoming the implementation o f therapeutic actions, rather than "an experience lived between human beings" in becoming as human as possible in particular life situations (Paterson and Zderad, 1976, p. 3). More importantly, nursing as an intrinsically moral practice risks being forgotten under the weight o f 'doing for' and 'knowing what we do' that leaves little room for what is not yet known or unknowable in each encounter.  Abraham Maslow, one of the first psychologists to explore and promote transpersonal psychology believed that there are states of awareness in which human beings transcend the ordinary limits of individual identity and experience. Transpersonal dimensions of experience include those that leave one transformed; experiences that are impossible to explain to others, if not to ourselves, that alter the very fabric of one's being in the world (Valle, 1998).  4 7  202  Knowing / Un/knowing Un/knowing, as a state o f mind, is intrinsic to mindfulness awareness; the slash disrupts, pointing to a metonymic space between knowing-and-unknowing. San Francisco Zen Center, also called 'Beginner's M i n d Temple', illustrates the importance of un/knowing in Zen. 'Beginners mind' implies a mind unfettered by preconceptions, ready to accept and doubt, and open to all possibilities. Therefore, as Buddhist practitioners, study participants cultivated beginner's mind through meditation in order to see beyond pre-determined stories about what is, or ought to be. Instead, they practiced simply resting with whatever was arising.. .seeing what was happening...being curious.. .not identifying with thoughts yet seeing them as thoughts.. .meeting each moment with residents, letting go o f expectation. Such was the aspiration for meditation and hospice care. In nursing, Munhall (1993) and Silva, Sorrell, and Sorrell (1995) offer a perspective that encourages nurses to consider a shift from patterns o f knowing to ways of being. Sorrell et al. describe two ways of'knowing-being' called the 'inexplicable' and the 'unknowable.' In brief, inexplicable and unknowable ways o f knowing are described by these authors in an example o f searing grief from a mother who witnesses her four year old daughter killed by a car. Such grief, claim the authors, occurs both in nursing and i n life. It is an experience that is profoundly felt, yet often inexplicable and, for those who have never experienced it, it is unknowable. Munhall (1993) introduces 'unknowing' as a condition o f openness required in order for authentic presence to occur. Unknowing is viewed not simply as a gap in knowing that must be filled, but as an art not presently acknowledged, and another way  203  of knowing that determines knowing. After all, knowing that we do not know, and recognizing what does not fit into pre-existing theoretical understanding, opens one to learning and new possibilities. Munhall called for unknowing to be recognized as a fifth pattern o f knowing, adding to the ways o f knowing reflected in Carper's (1978) Fundamental  Patterns  of Knowing  in Nursing.  Little response was found i n the literature,  with Heath (1998) supporting Munhall's view o f unknowing and integrating it into steps for reflective practice. However, although acknowledging the importance o f unknowing, Heath's focus is on the openness, equated with unknowing, and its relationship to attaining knowledge, rather than unknowing itself. In the Zen context o f hospice, un/knowing was cultivated through mindfulness while Munhall (1993) proposed a process o f de-centering or temporarily suspending the self as "the nurse allows the patients' subjective structure o f reality to become known" (p. 126). Interestingly, Munhall's unknowing seems congruent with mindfulness awareness in many ways and yet differs slightly. Again, the emphasis for the nurse is said to be allowing "the patient's subjective structure o f reality" to be known. Mindfulness awareness seems broader; as I search for words to describe how much broader and what else may be encompassed,  I sense the diminishing returns o f such efforts. The  underlying assumptions are different from the outset; study participants assumed a relative subject as subject/no subject. Where does that leave intersubjectivity? Munhall (1993) draws on Atwood and Stolorow's  ^  "Intersubjectivity is not a difficult concept to understand...What is challenging is practicing it in a wide-awake manner."  (1984) notion of'intersubjectivity' as the interplay o f one  (Patricia Munhall, p. 126) organized verbal and non-verbal subjective world  204  encountering another. H o w one temporarily suspends the self in this encounter is not addressed; however, Munhall's "intersubjective space" is also referenced to Paterson and Zderad's (1976) 'in-between'. Within this space, Munhall suggests that understanding, empathy, and conflict arise, pointing to similar notions o f liminality. Whereas Munhall acknowledges the challenge, although not an approach, o f being awake to intersubjective experience, study participants practiced mindfulness to intentionally cultivate being wideawake. U n / K n o w i n g or how we can know yet not know or be unable to explain or define, are pertinent in our discussion o f living/dying and caring for those in the midst o f living their dying. B y introducing possibilities o f an ambiguous space in the gap in-between living and dying, and un/knowing, nurses can assist patients and themselves to simply rest in this open space, from which new meanings may arise. Our usual compulsion to make sense o f experience is said to be a natural resistance to unknowing (Kurtz, 1998) and is countered by mindfulness practice. Learning to stay open allows room for everything, including the anxiety o f not knowing. Those who are chronically i l l , struggling in a space o f uncertainty or dying may benefit greatly from nurses who value this ambiguous groundlessness o f life that is always changing, and can be appreciated along with the security o f certainty. In order to constitute and reflect knowledge(s) about that which is unknowable, indistinct, and ambiguous, nursing w i l l benefit from diverse philosophical sources. A s practitioners and inquirers we need to go beyond dualistic views towards a multiplicity o f contexts that provide guidance for abiding in the midst o f difficulty, in the midst o f that  205  which is beyond knowing. Herein, non-modernist traditions such as Buddhism are particularly useful. Towards this end, this inquiry lends support to Munhall's (1993) call for recognizing un/knowing as an important way o f knowing in nursing. While human experiences o f change, dissolution, illness, and suffering often resist articulation, the process o f 'abiding with' rather than identifying [what is happening] is also a nursing option. Although patients and families may at times be unable to locate or describe what is happening as they face their dying, nurses can still be t/here in that liminal in-between space — wherever that is, within each encounter. Not knowing what to say or do can be a skillful and compassionate way o f being with patients, i f one can abide there with ease, with the best interests o f the patient in mind.  Re-configuring death This inquiry suggests a re-configuring o f living/dying that is different from Western perspectives where ' l i v i n g ' holds hegemony over 'dying'. Death, re-interpreted in the Buddhist sense o f participants, is also a momentary experience occurring each mind-moment; life is not necessarily privileged over death but rather is seen as a doubling o f life-and-death intertwining within momentary awareness. While not denying biological death, death is not interpreted as a finite end, but is situated in the midst of—'\n a liminal space o f being/not being and ubiquitous change. In addition, mindfulness meditation practice is seen as a parallel process providing an embodied realization o f this transience. Such realization is felt to diminish fear and open an understanding o f dying as  206  no longer tragic but a natural transitioning into places o f unknowing. In short, dying could shift from a discursive space o f tragedy into one o f curiosity and inter-rest. However, most nursing literature on death and dying is grounded deeply i n the body. In Western biomedical constructions, the brain is the source o f mind (awareness, cognitive functioning) and what constitutes us as 'persons'. When vital organs cease to function and physical and chemical processes required to sustain life end, a person is considered dead. Or, when a person's brain is vitally damaged, as in irreversible comas, the person is also designated as dead, or more precisely, as 'brain dead' (Miller & Keane, 1987). Complex questions about 'when death occurs' and 'where death occurs' are currently driven by technological capacities to artificially sustain vital organ functioning, advancements in organ transplantation, and pluralistic views on what constitutes death. Consequently, what was previously a clinical judgement—you were either dead or you weren't— is replaced by an ongoing re-construction o f death. Reconfiguring death as a momentary experience in every mind moment may be particular to a Buddhist view (Levine, 1982; Longaker, 1997; Lief, 2001) — similar views were not found in nursing literature. Bonadonna (2000) was the single nursing study found that specifically examined mindfulness practice and living with life-threatening illness. Bonadonna used a Grounded Theory approach to explore the process o f 'managing' cancer with mindfulness meditation. The perspective o f life-and-death in every mind-moment was not addressed. However, the study shows parallels with this inquiry in its descriptions o f how meditation influenced participants' interpretations o f what was happening to them. They reported less resistance to the natural cycle o f living and dying, appreciating both the pain and pleasure inherent i n life, and feeling more  207  equanimity in facing mortality. Realizing impermanence was identified as the central phenomena o f interest. While Bonadonna (2000) joins others (Kreitzer, 1989) in recommending that nurses assist patients to explore mindfulness as a self-help strategy, this inquiry cautions against an instrumentalist view o f mindfulness meditation in this way. A s a 'strategy,' there is an undercurrent o f ambition and hoping to achieve a particular outcome from mindfulness—usually the relief from some form o f suffering. However, without a context of mindfulness as both a method and not a method, meditation may be used to hold on rather than letting go. According to the Buddhist view from which mindfulness stems, the practice o f directing attention is not intended to remove suffering but to open to it. In constructing mindfulness as a tool for self-help, nurses may be decontextualizing the practice and circumventing the potential benefits the practice may provide. There is insufficient inquiry into mindfulness meditation to support or deny these concerns, however Hayes and Alexander (2000) reported i n a survey o f 202 Connecticut nurse practitioners (NPs) that meditation was the second most highly recommended alternative 'therapy' referred by N P ' s with 11.4% o f nurses providing meditation instruction in their offices. Meditation is rapidly entering the domain o f nursing practice. Is meditation being co-opted into a system o f (spiritual) materialism that w i l l limit its capacity to benefit those who practice it? Further inquiry into how mindfulness is currently constituted within health care and its impact on patients is warranted.  Living/dying  208  Although living/dying experienced as mind-moments was not seen in the literature, constructing life-and-death as inseparable phenomena has been expressed many times before. One o f the central tenets o f hospice and palliative care is that dying is part o f living. While a terminal diagnosis often means the end o f meaningful life from a medical standpoint, hospice philosophy conceptualizes dying as a stage in the human lifecycle, like adolescence and advanced age, where the potential for growth continues (Byock, 1996). Although conceptualizing death in this way may help 'normalize' the dying process, it also leaves open the process o f standardizing what 'growth' or developmental milestones are occurring in this life transitioning. Modernist penchants for categorizing have led to binaries o f ' g o o d ' and 'bad' deaths (see Bradbury, 1999), and the double-edged sword, o f developing new knowledge to better serve those who are dying, that cuts both ways. Attempts to create meaning and order out o f what may ultimately be meaningless, nonsensical, and unknowable, may also be motivated by the wish to alleviate our ultimate lack o f control and vulnerability o f not knowing. Such efforts may add to our understanding o f the dying process but never address the underlying conundrum o f living well with the im/possibilities o f death. Rather than asserting a position o f knowing what is best for someone and 'managing' their dying, hospice philosophy incorporates a deeply embedded view that each individual has a unique response to his or her dying experience. The practice o f meeting people where they are, and engaging without an agenda, has been part o f the aspiration o f palliative care nursing. However, this is more easily said than done and this inquiry contributes to practices and discussions in this area. Linda Durkee, education coordinator for Casey House Hospice in Toronto, shares:  209  Caring is a nebulous kind o f thing, especially when dealing with death and dying...I don't know how to describe care, and I'm a relatively articulate person. It's a way o f being, a way o f being present with people—where they are. A n d it's really hard for us to go where some people are.... There are some people who can do it; but I don't believe there are a lot. I do believe that it involves life-long education, It would be my dream to figure out how to teach people to be able to go where somebody is. (cited in Banerjee, 2000, p. 105)  Mindfulness in hospice care is an attempt to address this dream o f going to where somebody is; and one starts from t/here, in the liminal spaces o f self/other. If this position is conveyed as another truth or 'the answer', it is not intended to be.... A n d yet Hospice care and palliative care research are increasingly recognized as specialties in health care. While inquirers and clinicians are adding knowledge(s) o f developmental landmarks, tasks for the end o f life (Byock, 1996), and standardized norms o f care ( C H P C A , 2002), such privileging o f knowing vis-a-vis dying and death can too easily slip into discourses o f certainty, solidity, and distancing from. Acknowledging our ultimate 'unknowing,' especially in palliative care, is not new. Neither is Saunders and Baines' (1983) advice that although we may not be able to remove the inner angst o f a dying patient, we can at least stand with them. However, more important than seeking what is new, is re/cognizing, as Munhall (1993) contemplates—that some old ideas are always new.  210  F u r t h e r Implications This inquiry is about changing and trans/forming what is old, yet always new. Many implications from this inquiry have been sprinkled throughout the Fruition and previous Discussions. However, this final strand raises our gaze, sensing possible reverberations in other areas o f Indra's net.  Relevance for nursing practice If we accept that inquiry is a cooperative endeavor that, in this case, enables us to act differently in caring for those who are dying and their families, what direction does this study provide for palliative care nursing? Foremost, this inquiry is pointing towards direct human experience. It suggests that as nurses we are privileged to share nonconceptual, everyday, raw happenings, by virtue o f our presence with others during extra/ordinary experiences o f forming and dissolution. This inquiry points to practicing awareness [of] these processes through mindfulness meditation, and an appreciation o f conceptual and non-conceptual  In the gap between thoughts, non-conceptual awareness shines continuously Milarepa (cited in Welwood,  2000)  interplay that is continuously available. Moreover, the privileging o f Western binaries o f life over death, knowing over unknowing, presence over absence, and their impact on human experiencing is questioned, opening spaces for in-between configurations to arise. The implication o f this inquiry is first in pointing towards these gaps  211  Integrating philosophical questioning and nursing practice This study also suggests a direction o f bringing philosophical questioning, as a practice, into everyday nursing work —and particularly into hospice care. Where is living/dying happening? Where is suffering arising? W h o dies? Where is reality? Such questioning is not idle intellectualism but cuts to the heart o f the tension within living/dying and accompanying another in their dying. Such 'noticing' is not merely cognitive questioning but is paying attention to the conundrums o f life that renders a nurse open to a doubling o f 'answers without answers'. Such openness contributes to an environment where patients and families are able to probe and venture into what previously may have been unspeakable. Entering ambiguous spaces through paying attention to what is happening beyond language cultivates one's capacity to re/cognize and stay with unformed, raw experiences o f groundlessness. Although further inquiry is needed, such questioning and abiding also points to the possibilities of: •  Increasing comfort levels in speaking and thinking about dying and death that arises from experience rather than theorizing alone...  •  Enhancing appreciation o f one's interpretation o f dying as culturally scripted and only one among many possibilities....  •  Experiencing an inherently philosophical or spiritual pervasiveness embedded in nursing practice, particularly in palliative care, that does not require 'doing' but rather abiding i n . . . .  •  Providing avenues o f response to engage existential fears o f patients, families, and care providers....  212  Enacting such 'noticing' by study participants was supported through short periods o f silence, meditation, and reflecting on one's intention at the beginning and end o f hospice shifts. Periodic retreats for staff and volunteers dedicated to meditation and contemplation acknowledged the importance of'suffering the questions' through nondiscursive practices. Finding ways to support nurses, who in turn support patients and families in their existential quests, is a current challenge for nursing practice. Although spirituality and assessment o f spiritual needs is becoming an expectation o f nursing care, McSherry and Ross (2002) suggest that many nurses do not feel comfortable i n this role, or with their skills, knowledge, and experience i n this domain. Spirituality as it is being developed i n health care is based on a Judeo-Christian version o f spirituality (Markham, 1998) and may not speak to those from other traditions or secular backgrounds. Integrating philosophical questioning using non-discursive practices may provide opportunities for diverse groups o f nurses to engage in these domains together. In-services 'about' the ineffable can go beyond content information and create spaces for nurses to explore directly their own experiences. Integrating philosophical questioning as a practice also questions perspectives o f nursing as an interventionist discipline aimed at doing something to or for people. Through ongoing attention to how reality and experience are unfolding relationally within each engagement with patients, nurses may see an interplay o f action-and-stillness where abiding in-between is a skillful option. Engaging the mystery o f dying and accompanying those during such experiences calls nurses who are willing to continuously wonder and open into the questions themselves.  213  Adding new interpretive scripts for dying and death Death is not only the cessation o f vital organ functioning. This inquiry points to additional configurations o f what constitutes death and where death happens. Constituting living/dying as momentary experiences, as many Buddhist practitioners do, has implications for nursing care. In addition to providing another way o f interpreting death, caring for people who hold this view may include creating spaces for meditation and appreciating that their response to dying may be different. The possibility o f consciousness that transcends awareness o f self and environment is not yet considered in western nursing. A l s o , the potential for people to be aware o f their dying process on more subtle levels as suggested by the Bardo Thotrol, is also a possibility that warrants further inquiry. Understanding that awareness and mental clarity may be important for some meditators as they are dying necessitates discussions concerning medications and their side effects and clarifying with patients and families how they wish to proceed regarding pain and symptoms. Finding alternatives to medication in relating with pain, nausea, and anxiety would need to be explored. Appreciating that death may be viewed as an opportunity rather than a tragedy, or possibly a tragic opportunity, points to the need for nurses to engage each person without fixed assumptions but with curiosity, seeing the transparency o f any held preconceptions. Nursing requires skillfulness in moving back and forth between the nomothetic (universal) patterns o f signs and symptoms and the idiographic (particular) o f each unique encounter in this moment. Reconciling this movement, cultivating a capacity to recognize what is needed and to engage fully yet with openness requires a suppleness  214  of awareness and practice. Such awareness goes beyond reflective practice, and is conceptualized in this inquiry as mindful reflexivity.  Awareness and Ethics Awareness o f the interplay and relational space in-between self and other and the flow o f momentary experience cultivated through mindfulness practice has relevance for ethical nursing care. Although further inquiry is needed, it would seem that insight into one's habitual thought patterns, or more subtly, awareness o f how one is perceiving and then constructing beliefs has important ethical implications. Even though Registered Nurses have a Code  of Ethics  to guide nursing actions,  these principles constitute the aspirations and ideals for ethical conduct. However, the complexity and immediacy o f situations in nursing often demands an interpretation o f ethical behaviour in accordance with each situation. For example, a situation arose during my fieldwork where a resident chose to abstain from pain medication for personal reasons, including the mental clouding they induced. Over time however, the resident became disoriented and confused; he became increasingly distressed and seemingly in pain. The care team discussed the issue o f administering pain medication in light o f the new situation, taking into account his previous request to not be medicated. Interestingly the caregivers' awareness o f their own distress in caring for this resident and their need to alleviate both their own distress in witnessing such suffering, along with the perceived suffering/pain o f the resident, provided another layer o f understanding. Awareness o f the complexity o f needs in any situation allows for interrelated threads to be identified  215  alongside moral principles guiding the decisions. Whose needs are being served? Where do they overlap and where do they diverge? Ethical behaviour unfolds moment-to-moment in often messy and complex situations. Regularly setting one's intention (aspiration) at the beginning o f hospice shifts and attending to experiences o f dissonance and conflict as they occur, allows for selfcorrecting behaviour at best, or at least an accountability o f awareness o f what is happening, and how one is responding.  Environment This study contemplates the role o f caregivers in creating an environment that values non-dual, ambiguous, uncertain, and paradoxical human experience. Through opening into these dimensions with another, caregivers help create an environment where such qualities can be held. In many ways, this inquiry points to an appreciation o f these sites o f tension and interplay as vital spaces o f human  I am aware of the dance between definitive and nondefinitive language. Although the question remains, how is this inquiry relevant for nursing practice, I hope to elude the pitfall of prescriptive discourse as my intention has always been otherwise. Death is not a problem to be remedied. Accompanying those in this journeying is also seeing the interplay of y/our dying and the limits of pre-scribed 'doing' and yet....  connection, compassion, and insight into an ultimate indivisibility between self/other. Creating an environment that supports patients' natural healing capacities has been a nursing function since Florence Nightingale (Macrae, 2001). Through sensitivity to in-between spaces o f human experience, nurses can open an environment o f spaciousness that supports reintegration, deconstruction, letting go, or whatever is required during a person's dying process.  216  Is mindfulness meditation a recommendation for nursing practice? Mindfulness is only one way o f cultivating embodied awareness. Although I am not suggesting meditation as a practice for nurses, this study signifies the importance o f attending to non-conceptual experiences located in alternative discourses; finding ways to disrupt privileged views o f reality while re-cognizing other possibilities o f living/dying. Although Western nursing practices are re-turning to the elusive, non-material, and relational aspects o f spiritual nursing practice, this study points to ways o f refining awareness o f nondual spaces in caregiving from non-theistic, non-modernist and nonwestern locations.  Relevance for Nursing Education Mindfulness is configured here as a process o f leading the mind back from theories and preoccupations, back from abstract attitudes, to the situation o f immediate experience. Helping students to discern the edges o f mindful presence and learning how not to fill in the gaps with busyness while leaning into the stillness o f whatever activity they are doing seems an important aspect o f nursing education. Awareness practices such as: moments o f silence; checking in with what physical sensations are arising; becoming aware o f one's state o f mind/body or intentions (without judgement, simply becoming aware); or experiential, process-oriented approaches to education, are some ways to foster student awareness. Activities that turn the mind back to one's experience may also help students locate curricular content within their own experience. This study suggests that cultivating awareness in this way would nurture, not only reflective practitioners, but mindfully  217  reflexive nurses. That is, nurses who are not only able to critically reflect on their practice but also appreciate the process o f perceiving and interpreting as it is happening. Further inquiry is required; however, hunches shaped by my experience in engaging this study lead me to suggest that such practitioners may also experience the gendered, contingent, culturally and socially determined nature o f their interpretations. In turn, such realization would potentially lead to greater comfort with difference, ambiguity, and change. Learning to shift back and forth from a modernist emphasis on content to a less familiar and graspable emphasis on context may also expand the learner's repertoire and patterns o f awareness and their ability to attend to the textures o f situations. Reconciling the dichotomy o f content and context and the liminal space in-between is an ongoing challenge in nursing education. Other implications include: •  Questioning perceptions o f time as commodity, and how these interpretations both help and hinder nursing care...  •  A r e there ways we need to prepare nursing students differently regarding notions o f time? H o w do those who are dying, and their families, think about and experience time?  •  Preparing nursing students from a location o f doubling (where things are not as they seem, but nor are they otherwise), may sensitize learners to contextual considerations that are always changing. The emphasis shifts from an abstract 'right' or 'wrong' to constant re-viewing and re-assessing as situations continuously change. The 'right' response would be contingent, partial, and open to re-newed assessment depending on the person(s) and context.  218  Relevance for Future Inquiry This inquiry is a beginning dialogue with Buddhist philosophical views and practices in the context o f living-with-dying and hospice care. Continued engagement with approaches and discourses that open up assumed views o f reality are required as the diversity o f patients and health care environments continues to expand. The path o f this inquiry is a beginning effort in moving outside o f conventional structures without rejecting these forms, and calls for greater experimentation in embodying ways o f articulating indistinct and liminal spaces o f human experience that both 'shows' the phenomenon being studied and demonstrates through its explication. Further inquiry is needed into ways o f articulating and approaching nonconceptual awareness and its relationship with health and wellness experience. Synchronizing mind-and-body through mindfulness seemed to provide caregivers with insights into the in/separability o f caregivers-and-residents. Some participants saw this relationality o f self-other as key to empathy and compassion in care. More investigation into these experiences and the impact for both caregiver and patient is required. Further exploration into non-conceptual, pre-reflective experience and its relevance in different cultural understandings o f change, death and dying, and health and wellness, is needed. Suggestions sparked by participants also calls for further investigation: •  H o w does regular meditation affect death anxiety amongst caregivers?  •  Is there a relationship between quality o f life and meditation practice for hospice caregivers, and those living with chronic or terminal conditions?  21  •  H o w can awareness practices be incorporated into approaches to educate health care providers in providing effective support for existential or spiritual concerns o f patients and families?  •  H o w can Tibetan Buddhist typologies o f consciousness inform Western understandings o f mind and consciousness and existential concerns at end-oflife care?  •  What is the experience o f liminality amongst non-meditating hospice nurses and residents?  •  H o w is spirituality understood by those in non-theistic, non-existentialist traditions?  Although volunteer caregivers comprised the majority o f participants in this inquiry, the role o f volunteer service in hospice care was not addressed per se. However, the high degree o f commitment and competence amongst volunteers at Zen Hospice has led me to wonder what factors in volunteer preparation and support have contributed to this? Only limited inquiry into volunteers and their impact on hospice service has been conducted. Future studies need to address a wide range o f questions including:  48  profiling  hospice volunteers and the knowledge, skills and experiences they bring; what is the impact o f volunteers on patients and families?; what roles are played by volunteers in hands-on care?; how are volunteers perceived by health team members?; are volunteers  I'd like to thank Jerry Rothstein, the Victoria Hospice Society Coordinator of Volunteer Services and Quality, with whom I have been discussing and communicating via email concerning the lack of inquiry into volunteer services. Mr. Rothstein is a member of the Volunteer Issues Committee of the C H P C A and is currently compiling a list of potential research questions in order to establish a research agenda for the volunteer component of hospice palliative care in Canada.  4 8  220  adequately utilized?; what is the impact o f hospice volunteering on the volunteer?; what is an effective training model for retaining and challenging volunteers?; and what innovative models o f volunteer service exist that address non-traditional settings or special populations? Finally, potential benefits o f meditation i n working with chronic pain and discomfort remains open for exploration. Although relating with pain was discussed by participants in relation to discomfort while sitting cross-legged in a meditation posture, the ability to separate their narratives about pain from their physical sensations, and the sense o f 'control' that provided, holds promise for complementary approaches to relating with chronic pain and discomfort.  221  STRAND SIX ~ LINGERING MEDITATION  Where can I find a man who has forgotten words? I would like to have a word with him. Chuang  Tzu  1  What is necessary, after all, is only this: solitude, vast inner solitude. To walk inside yourself and meet no one for hours— Rainer  Maria  Rilke  We need to practice compassion every day. In observing our attitude towards others, we can learn to deal with all beings compassionately—with friendliness, attentiveness, and care. All we have to do is just continue expressing our compassion with our best intention, under all circumstances, day by day. True compassion works beyond our intention. It is inconceivable and wondrous. It can manifest in even the most ordinary moment. Katagiri  Roshi  ' Quoted in Nisker (2002). The dharma & the drama, Inquiring Mind (18) 2, p. 51; quote from Katagiri (1998). You have to sav something: Manifesting Zen Insight, Boston: Shambhala, p. 18.  222  Living in spaces between words Beyond self Compassionately  The conundrum o f Chuang T z u has been the joy and impossibility o f this dissertation journey; texturing a life-world that tarries in-between the 'writable'/the 'nonwritable'. Sometimes the voice is that o f the 'writable' (perhaps more often than necessary), and sometimes 'un-writable' spaces seep through (an effect I cannot 'direct'). W i t h each reading and re-reading, sentences and paragraphs are added or re-written as new ideas are sparked—it's exciting at times. I've been forewarned however, that the word always contains the other, and therefore writing can never be finished— it can go on f(or)ever,.... one can merely pause  Peter Reason and Judi Marshall (1987) question why people do doctoral research and acknowledge conventional assumptions that we conduct inquiry i n order to contribute to disciplinary knowledge, but suggest that this motivation is only partial. According to these authors, the purpose o f inquiry is also for inquirers to be able to make sense o f their worlds, to see what works, and for the endeavor to be an aspect o f personal transformation. In this way, Reason and Marshall suggest that inquiry is 'for them' (disciplinary knowledge), 'for us' (clinical application) and 'for me' (transforming process) and that the inquiry degenerates if, any one o f these purposes becomes dominant and overwhelms either one o f the others. A l l three are important and complementary in an inquiry endeavour.  223  * ** * A s the numbers o f people with life-threatening illnesses continues to grow, as the population ages, and as interest in dying and death increases, inquiry into the subtle and complex aspects o f human experience at the end-of-life is being called for. Exploring complexly layered experiences o f living/dying has been a fascination for me since the early 1980's when I first ventured into Bangladesh as a volunteer nurse. Although questions o f death were not i n the forefront when I first arrived, they soon became a vital part o f my experience: many o f the young patients I cared for were dying, the life expectancy for Bangladeshi adults was 45 years, and the radical assault on my understanding o f the world, uncovered an abyss o f groundlessness—a free fall from reference points. Immersion in a culture and way o f being that was utterly different from anything I had ever known, cracked open my solid understandings. It was unsettling and disturbing. Things were not as they seemed. Perception shifted. I could no longer take for granted what was previously accepted— my life-world became fluid, unstable, alive, and bitter/sweet. In the crack there was groundless vitality. I sought to understand what was happening by reading the sages o f literature and philosophy. Although I couldn't articulate what it was I was looking for, there was a sense that I would recognize 'it' when encountered. Various writers including W i l l i a m Blake, Jack Kerouac, and T.S. Elliot were helpful, but it was Buddhist writers who offered a practice, along with language, for exploring these subtle experiences. Life turns full circle. This inquiry, is a continuation o f that curiosity into what it is to rest i n a space o f living/dying, knowing/unknowing, where things are simultaneously not what they seem, nor otherwise. H o w do we recognize these spaces? H o w do we rest?  224  What does it feel like? A r e these deathless spaces, as one participant intimated? Are these sites where compassion abides, as another participant suggested? A r e these spaces o f ultimate freedom without distinctions or separations? Is this where in/dividuals are no longer divided? Where selflessness rains (sic)?  Is this Bhaba's third  space?  And Aoki's  metonymic gaps?  Can these questions be answered? Yes and no  ?  What is it to tarry in a space o f living/dying?  What is it to write from the writable / non-writable?  It's a bit scary. There is a lot o f mean(der)ing and places of open sky and.... not knowing where one is going, .. .1 sense this may be similar to what Derrida (1993) describes as aporia...  although he questions whether we can speak o f an experience o f aporia. That  said, Derrida admits, I would like to situate, form very far away and very high up, in the most abstract way, in a f few sentences,.... the places o f aporia in which I have found myself, let us say, regularly tied up, indeed, paralyzed. I was then trying to move not against or out of the impasse, but in another way, according to another way o f thinking o f aporia, one perhaps more enduring, (p. 13) Aporia points to a place o f impossibility in which we struggle, or not, listening to the space itself. Following the echoes and intuitions arising with/in this space, according  to,  in harmony with, another way o f thinking....  * ** *  225  }  * *** Languishing in Language  In writing (about) experiences that participants found difficult to articulate and which are perhaps beyond conventional language, and in framing this interpretive process within a Buddhist context, the sign/ification of language could not be overstated. After all, as Kristeva (1989) and other writers have clearly demonstrated, there is no such thing as neutral language. Just as feminist and post-colonial writers have successfully argued, all knowledge is partial, and culturally bound (Banerjee, 2000). These same arguments can be applied to language which constitutes, in part, knowledge. In assuming a neutrality within language, syntax, tropes and figures of speech, we risk losing our ability to see how language inclines our thoughts and actions in certain directions. This becomes a challenge with moral, ethical, and political implications in the pluralistic world in which we live and provide nursing care.  If we accept that language is not neutral, then a Buddhist ontology of binegation where phenomena are said neither to be nor not-be must be attended to in language that infers/implies/suggests or de/scribes 'it' as such. Finding words/non words to convey this has been a koan and a challenge- the best response may be to follow the lead of one participant, Sophia, and burst into laughter! Although humour was a significant part of my experience at Zen Hospice and is recognized as an important factor in palliative care, the question of language remains. How to articulate 'that' which is and is not, or is perhaps ineffable? How to articulate in a meaningful way without relying on language that asserts without simultaneously negating? Have conventional tropes such as explanatory prose and metaphor adequately addressed the negation or binegation inherent in Buddhism and this inquiry? How else could I have avoided the desire to pin-down and explain while at the same time being meaningful and respecting the unstable nature embedded in the very notion of bi-negation?  226  To begin, I expressed this challenge as 'clearly' and solidly as possibly. Next, I played with a back-and-forth in languaging. Reading the transcripts over and over and in writing, I kept the following questions in the forefront: How is it that we encode our ontological/epistemological assumptions in the language and conceptual constructions we create? Are we aware of the dominant views of reality embedded in privileging particular figures of speech such as metaphor or metonymy, for example, and how does the use of language limit certain understandings of reality? In the Zen tradition for example, where conceptual thinking (language) is said to entrap meditators, words are seen to be too fixed, too logical, too vulnerable to the binaries of this and that, good and bad, here and there, to be adequate to reality. Nature and human experience are more varied and inconsistent than word(s), and from a Buddhist perspective one must always re/mind ourself of the relative place of language. Perhaps this is why many conventional koans and stories are seemingly nonsensical using language to interrupt conventional thinking while evoking a gap of non-conceptual experience. In addressing language and the ideological embeddedness inherent therein, I attempted to develop sensitivity towards how assumptions about the nature of language turn our minds towards particular views and actions and may limit our acknowledgement of other possibilities.  I've suggested that there is a growing awareness in nursing of multiple realities and epistemologies, albeit slow and fledgling, but this awareness is a flickering candle within the glaring mid-day brightness of what Derrida (1993) refers to as the "fundamental ontology" of the universitas and its underpinning in "the project of a science of being" (p. 210). Despite the growing awareness of language and knowledge as never neutral, I seemed to need frequent reminders as I went about the process of 'interpreting' or 're/presenting' or creating a narrative about what happens when we bring our awareness fully to the moment,  227  and how this shapes our experience of living/dying or caring for those who are dying.  Writing from a Buddhist position(ing) requires a loosening up on the part of writer and reader. A loosening of fixed views about the functioning of languag(ing) in directing the writers/readers experience. Therefore, attending to language, and our common assumptions seemed worthwhile in an attempt to bring to awareness the partial, transient, fluid and con/textual nature of language, mind, and our experience of reality. In other words, to bring awareness to and questioning the often unquestioned process of languaging that occurs in the writing and re-writing with each read.  Not only is the university and its research disciplines engaged in what Derrida (1993) calls "a project of the science of being and [its] fundamental ontology" (p. 210), but we must not overlook the significance of this 'being-ness' epitomized in our reverence for logos - words. Logos, the Greek term for logic, 'the word'; rationally ordered arguments and thought still reign supreme in Western academic thought. How well we command language through persuading, provoking or convincing become the benchmarks for success in the academy. The shift towards 'evidence-based' practice emphasizing a reliance on published research and empirical evidence that supports given practices also demonstrates the power of the 'word' in turning our minds and behaviours in certain directions.  Such privileging of logos has been criticized by feminist writers for its tendency to effectively exclude other ontologies and perspectives. In meditation practice for example, thinking, discursive thoughts - words are not given any particular attention. However for most Western students of meditation the fixation on the content of their thoughts or the opposite position of trying to avoid thoughts altogether, are reflective of the dominance of being-ness - isness—  228  words. What meditation practice offers, is an experience of both thoughts and the edges of thoughts and the open space between them.  One could say, meditation practice allows an opening of language, the limits of language, and the space wherein languaging can be appreciated. Such experiences are at times non-conceptual, beyond logos, beyond language, and yet pristinely clear.  In/scribing such experiences in language was difficult as many participants in this study attested. This difficulty was fraught with challenges. For example, the storyteller/narrator must be able to stop, open up to his/her experience and speak from that location. In other words, when the narrator spoke from within the experience rather than 'about it' there was a dynamic quality of languaging that happened. When this happened there was no longer a sense of separation between the speaker and that which was spoken—they were speaking in the moment rather than recounting about some past event. Next, the writer/reader needs to also open up and enter into the narrator's story in a similar way; in the moment, from within their own experience of reading  229  Without discarding conventional nursing science discourse, this inquiry is located at its margins and has chanced into sites without solid g/round. The intent has not been to reject modernity and science and replace them with other traditions such as Buddhism. Instead, my interest has been to move in-between these discursive spaces in a way that neither excludes in an oppositional binary nor tries to merge understandings o f science and Buddhism. In this way, the inquiry has attempted to reflect Bhabha's (1990) 'third space', a space o f potentiality for something new, and in what A o k i (1996) calls metonymic moments between modernist and non-modernist discourses. Exploring mindfulness as a particular meditation practice or technique within a representational discursive space familiar in nursing texts, allowed discussion o f the perceived benefits and outcomes o f using this form o f mediation. However, as cautioned earlier, writing about mindfulness practices as interventions for relaxation, stress reduction, or applying 'presence', is both incongruent with the Buddhist tradition from which it arises, and reinforces a medicalized construction o f applying a technique to relieve symptoms. Therefore, in exploring mindfulness, it has also been important to inscribe non-representational discursive spaces in which Buddhist thought is  !  '.  W e can never finally determine what things mean. However, we can open up spaces that show meanings as partial, open to questions and always changing....  embedded. For example, what distinguishes Buddhist meditation is its premise o f nonduality that immediately calls into question the limits o f language, or at least the possibility o f language taking us to its limits. This has been more challenging, as some textual habits are deeply ingrained. Even so, as practitioners and  230  inquirers we need to experiment and go beyond dualistic views towards a multiplicity o f conltexts  that provide guidance for abiding in the midst of difficulty, in the midst o f  suffering that may be beyond knowing. Herein, non-modernist, traditions such as Buddhism are particularly useful. Learning to listen to the echoes within slashes, in-between what is living/dying and knowable/unknowable is a potentially trans/forming strand o f this inquiry. Listening to how as writer I am written, and as inquirers we are researched through the process, was a way into and a path towards keeping the text(s) open.... 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Zenhospice (2000) San Francisco, C A : Zen Hospice Project. Retrieved A p r i l 2000 from the World Wide Web: http://www.zenhospice.org/  246  Appendix B Wandering With  i  Permission to meditate together for 10 minutes Overall aim: To explore how i n the midst o f living-and-dying and caring for those who are dying... .what is the experience o f mindfulness? What role do mindfulness and meditation play? S Can you share with me what brought you to do this kind o f service? •S Can you share with me a story o f learning meditation, how, when, what kinds,... that sort o f thing? S  In the training we spent a lot o f time sitting (meditation), can you talk alittle about i f and why you think meditation/sitting is important in this kind o f work?  V  Can you think about the residents and people you're working with or worked with here at Zen Hopsice, is there any experiences that stands out for you as being especially important for you in your own spiritual journey?  S  Can you think o f any residents or situations that were especially difficult? (how did you work with it?)  S  In your experience....where is the Zen in Zen Hospice Project?  *S I'm interested i n what mindfulness means to you.. .in your own experience...not theoretically. Can you talk a bit about when you experienced or began to understand what it means to be mindful? •S Can you tell me a story about learning meditation for the first time?  S  C a n you give me an example o f a time here i n hospice when mindfulness took on meanng for you?  •S H o w has your experience working at Z H P changed over time? •S H o w has your practice (of meditation) changed over time?  •/  Have you gone through periods when you think about leaving Z H ? W h y ?  249  S  In general, I'm wondering how mindfulness influences our reality o f living-and-dying, especially for those who intentionally cultivate awareness through practicing it formally. D o you have any thoughts on that?....how meditation/sitting practice fosters an awareness o f living-anddying? Is such an awareness helpful? Why?  S  In the buddhist sense, there is a view that each moment is a moment o f birth and death. Can you talk alittle about i f that makes sense to you in your work here at hospice?  S  Are you familiar with Stephen Levine's book Who Dies? From your own experience, can you tell me a story about 'who dies?'  250  

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