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Abiding in liminal space(s) : inscribing mindful living/dying with(in) end-of-life care 2002

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A b i d i n g i n L i m i n a l Space(s): I n s c r i b i n g M i n d f u l L i v i n g / D y i n g W i t h ( I n ) E n d - o f - L i f e C a r 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 P H I L O S O P H Y 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 N U R S P N G We agcepPthis thesis as conforming to the required standard T H E U N I V E R S I T Y OF B R I T I S H C O L U M B I A October 2002 © Winifred Anne Bruce, 2002 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department-of 3 C . K Q Q \ Q-P K)U/S>' The University of British Columbia Vancouver, Canada Date Oct- n ,^ooa DE-6 (2/88) 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 of this Eastern practice are limited. This inquiry engages Buddhist philosophical thought and the experiences of meditation practitioners. The purpose of 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 of residency in a Zen monastery, and participation in day-to-day volunteer caregiving in the Zen hospice were undertaken. In- depth 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 of representational binaries that value words over silence, life over death, clarity over paradox, and knowing over unknowing. Death, re-interpreted in the Buddhist sense of 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 of living/dying intertwining within momentary awareness. A re-configuring of living/dying is suggested that differs from Western perspectives where ' l iv ing ' holds hegemony over 'dying' . Death is situated in the midst o/ :—liminal space(s) of being/not being and ubiquitous change while mindfulness meditation is seen as a parallel process providing an embodied realization of this transience. These perspectives may help nurses and health care professionals go beyond dualistic views and provide guidance for abiding in the midst of suffering that may be beyond words. Further inquiry into non-conceptual awareness and its relationship with health and wellness is needed. 11 TABLE OF CONTENTS ABSTRACT TABLE 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 Views Edges of Non-Modernist Views Attending to Language Locating Theoretical Context (s) of Buddhism Buddhism in Nursing Theorizing Eastern and Western Philosophical Views Twofold Truth Buddhism G/round of Buddhist Thought Four Noble Truths Nonduality Self/No-self Meditation Practice Introduction to Meditation Meditation and Relaxation Types o f Meditation Concentration Mindfulness i i i STRAND TWO ~ Diverse Voices in End-Of-Life 48 Changing Conceptualizations o f Death 49 Contemporary Hospice/Palliative Care Movement 51 Shifting ground- Hospice and Palliation 52 Shifting ground ~ Humanist and Transpersonal Orientations 54 Meditation and Dying: Death of the Body, Death of the Self 58 Integrating East and West ~ Zen Hospice Project 61 Mindfulness Meditation and Health 64 Current Inquiry 65 Missing Voices 69 STRAND T H R E E - Path of Inquiry 71 Introduction 72 Mindful Reflexivity 76 Reflexive Approaches 76 Reflection and Reflexivity 76 Mindful , Open-ended Reflexivity 78 Inquiry Design , 80 Locating Sites and Negotiating Access . 80 Inviting Participation 85 Generating Data 89 Reflexive Participation 89 Audiotaped Conversations 93 Engaging with Texts - Practical Considerations 95 Audiotaped Conversations 95 Ensuring Ethical Inquiry 99 Approaches to Interpretation 100 Preliminary Approaches in Analysis and Interpretation 100 Strategies of Mindful Reflexivity 102 Steps along the path 103 Koans 107 iv S T R A N D F O U R - Fru i t ion of Inquiry F R U I T I O N K O A N C O M M E N T A R Y 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 of M i n d Meditation and Dying as Parallel Processes Turing Inwardly Outward Silences Inter/play of Silence Letting Go Letting Go of Fixed M i n d Letting Go of Time Linear time Cyclical time Present time Dissolution Martin's Dissolution Story Dissolution of Elements Inner and Outer Manifestations of Elements Sophia's Dissolution Story Hospice Care as Meditation-in-Action Intentionality of Service Caregiving With a Unique V i e w Engaging and Being Engaged Cultivating Un/Knowing Discovering More Possibilities Doubling: Seeing Differently Realizing Impermanence Resting In Groundlessness V E R S E STRAND FIVE ~ Discussion and Implications Introduction Situating within Nursing Philosophy Resonance and Disjunctures Presence/ Absence Knowing / Un/knowing Re-configuring Death Liv ing / Dying Further Implications Relevance for Nursing Practice Relevance for Nursing Education Relevance for Future Inquiry STAND SIX ~ Lingering Meditation REFERENCES APPENDICES Appendix A : Copy of Consent Form Appendix B : Copy of Conversation Questions v i LIST OF TABLES TABLE 1 : Demographic profile of inquiry participants TABLE 2 : Inner and outer manifestations of elements i . v i i A C K N O W L E D G E M E N T S 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 Bai 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 of Zen Hospice Project. Thank-you to Zuza Engler, Si lvia 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 Al ison Jordan who made my stay at the San Fransisco Zen Center an embodied experience of loving-kindness. The hidden skills and tenacity of friends who stayed the course over these years cannot go unnoticed. Nine bows (Zen form of appreciation) to Barb Moffat, Katherine Doranne McGeean, Stephen Swick, and Jacques LaCroix for their editorial sensibilities and warm friendships. In addition, thanks to Camil la Morrow, Sonia MacPherson, and Wil 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 of 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. vi i i D E D I C A T I O N 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 / R O U N D 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. When 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'1. 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. 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 of mind. A l l Buddhist teachings are aimed at the single point: to look into the nature of the mind, and so free us from the fear of death and help us realize the truth of 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 of mind-body connections and in particular, I am drawn to the philosophical views and practices of Buddhist meditation and its relationship to the experience of death and dying. Buddhism is a 2500-year-old tradition that contemplates the experiences of 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 of both health and disease (Pelletier, 1992). Although extensive evidence illustrates the positive health outcomes of mindfulness meditation in responding to anxiety, chronic pain, and stress (Kabat-Zinn, Lipworth, Burney, 1985), little is known about the experience of meditation by those facing the inevitability of death or caring for those who are dying. Recent studies within palliative care nursing urge further exploration of mind-body approaches such as meditation in supporting end-of-life care (Adams, Hershatter & Morritz, 1991). 3 Purpose The purpose of this inquiry is to explore the experience of mindfulness by those who regularly practice mindfulness meditation and who are living-with-dying or caring for persons at the end of life. M y curiosity lies in the constructions and experience of 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 of the plethora of alternative health care practices now available. Alternative approaches to conventional biomedicine are being used by a growing number of 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% of adult Canadians reported having tried alternative therapies (Angus Reid, 1997). Although the use of alternative therapies, including meditation, seems like a recent phenomenon, ancient traditions and non-Western approaches to healing have offered differing understandings of health, illness, dying, and death. It is only recently however, that non- medical forms of 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 of 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 of 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 mill ion identified Buddhists in the United States, of which about 800,000 are converts (Baumann, 1997). Historically, Buddhism originated in the life and words of 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 (Von Glasenappp, 1970). Most inquiry using theoretical frameworks drawn from Buddhist systems of 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 of mind and human experience may overshadow the practice of '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 of 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 of hybridized American Buddhism. Historically, Buddhism has accommodated cultural mingling during its transplantation throughout As i a and seems to be continuing this process of hybridization in Europe and North America. In its newest North American form, Ryuken Will iams and Queen identify: democratization (the emphasis on lay practice and the rise of 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 of 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 of dying. I went to the closet and wrestled with an old suitcase perched up on the shelf beside a stack of 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 of 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 of 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 of 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 of 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? How 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 of this inquiry is nestled: 7 We 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. We 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. We 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 wil l ing to try to give it up through the regular practice of 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? How 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 of dying? If there is no fixed self to hold on to, then who dies? H o w does such a person relate to l iving 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 How we perceive reality and the nature of knowledge is said to be crucial in determining the lenses through which we conduct our inquiry. From the research question, to one's perception of what constitutes 'data', the inquirer's location(s) w i l l govern the directions taken. Explicit identification of one's orientation to particular philosophical view(s) is suggested as a vital component of 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 in nursing and in 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 of science/practice, and Buddhist philosophy and awareness practices. 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 is 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 9 Edges of modernist views Traditionally in nursing, the model for generating knowledge has been embedded within a modernist discourse of science. This model has shifted in the past 20 years, recognizing the necessity of interpretive and phenomenological approaches to inquiry. Even so, despite advances in qualitative research, the distinctions between different aspects of reality and epistemologies to access and understand varying domains of experience are not explicit in nursing literature (Wolfer, 1993). The issue is not that different ways of 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 of scientific, modernist discourse in Western thinking and consequently in nursing theorizing and practice. To illustrate, David Al len (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 en 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 Al l en that the appeal of 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 of a modernist academy) into discursive spaces of foundationalism. Similarly, scientism is a matter of putting too high a value on science as a branch of learning in comparison with other ways of knowing (Dzurec & Abraham, 1993). With scientism, the belief is that science is the most beneficial form of learning and as 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 of scientific status are desirable (Sorell, 1991). In nursing, Kikuchi and Simmons (1986) provide examples in which nurse researchers attempt to answer philosophical questions such as, 'What is the nature of health?' or 'What is the purpose of caring?' using exclusively scientific means, thereby demonstrating nursing's vulnerability to scientism. Edges of non-modernist views Recognizing different modes of reality (e.g. the body-mind-spirit, ambiguity, paradox) is difficult within the limited scope of language and ways of 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 of scientific knowledge depend on exclusion, and function to privilege one voice or perspective over another. Through valuing what we can know Is this old argument of scientism still relevant in these 'post' post-modern times? 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 11 within a fixed idea of 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 Homi 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 of "original difficulty" where there is "always something left to say, with all the difficulty, risk, and ambiguity that such generativity entails; the ambiguous nature of life i t s e l f (p. 199). In this inquiry, ambiguity and uncertainty are invited as contested sites, signifying a multiplicity of interpretations. Re-conceptualizing ambiguity, uncertainty, and the 'unsaid' in this way, allows for other possibilities of 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 in an oppositional binary nor tries to merge understandings of science and Buddhism. In this way, the inquiry is attempting to reflect Bhabha's (1990) 'third space', a space of 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. No 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 of 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 of possibility in this inquiry, language and form are interrogated and playfully explored. Specifically, experimentation with the use of personal story fragments, randomly placed quotations, disruptions, hyphenation, and word slashing (i.e. g/round) are incorporated. For example, the hyphenation and interrupting of 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 Min-ha (1992) and Helene Cixous (1997). The simple act of 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 of language and a multitude of possible interpretations. These textual 13 disruptions also unsettle the momentary continuity of 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 of living/dying and meditative awareness. A talent for speaking differently, rather than for arguing well , is the chief instrument of cultural change. -Richard Rorty 2 2 Cited in Batchelor (1997) 14 Theoretical Context(s) of Buddhism 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 of nursing frameworks. In addition, Sarter (1988) suggests, "It is time that serious attention be paid to the formal systems of thought of 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 of knowing cannot be understood using Western philosophy and science alone (Wilber, 1990; Wolfer, 1993). Therefore, investigations and knowledge claims about the more 'indistinct' aspects of 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 Views What follows are broad brush strokes in exploring the differences in philosophical thinking within Eastern and Western traditions. A s the underlying ontological 3 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. 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 of 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 of Western philosophy, is defined in different ways within the literature. Flew (1984) describes ontology as a branch of metaphysics that focuses on the study of existence that differentiates what is 'real existence' rather than 'mere appearance'. Johnson (1995) provides a broader definition and includes the nature of existent objects within the purview of ontology. In other words, Johnson defines ontology (Western) as a branch of philosophy that is concerned with what exists and what does not exist; the nature of being or 'isness'. That a pine is - its isness - indicates its ontological character. Ontological questions of this genre explore the nature of reality, what can be known about reality, and the nature of Being in beings. Such privileging of presence and Being is particularly Western in view and dominates most nursing and thanantology literature5. But what of Non-Being and 'absence'? What of the space in the midst of presence/absence, neither being nor non-being, but possibly in-between? The distinction between Being and Non-Being, and determining Being or the ' l imited' as superior objects o f investigation in Western thought, has been attributed to 41 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. 5 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). 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 of concepts and language traditionally employed in Eastern and Western philosophies. Northrope (cited in Fung, 1948) suggests there are two major types of concepts that characterize the Eastern and Western systems of 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 of nonduality posited in Buddhist philosophy presented later. What follows is an interpretation of how Eastern and Western philosophical views differ, and explores what it means to be located somewhere in- between. To begin, an exploration of 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 of this genre leans towards ambiguity, poetics, inference, and open-endedness. On 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 of the number of 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 ' l imited' are distinct whereas the others are indistinct. 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 of 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 of 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 of 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 of analyses do not contradict but complement each other as is demonstrated in some Buddhist systems of thought. Furthermore, "it is the combination of the two (positive and negative) that w i l l produce the philosophy of the future" (Fung, p. 342). Prophetically, these words were written before the logocentrism of 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 of East/West thought, but cross the boundaries with antifoundational critiques of any inherited way of thinking. For example, Smith (1999) asserts that within postmodern 6 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. 1 8 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 of 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 of a given time and place" (p. 123). Emphases have shifted from an essentialized reality of modernity to a de-centred, highly interpretive and constructed blending of being/not-being and knowing/unknowing. Binary positions are no longer tenable, and the ground, we now realize, is moving. Twofold truth was inscribed by Buddhist scholar Nagarjuna (Corless, 1989) in The Root Verses on the Middle, responding to the question of the nature of 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 Twofold Truth only to ultimate reality in the negative—what is not. 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. 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 Stcherbatsky cited in Komito (1987) 19 that when we look for the substantiality of 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 of interest in this inquiry, is to explore spaces between these twofold truths of kinetic reality that is moving and alive. . . . and yet includes stabilized realities of concept. Buddhism Buddhism values direct experience as a way of knowing rather than abstract logical inference alone; a brief introduction to mindfulness and the experience of awareness wi l l provide the ground for more theoretical discussions of Buddhist thought. This is followed by a brief survey of the basic tenets shared by all schools of Buddhism and includes: 1 ) the four noble truths, 2) a view of nonduality, and 3) the lack of an inherently existing ' se l f . A Story of 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. "You ' re awfully cold", the attendant said. And 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 of 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? And , 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 wi 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. At the hospice, it's not appreciably different. We sit at the bedside and we listen.... A t the heart of 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 of paying attention, of attending to whatever is happening without judgment. A s in Adele's story, awareness of 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 of us may be more familiar with— mindlessness. For example, most of us, especially when we are busy, live in a disembodied way, that is, we are not actually aware of 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 of absent-mindedness, a more troubling aspect of 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 of 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 of 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 of mindlessness for learning, behavioural competence, memory, and health (Langer & Imber, 1979; Langer et al. 1987, 1988). The disconnected attitude of mindlessness in everyday life is one that habitually distances us from our own experience: From a point of view of meditation, humans are not trapped forever in this abstract attitude. The dissociation of mind from body, of awareness from experience, is the result of habit, and these habits can be broken. A s the meditator again and again interrupts the flow of discursive thought and returns to be present with his breath or daily activity, there is a gradual taming of 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 of a more panoramic perspective. This is called awareness. (Varela, Thompson & Rosch, 1991, p. 26) Likewise, mindfulness is a state of 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 of one's experience itself. (Varela et al., p.22) The theory and practice of 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 of how our mind works and an appreciation of our thinking patterns allows us (as patients, caregivers or inquirers) to be aware of the process of perceiving itself— how interpretation and understanding are happening. Cultivation and practice of mindfulness is traditionally fostered through meditation. 22 The G/round of 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 of 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 of Westerners trained in Buddhist philosophy and meditative practices. These teachers and practitioners have led the way in interpreting practices and theoretical underpinnings of 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 of mind so that one can be free from suffering and be of benefit to others in our quest for happiness (Nyima, 1987). This broad intention is based on four assumptions or conventional 'truths' that provide the ground of '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 71 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. 23 enough (Loy, 1996; Trungpa, 1973). Human existence is said to be marked by: 1) the realization of impermanence of all phenomena (the transitory nature of all existence); 2) realization of no independent self, T , or separate identity; and 3) an underlying 'unsatisfactoriness' or pervasive undercurrent of anxiety despite periods of happiness and appreciation. From a Buddhist view, to acknowledge and confront this sense o f dissatisfaction, a form of 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 of 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 of suffering and propose a way out. The second noble truth addresses the question of 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 of 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 of losing what we have or hoping conditions wi l l not change. According to Buddhist thought, the most problematic attachment is holding on to a fixed sense of T . This aspect of 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 of struggling for permanence and a secure sense of T is a way to free ourselves from suffering. Through insight into the constantly changing nature of phenomena, we can let go of trying to make things other than they are and learn to ride with the constantly changing flow of 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 of ' 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 of 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. Nonduali ty N o concept is more ambiguous, or important, in Asian philosophical thought than nonduality (Loy, 1988). In part, this seems to be the crux of 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 of language. Although notions of nonduality may seem counterintuitive, they may also provide an alternative to modernist binaries. In part, this counter-intuition arises because most of us interpret our world by clearly distinguishing ' se l f and 'other', 'this' and 'that'. Furthermore, it is claimed that this kind of dualistic experience can be understood from the perspective of nonduality, but not in reverse (Loy, 1988). This wi l l , I hope, become clearer as this strand unfolds. 25 Put simply, duality can be understood as a separation of reality into discrete entities (e.g. self versus other, this versus that, being versus non-being) resulting in a "superimposition of 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 of us have nondual moments when there is simple experience without distinction of "I am experiencing." Traditional texts identify moments of shock, orgasm and the moment of death as examples of non-dual experiences (Sogyal,1993). Buddhist ontology asserts that ultimate reality is nondual (see previous discussion of 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 of conventional languages that lead to paradox and self-negation. In his text Nonduality, Loy (1988) presents three aspects of nonduality. These include: nonduality of thinking, nonduality of phenomena, and nondifference of 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 of 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 of dichotomizing is to promote choice of 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 of nondual thinking, David Loy (1988, 1996) uses the example of 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 of knowing that is inherently dualistic— there is no consciousness without an object of consciousness. Conscious experience requires a subject/object relationship 8 (Varela, 1991). Instead, wisdom is described as "knowing in which there is no distinction between the knower, that which is known, and the act of 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 of knowing that 8 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). 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 of discrete objects (including a sense of 'you' and 'me') interacting causally in time and space. Reification of this process renders concepts including 'sickness,' 'meditation,' ' l i fe, ' 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 of self from experience leads to a sense of 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 of 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 of se l f are viewed within Buddhism as interactive clusters of processes dependent on causes and conditions and empty of '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 of the complex processes resulting in a rainbow's appearance. However, to mistake the appearance of 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 of T and 'me'. The third and final aspect of nonduality is the nondifference of subject and object. Asserting a sense of subject separate from that which is experienced is understood as illusion; a mental construction of duality. Again, Buddhist philosophy claims that all experience is ultimately nondual. Our usual interpretation of experience as dualistic is merely a conventional truth and creation of mind that can be deconstructed and un- created through the practice of meditation. Consequently, the questions arising in this inquiry included: 1) how is the experience of nondifference of subject and object expressed, 2) how does nondual experience shape one's experience of 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 of other connections with one's life-world leads to unquenchable desire and suffering. How we come to experience the world as / /we were solid and 'real' can be understood through a theory of ego development. The term ego is understood differently from that of Freud in psychoanalytic theory. Ego here refers to an incessant activity of 29 identifying with the objects of consciousness (thoughts, feelings) and holding on to anything that maintains our sense of self-identity, separateness, and individualism (Welwood, 1979). Such repeated activity creates an imaginary ' s e l f and 'other' and the binaries of subject and object. Claxton (1986) explains, The sense of 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 of 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 of 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 of making and unmaking our sense of self. This process of self/ego development is known in Buddhism as the five aggregates or skandhas (Sanskrit). These five aggregates constitute one model 9 of how we experience 'reality' and together comprise a matrix that we identify with as personality or T . The five aggregates are identified as: forms, feelings, perception-impulses, concept- formations, and streams of 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 of language in efforts to explain what must be experienced to be understood. 9 See Joseph Goldstein (1987) and Mipham Rinpoche (1997) for a detailed description of the theory of skandhas. 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. 30 Further, the theory of aggregates is used as a heuristic to assist in our understanding of fear, frustration, and the painful aspects of life which are linked to beliefs in a fixed 'sense of se l f (Trungpa, 1975). Self-formation The importance of understanding the process of self-formation and how we construct our experience of 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 of meditation provides a way to see the construction of self as it is happening and therefore opens the meditator to a realization of the simultaneous doubling of self and selflessness. Such realization allows the meditator to see the relative existence of a self that functions in the world yet does not exist independent of causes and conditions. Although the process of 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 of self-constituting-self. Difficult emotions such as fear, craving, anger, and anxiety are predicated on a perception of a solid, essential self (Epstein, 1995). Epstein explains that through mindfulness, the constructed nature of 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 of knowing without imputing someone behind it all....To reach this point requires not the obliteration of ego but the development of mental faculties beyond those that are conventionally accepted as adequate for 'normal' functioning. The progress of 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 of 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 of self and its stories, any threat to this identity w i l l certainly result in some form of suffering. From this view, the threat of not 'existing' as a solid, essentialized being is the source of great fear (as a form of death) (Loy, 1996). A Buddhist view is seemingly pragmatic. That is, although we can do nothing to eradicate the inevitability of death, we have a prescriptive approach (meditation for example) to address the fear and anxiety of impermanence and non- inherent existence. Moreover, experiencing the constructed nature of self can be both fearful and liberating. Instead of thinking of oneself as a fixed nugget in a shifting current of 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 of our being. (Batchelor, 1997, p. 104) The notion of 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 non- existence of self renders life meaningless. Nihi l i sm is said to arise when we realize that our most cherished beliefs are empty and yet we are incapable of l iving without them (Nishitani, 1982). T/here in the experiential realm of being able to live well without 32 believing in the solidity of 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 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 My first experience with meditation practice was in India. It was a 10-day silent retreat. We were asked to maintain silence, avoid eye contact and physical gestures, and abstain from writing letters or in journals. We were asked to avoid participating in any kind of distraction....the idea was to simply be present with our own experience. Slowing down. Everything slowing down and becoming painfully boring. Why is it so difficult to simply sit still? Be present to the experience of being here now. What is this heavy sadness that envelops and 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 of sadness that makes one's heart break, when seeing beauty in snow-capped mountains, or a dancing plastic bag swirling in the wind? Or is this the sadness of lost loves, of wounds not healed, of a life set adrift in a sea buffeted by winds and gales in all directions without destiny or shore? Sad, Sob, Weep, Hurt, Heavy Hollow (W)hole. Simple words pointing to, a simplicity of human pain and suffering suffering and human pain. It's part of 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 discursiveness of mind chatters away commenting on this and that, wondering about this or that person sitting in the meditation hall. Wondering about why I m doing this at all, wondering about the erratic patterns of thoughts, emotions and feelings, wondering, ceaselessly wondering. There we are, sitting quietly in a large airy room; sitting in silence with our bellowing minds. As the days pass the texture of boredom slowly changes. Cool boredom, hot boredom, indifference. A quality of settling down, calmness and spaciousness opens up. The struggle to keep busy to hold on to this or that starts to let go. Letting go. Just sitting. Feeling the body, the simplicity of being present, the vast open sky of awareness. The process of perception has a kind of standing- still 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 of 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) The practice of meditation, as with many things in life, seems to contain paradox. In order to do nothing, one must apply some effort and technique. There are marked stages of 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 Brown (1986), most of the West's mystics practiced in isolation and may account for this view. However in the East, meditation practice was part of the larger social organization. For example in Tibet, some of the monasteries housed thousands of 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 of traditions where meditation was socially organized, a technical language for meditation experience evolved. ThisJanguage and body of 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 of 36 There are talks presented in the evenings to help explain the theory behind this experience of training our minds. The so-called 'inner sciences' of contemplative traditions have been studiedfor eons, since recorded time. Some enthusiasts have gone into caves for years exploring the nature of mind; identifying how it functions, what happens, the patterns and systems that arise. They share what they have learned and offer it for scrutiny. Try it and see. Examine and compare with your own direct experience. teaching. The language and complex theoretical explanations are not the direct experience of our mind. Simply experiencing our life directly is what meditation seems to be about. Instructions Well and good for yogis in caves, but I am an urban dweller with a job and day-to-day responsibilities. Label the thoughts thinking and come back to the present. Slowly a distinction between present and not present arises. A qualitative difference in being here and being lost in a world of abstraction.... "life passes us by while we 're busy making other plans "....nothing new, yet fresh. 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 of your body; bringing your awareness to the physical sensations of sitting on the chair or cushion, Now, place your awareness on your breathing. Be aware of breathing in and out, going out with the out-breath. 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 As the days pass in silence, the multi-layered dimension of experience becomes more evident. Impermanence and constant flow of thoughts, feelings, emotions, ideas. Awareness of holding on, grasping hold, struggling. Glimpses of space between thoughts. Gap. Open sky. N o matter what thoughts of 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 iv id luminous awareness, free from "What is happiness? This is happiness;" What is sadness? This is sadness." this is the nature of the mind of all sentient beings. (Khenpo Gangshar) Trungpa Rinpoche explains that when dwelling on thoughts, we are just producing more thoughts and never experiencing any of them. In fact, we do not even know we are thinking but are often lost in our fantasies. Suddenly awareness; little gaps of 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. A s I experience the quality of struggle in my daily life: a sense of 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 of nothing tangible about the struggle or the struggler. There is just awareness of what is happening. This awareness has a quality of 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 Ring 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 Fifth-month rain— poems posted to the wall , peeled off, leave traces. Matsuo Basho (1644-94) Hedda and I have been in Kopan Monastery for almost two weeks. It seems like months, perhaps years. M y sense of time has shifted since leaving Canada, and here on top of Kopan mountain, time is marked by dulcet gongs and shades of silence. This month- long course is called Lam-Rim, a Tibetan title translated as Graduated Path to Enlightenment. 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 of heaviness to arise and then suddenly.. .snap!... everything seems simple, uncomplicated and basically good. It all seems to circle around being right here in the midst of whatever is happening, in the thick, sticky layers of 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 of laughing, or sighs. We're getting to know the textures and 39 subtle pathways of our minds, becoming familiar, coming home. A t the same time we're resisting, protesting, and fearing the White dew ~ space, open ended now. Afraid i f I go out one drop ^ Q ^ . ^ j - g ^ a n c j i e a n m t o m e s j i e n c e \ on each thorn might disappear... Matsuo Basho Lighting the lantern the yellow chrysanthemums lose their colour. Matsuo Basho 40 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 of 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 of 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 of human nature. Increasingly, interest in meditation and Eastern techniques of consciousness transformation is growing in North America. While mystical awakening in some form is found in most cultures, Asian traditions of 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 of 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 of practices that 'train' attention in order to cultivate awareness, followed by a specific focus on the theoretic roots of mindfulness meditation that is emphasized in this inquiry. A s a generic term, meditation refers to disciplines that cultivate particular ways of paying attention in one's life. The disciplines range from the act of inward contemplation, to placing attention on an object of meditation, to the experience of complete absorption in the object of attention (Murphy & Donovan, 1999; Walsh ,1982). A t the same time there exit some misleading understandings of meditation commonly held in North America. For example, meditation is often understood to be: 1) a state of 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 of 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 of 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 of 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 of 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 (EEG) recordings using 19 scalp recording sites to differentiate between mindfulness and concentration forms of 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 of 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 of 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 of these practices by applying a technique to relieve symptoms. Kabat-Zinn (1996) suggests that the goals of relaxation training are primarily to relieve symptoms of 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 of circumstances" (p. 162). If one can say there is a goal, it is to cultivate curiosity and insight into the nature of mind, and experience directly what is present from moment to moment. Therefore, meditation is viewed as the intentional self-regulation of attention from moment to moment. Relaxation is a possible outcome but is not necessary to meditation itself. Types of Meditation The two most commonly used categorizations of 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; Mil ler , 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 of attention and whenever the mind wanders away it is gently redirected back to the object of attention (Delmonte, 1987). The mind gradually focuses solely on the object of meditation while conceptual thinking is progressively peripheral or suspended. A s one's concentration increases, background mental chatter decreases and states of calmness, relaxation and equanimity arise (Vanderkooi, 1997). A t the same time, the binary sense of subject and object begins to blur. Everyday experiences of focused concentration can evoke similar results; a sense of time and ' s e l f are lost, there is merely an experience of total absorption. 44 Concentration meditation is practiced in many contemplative traditions and was popularized in North America in the form of 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; Mil ler , 1993; Murphy & Donovan, 1999). The most prolific research on meditation since the 1960s has been the study of 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 self- awareness 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 of 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 of attention (e.g. breath), in mindfulness one is aware of whatever arises in the mind, only returning to the object of 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 of the mind without awareness of the process of thinking), then his/her awareness is gently returned to an object of 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 Kabat- Zinn'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 of 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 of 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 of struggling and suffering are reduced (Kabat-Zinn). These principles apply equally to all other sensations including fear, calm, and loss of 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 of it. A l l feelings and thoughts are recognized as impermanent phenomena that arise and pass away. Awareness of 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. 1 0 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 of mental conditions and states of mind. Staying at the level of sensation the body allows us to see everything much more clearly within that field of 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 of attention whereas mindfulness explores the breadth and clarity of awareness. Mindfulness has an immediate applicability to a wide variety of present-moment experiences and has a quality of'ordinariness' (Kabat-Zinn et al., 1992). A s such, the perception of ordinariness makes mindfulness meditation accessible to a broad range of 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 CARE The etymology of '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 of what is happening... in the space(s) between and around us.... Resting tenderly, still, With 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 of dying and death. Over the past century, Western understandings of death and dying have drifted, almost exclusively, into the province of science and medicine. Yet, we have much to learn from other knowledge and wisdom traditions; many of the world's cultures and great religions have considered dying an art that can be learned. Most cultures, before the rise of secularism, have had instructions on the art of dying. For example, shamanic traditions and indigenous peoples have preserved and orally transmitted their rites and rituals of dying (see Webb, 1997). Judaism's mystical teachings of the Kabbala and Zohar and the textual instructions of the Egyptian or the Tibetan Book of the Dead have guided the dying and their caregivers for hundreds of years. Nevertheless, an application of technology and the dominance of scientific perspectives have undermined our understanding of 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 of denying death. Two views of 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 of death denial is also challenged by the media's powerful sensationalizing and its role in shaping our 49 understanding of death and bereavement (Walter, Littlewood & Pickering, 1995; Mellor) . Meanwhile, the dominant role of medicine in public discourse of death remains intact. Cl ive Seal (1998) suggests that Western social and cultural life involves dichotomizing and turning away from the inevitability of death towards a focus on life. He submits that the formation of self-identity and constructions of 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 of 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 of the body. 1 0 Any metaphysical aspect of death is relegated as a personal and cultural belief system that is inexplicable, at present, from a scientific standpoint. The medical classification of death under the rubric of disease further illustrates Western medicine's influence in the public discourse. However, growing public distrust in biomedical solutions for those facing death and caring for the terminally i l l has been linked to the emerging role and prominence of hospice/palliative care movements (Dudgeon, 1992; James, 1992). i 0 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. 50 Contemporary hospice/palliative care movement The founding of 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. By 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 of 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 in models, the philosophy and principles o f hospice/palliative care remain focused on individualized, family-centered and compassionate care of the whole person at the end of life. The provision of symptom control with a focus on pain management was an important aim of hospice care from its inception. Saunders' concept of 'total pain' that includes the physical, emotional and spiritual aspects of suffering introduced a holistic perspective of the patient (Saunders & Baines, 1983). In addition, a holistic view of the person extended to the family as requiring care, and as such introduced the family as the 'unit of 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 of 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 of 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 of this literature conjoined the terms with an understanding of 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 in Canada, the etymologies of '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 of 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 of physical suffering (rather than total pain), and assistance with treatment decision making. On one side of 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. On 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 of discourses; the modernist discourse of medicine and the 'revivalist' discourse of 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 of the people for whom they care" (p. 117). In the context of this study, the interplay also includes the discourse of Buddhism within North American culture and how these discourses interact in the lives of hospice residents and caregivers. For the purpose of this inquiry however, hospice and palliative care are used interchangeably in support o f the original spirit of these terms and also in congruence with the Canadian Hospice Palliative Care Association's inclusive stance: Palliative care, as a philosophy of care, is the combination of active and compassionate therapies intended to comfort and support individuals who are living with a life-threatening illness. During periods of 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 of care. Palliative care is planned and delivered through the collaborative efforts of 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 of the therapies that provide comfort and support, the services of a specialized palliative care program may be required as the degree of distress, discomfort and dysfunction increases. Integral to effective palliative care is the provision of 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 of how palliative and hospice care are understood, there is growing interest in returning to other traditions and to the art of dying or artes moriendix 1 (Webb, 1997). Perhaps this response is due to continued concerns about death and Western medicine's inadequacy in addressing this human experience. Or perhaps, as Seale (1998) suggests, we are searching for new cultural scripts for interpreting dying. Two 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 of 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 of patient-centered care in constructing a contemporary discourse of death. According to Seale, death in hospice is presented as orderly, and an inner quest facilitated by knowing guides. Such a discourse of 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 of bravery, that is open to any human being who seeks a genuine and fearless existence" (p. 13). The battle metaphor evokes bravery required in l iving the "experiences and challenge o f being human" (p. 13). These parallels also contain equally significant differences such as the understanding of ' s e l f (and 'freedom') as presented in the Buddhist theoretical context of 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 of 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 of structure prevails. Interestingly, creation of 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 of nonduality and no-self are reminiscent of Seale's liminal space where a lack of 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 l iving longer with life-threatening illnesses, they are looking beyond individualized humanistic 55 care and taking the process of living with dying one step further than in hospice care. That is, there appears to be a shift towards adopting a transpersonal perspective 1 2 wherein the very process of 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 of psychology that studies psychospiritual development and transpersonal dimensions of human experience (Valle, 1998). Abraham Maslow, one of the first psychologists to explore and promote transpersonal psychology as a discrete branch, believed that there were states of awareness in which a human being could transcend the ordinary limits of individual identity and experience. Transpersonal dimensions include experiences in which self-identity, "extends beyond (trans) the individual or personal to encompass wider aspects of humankind, life, psyche, and cosmos" (Walsh & Vaughan, 1993, p.3). Valle describes transpersonal dimensions of 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 of 'transpersonal' removes this 'psychospiritual' phenomenon away from a metaphysics of spirit into the potentially scientific realm of mind and psychology. In doing so, notions of spirituality can more easily move into the health science literature (see Raeburn & 1 2 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). 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 of human experience of living/dying is required as interest in dying and death grows. Those who consider themselves non- religious are also interested in pursuing a deeper understanding of 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 of 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 of 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 of this inquiry. 57 Meditation and Dying: Death of the Body, Death of the Self Stephen Levine (1982) in his book, Who Dies?, presents an alternative conceptualization of dying from one of 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 of meditation in guiding the reader towards opening to death through learning to let go of each moment and opening fully to the next moment of experience, that is, "to die consciously moment to moment" (p. 249). Levine asserts that through meditation practice, we experience the rising and passing away of ever changing mind states that we strongly identify with as 'me'. Through repeated observations o f the arising and passing of 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 of self/no-self within Buddhism and the experiences of fear and suffering when the sense of self is threatened. Theoretically, through the practice o f meditation and seeing the moment-to- moment birth and death of the mind, the impermanent and transitory nature of our For many, disease is the way back into life. (Levine, 1982, p. 204) 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) experience, including fear and suffering, becomes increasingly clear and more workable. Levine suggests that once one begins to experience how the content of mind is constantly changing, the sense of a solid independent ' se l f begins to soften and a quality of 58 13 equanimity arises. The development of equanimity through such experiences of 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 of 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 three- month 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 of extreme bodily and mental changes. Among practitioners with strong concentration and mindfulness, periods of strong fear and insecurity were reported. These periods of intense emotion usually resolved by "surrender, by fully experiencing them, leading to a greater development of 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. 1 3 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). 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 of doing this. Specific meditation practices draw on the experience of self-forming and guide the meditators in visualizing and rehearsing the stages of 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 in these texts however, that the emphasis is on an interrelationship of living and dying. Preparation for death can be cultivated through regular mindfulness practice and becoming familiar with the inevitability of 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 of 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 of this l iving 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 of the San Francisco Zen Center integrating Western hospice care with Buddhist philosophical views and practice. The project is guided by a community-based Board of Directors, six employees and over 100 volunteers who are recruited because of 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 of hospice care within a broader context of 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 of 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 To 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 in a public hospital, and c) education programs for the public and volunteers. The residential program serves adults with a life expectancy of 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 of end-of-life care. Clients could not stay in their hotels or receive home care nursing without a primary caregiver that was required by visiting nurses. Further, due to the lack of 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 of Z H P in 1988. This program provides a model for private collaboration in 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 of the project. The Z H P supports a mutually beneficial relationship between volunteer caregivers and individuals facing death. Volunteers are provided with 40 hours of training certified by the California Sate Nurses Association and commit to 100 hours of service (Moore, 1996). The training includes the fundamentals of care, such as listening, bathing, turning and skin-care; however, the basis of 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 of the founders Frank Ostaseski notes, "Crossing the threshold of a room of 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 of 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 of 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 of 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 of meditation or experiences of meditation practice. Selected literature on mindfulness meditation is re-viewed to illustrate the differing voices and configurations of meditation in the literature, followed by identifying those voices that are absent. Most of 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 of meditation and its role in fostering spiritual growth and understanding (Astin, 1997; Hawkes, Hul l , Thalman & Richins, 1995). Murphy and Donovan (1999) conducted an extensive review of inquiries into the physical and psychological effects of meditation from 1931-1996. Most of 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 of meditation has received more attention than any other dimensions of meditative experience. Nevertheless, physiological outcomes remain the center of most research efforts into meditation. A re/view of studies emphasizing mindfulness 64 meditation vis-a-vis stress, anxiety, pain management and the experience of 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 of 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 8- week 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 of health concerns including physical and psychological symptoms of stress, chronic pain, anxiety, psoriasis, and fibromyalgia (Bernhard & Kabat-Zinn, 1988; Kabat-Zinn et al., 1988; Kabat-Zinn, et al., 1985; Kabat- Zinn, Lipworth, Burney & Sellers, 1987; Kaplan, Goldenberg, & Galvin-Nadeau, 1993). Much of the critique of Kabat-Zinn's earlier work has focused on the small sample sizes and lack of 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 of 22 participants examined the effectiveness of mindfulness meditation programs in psychiatric patients with generalized anxiety disorder, panic disorders, and agoraphobia, and found that M B S R can effectively reduce symptoms of anxiety and panic and help maintain such changes (Kabat-Zinn et al., 1992). Another area of 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 of everyday activity by pain, mood disturbance and psychological symptomatology including anxiety, depression and hostility. Kabat-Zinn notes that the central and underestimated therapeutic importance of 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 of 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 of distress related to chronic pain. Maximiz ing dimensions of human consciousness for achieving well-being, even in the midst of suffering, may be possible through meditative practices (Kabat-Zinn). To this end, further inquiry into understanding the underlying psychobiological mechanisms of meditation and the self-regulation of pain are required. With respect to adherence to the meditation practice, Kabat Zinn et al. (1987) reported that more than half of 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% of participants indicated they maintained that level of 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 of the literature. Brennan and Stevens (1998) explored the perceptions and experiences of cancer patients and the role of 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. Ast in conducted a randomized experimental inquiry with sense of control as a variable and found overall increases in the Sense of 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 of intensive meditation practice in retreat settings (7-14 day retreats). Craven (1989) cautions that meditation is contraindicated for clients with histories of 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 of extreme mental states in Western meditators, and the experiences of 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 of 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 of over identifying with non-ordinary states of consciousness and being unable to disidentify and let go" (p. 40). O f note, is that one person had a prior history of 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 of 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 of 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 of experiences is necessary to better understand negative experiences associated with intensive meditation practices. Critical examination of cultural constructions and interpretations of'negative' outcomes would also provide a better understanding of 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 of meditation far outweigh the negative results presented in Vanderkooi's study. Nevertheless, this qualitative study provides insight into the experiences of a small number of people and contributes to a broader understanding of 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 of meditation in various ways. For example, much of the early research did not take into consideration differences of sex, age, or socio-cultural background, and participants were frequently college students with no previous meditation experience. Further, much of 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 of the effects and outcomes of meditation, new forms of inquiry into the complexity and ambiguity of 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 of 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 of 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 of mindfulness and its role in accessing the experience of living/dying may best be explored using qualitative and aesthetic forms of inquiry. The challenge remains of embodying Buddhist meditation and its theoretical frameworks within existing approaches to inquiry. This inquiry is a study of mindfulness, using mindfulness as the path or method. Addressing complex human experiences o f moment- to-moment awareness requires new ways What was marked formerly by the firm and rigid shapes o f a Eurocentric geometry is now the fluid, shape-shifting image of chemical flux and transformation, as margins move to the center, the center moves to the margins, and the whole is reconstituted...The whole concept of center and margins is being transfigured by methods, methodologies, research practices, and epistemologies scarcely dreamed of a generation ago. (Denzin and Lincoln, 2000, p.1063) 70 S T R A N D T H R E E ~ P A T H O F I N Q U I R Y Zazen, hands cupped in universal mudra thumbs touching. Curiously aware of breathing and sensations o f awareness Muffled swishes of 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.... P A T H 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 of writing for the sake of 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 of structure while experiencing a space without structure and then later intentionally 72 creating the structure of koans.]6 In part, the topic and question of this inquiry seemed to necessitate an iterative process of structure and no structure. The experience of resting in ambiguity and confusion, of not knowing what the dissertation would look like seemed an important step. After al l , the glimpses of 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) of knowing the path and not knowing—for the sake of inquiry, as it was happening.... I wondered how the content and process of the study could be integrated—where boundaries could be open-ended.... I came to view the topic and path as inseparable, that is, in examining mindfulness and the experience of 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 open- ended 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 in 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- 1 6 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. 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 of 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 1 7. Underlying assumptions guiding the inquiry: 1) Interpretation is a practice that can only be learned through doing and is never complete.... 2) We 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 in 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 of reader and text.... 5) A text can convince and persuade through rhetorical power while simultaneously holding a view of its partial, impermanent, nature.... Underlying intentions in the path of inquiry: The analysis and writing were interlaced and not intended to necessarily discover new elements but rather: o To heighten awareness about the experience of mindfulness meditation in relation to living/dying from an interpretive location in Buddhist philosophy/psychology and to do this within the social/cultural/disciplinary context of nursing.... 1 7 I'd like to acknowledge Dr. Carl Leggo for his contribution to my thinking in this area during a course on Narrative Inquiry. 74 o To explore a complex picture that invites the reader into multiple dimensions of 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 of 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 of quantitative research exists on physical and psychological outcomes of meditation, little is known about mindfulness and its meaning for those l iving 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 of ways. In this inquiry, the concepts of'reflection' and 'reflexivity' were distinguished. The importance of this distinction lies in their underlying ontological assumptions. For example, within the notion of'reflection' is an assumption of something 'out there' that can be reflected back upon, as a mirror reflects back whatever is in front of 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 of 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 of reality through language is part of a postmodern critique of 76 research that has culminated in what Marcus and Fisher (1986) call a 'crisis of representation', that is, a crisis resulting from disrupting the belief in an underlying reality independent of 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 of a singular shared reality and supports notions of different g/rounds or realities that are continuously shaped and constituted relationally. Reality constructed by representations and therefore of 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 of meanings. The 'truth' of 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 of reality, constructed through languaged representations, where reflexivity is clearly distinguished from reflection. This view is also congruent with Buddhist notions of interdependence and relationality. These ideas are complex and run counter to the representational discourses in much of the Nursing literature in which I have been educated. A n d yet, a view of reality that is continuously constituted with each moment of 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 of how we are perceiving and then interpreting through language is an important aspect of qualitative inquiry that is currently undeveloped in the literature. In the current notions of reflexivity the ability to be aware of 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 of identifying what the belief is . . .rather the actual perceiving and then constructing of 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. To illustrate how reflexivity and mindfulness can be connected, I offer an example drawn from a nursing text: I was at the point of 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 of the emotional experience of 'feeling discouraged' and what was going on in the mind. The inquirer observed a pattern of classifying based on judgements of '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 of the discursive contents of mind, but awareness of the lived aspect of 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. 1 8 Varela and his colleagues call this mindful, open-ended reflection where reflexivity leaves open the possibility of something new. What we are suggesting is a change in the nature of 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 of experience itself—and that reflective form of experience can be performed with mindfulness/awareness. When reflection is done in that way, it can cut the chain of 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 of the life space. We call this form of 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 of what is going on in our experience even before the step of identifying our beliefs that shape what become fieldnotes or journal memos. Just as critical thinking and appreciation of 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 of this dichotomy) (Epstein, 1995; Trungpa, 1975; Welwood, 1996). The notion of mindful, open-ended reflexivity has been the path for all aspects of this inquiry. H o w this approach was specifically used in analyzing and writing wi l l be addressed in an upcoming discussion on 'Approaches to Interpretation.' 1 8 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. 79 I N Q U I R Y D E S I G N Specific details of 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 (SFZC) were the physical sites of 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 of programs including residential care, an extensive volunteer program, and training. The hospice program was founded in 1987 as a branch of 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 of 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 Apr 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 of mindfulness meditation and a non-modernist understanding of 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 of Z H P were people who had neither engaged in meditation practice nor were necessarily interested in this area, the hospice staff, as members of 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 of California in San Francisco (UCSF) and has many years of 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 of 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 l iving at S F Z C for the duration of 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 of an extension. This is indeed what happened and I spent the first ten weeks l iving 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 in 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 of an established Buddhist community and as a practicing nurse. After confirmation of participation was received, ethical approval from the University of British Columbia Ethical Review Committee was sought. The fieldwork had two overlapping phases. The first focused on immersion in the culture and practice of Zen. This phase emphasized developing a meditation practice as "intellectual understanding of the meditative processes is dependant on an adequate base of 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 Guest Student Schedule an introduction to Zen practice and an opportunity to establish meditation as an integral part of 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 Monday to Fr iday Saturday 5:00 am wake-up bell 6:10 wake-up bell 5:25 zazen (sitting 6:30 zazen meditation) 7:10 service 5:55 kinkin (walking 7:40 soji meditation) 7:55 zendo breakfast 6:05 zazen 8:40 break or 8:45 6:40 service zazen instruction 7:05 soji (monastery 9:25 zazen cleaning) 10:15 lecture 7:20 breakfast 11:00 tea 9:00 work meeting &discussion 12:30 end work- 12:00 lunch lunch 1:30 pm afternoon 1:30 work off 3:00 end work tea with a practice leader Sunday (once per week) or informal study 7:30 breakfast 5:40 zazen 6:00 pm dinner 6:20 service (optional) 6:35 dinner 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 of 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 of the residents were accomplished by volunteers. A journal or diabook was kept throughout. 83 D i a b o o k E n t r y ~ N o v e m b e r 9, 2000 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 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 story- a 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 l iving 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 of the phenomena of 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 of the recommended participants were known to me and were aware of the study prior to being contacted. Inclusion qualities for participants involved: a) willingness and ability to talk about experiences of mindfulness and its relationship to the experience of 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 of mindfulness to any activity such as walking, washing residents, or listening. 85 The rationale for suggesting at least one year of meditation practice experience was twofold. For most beginners, meditation practice is often approached as a ski l l that is applied in developing some degree of mental 'stability', that is, the mind is able to stay with an object of meditation for increasing lengths of 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 of regular practice provided a baseline to work with. Second, most current research on meditation uses participants with only a few months of experience (Astin, 1997; Kabat-Zinn). Therefore, this study would offer an understanding of 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 of the few people l iving 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. Or possibly, l iving with the inevitability o f death added poignancy to his awareness? His insights reflected those o f someone who has a good understanding of 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 of 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 l iving 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 Volunteers, Health care & hospice staff People l iving with H I V - A I D S Age (X) 49 range 35-61 42-48 Sex M 4 2 F 3 # of years of meditation (X) 16 range 6 - 2 8 years 6 months - 8 years # of years providing care at Z H P (X) 5 range 1-13 years Buddhist tradition 1 9 Theravaden 1 Vajrayana (Tibetan) 3 Zen 3 2 1 9 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. 88 Generating Data Approaches to generating data included reflexive participation in volunteer caregiving (ZHP) and as a Guest student (SFZC) , field writings, ongoing Buddhist study and practice, as well as in-depth taped conversations. Reflexive participation Participant observation is often used in qualitative inquiry and suggests a special form o f observation in which inquirers immerse themselves in a setting so they can experience the milieu in which study participants reside. Emerson et al. (1995) go even further in claiming that inquirers (ethnographers) must get close to the activities of everyday life and "take up positions in the midst of the key sites and scenes o f other's (sic) lives in 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 in reflexive participation or mindfully attending to experiences. This does not mean to imply that I located myself as inseparable from others, but rather in 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 of doubling 2 0 . 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 of data generation used to contextualize my experience of living/dying and mindfully caring for people in the end-of-life in order to be better able to 'hear' those l iving through this experience. Attending a 40-hour volunteer training and engaging in hospice service over a five-month period provided experience of the ordinary routines and conditions of mindfully caring for those who were dying. Approximately 250 hours of 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 of 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 of my discomfort in the role as inquirer. I attributed this to background vestiges of 'research' as maintaining an observer position and 'taking' something from people in the form of observations or their stories. The irony was in aspiring to conceptualize inquiry differently, and yet holding these conflicting views. Some strategies used in 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 of other caregivers and health professionals in their provision of service, b) my experience providing mindful care, and c) observations of the volunteer training program and monthly support meetings. Instead, fieldwriting(s) were spontaneous articulations o f whatever seemed interesting and in the forefront of 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 of 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 of 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 of 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 of 5-7-5 syllables 2 1 . A s haiku is seen as a form of meditation and a path of awareness (Strand, 1997), the congruence of content and process was appealing, hence I explored its use as a form of 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 of experience and knowledge would be an obstacle and significant limitation i f I chose to use it as a main form of 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 ~ Diabook November 2000- January, 2001 " d i d I get my hug?" s p l a s h i n g warmth and 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 g e n t l y , f l a c c i d , s a g g i n g , s o f t muscle b o u n d a r i e s m e l t i n g s i t t i n g q u i e t l y l i s t e n i n g , f e e l i n g , w a t c h i n g c u r i o u s d e l i g h t s ' 2 1 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 deviated from the form. 92 k i t c h e n t a b l e t a l k c o m f o r t i n g s i l e n c e w a t c h i n g f o r t h e m o u s e a n g r y a n d h e l p l e s s s p i t e f u l w o r d s s p i t o u t t o h a r m s u f f o c a t i n g i n s i d e a n d o u t t h o u g h t s f l o a t i n g f r e e l y n o l o n g e r h o l d i n g o n t r a n s p a r e n t l y c l e a r p i n k b o u g a i n v i l l e a s h a d o w s c a s t o n t a b l e t o p a u t u m n ' s m o r n i n g l i g h t s i n g l e b i r d f l u t t e r s . s o a r s t h r o u g h t h e e v e n i n g s k y w i t h o u t a t r a c e , g o n e s t r e e t n o i s e f l o a t s t h r o u g h i l l u s i o n s o f i n s i d e - o u t s i d e m o m e n t a r y c h a n g e Audiotaped Conversations Kvale (1996) traces the etymology of conversation as 'wandering together with ' (p. 4) and perhaps better illustrates the kind of inter/views that we engaged in. Participants were invited to talk about meditation and how their practice shaped their experience and understanding of 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 of 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. Upon examining these transcripts closely, this seemed to occur i f I was not listening attentively or, conversely, when I was following their wave of 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 of 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 of excitement, as i f something had happened, and was followed by mutual expressions of 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. As these authors caution, i f the inquirer's perspective is interjected too soon, the participants "gestalt that is destroyed" (p. 32). Unlike the goal of achieving saturation or until new findings consistently replicate earlier ones (Sandelowski, Davis, & Harris, 1989), the number of 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 of 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 open- endedness imbued through participants' voices. Clearly, transcribing was re- 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 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 re- construction is read and re-read it is always in progress, partial, and contingent 96 shared space of conversation into Aramaic symbols on a page. Initially I hesitated in numbering the lines on the transcripts as the mere presence of numbers also altered what was a personal conversation into an object o f analysis. However, as the practical implications of 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 of '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 of 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 of the conversation. Even so, the emphasis became the record of what was verbally spoken.... In contrast, what was said... and unsaid, seemed to rest in the context of the conversations that was lost in 'verbatim' transcriptions o f the spoken words. Once again this reinforced the partial, contingent quality of all interpretations. Nevertheless, I 'transcribed' pauses with spaces to visually and rhythmically invoke the cadence of the speaker's voice and included other verbal responses such as sighs and laughter. Some words like "ah" or "um" 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 of changes to the original transcription. 97 Diabook Entry ~ 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. I feel 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 and follow 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 of 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 of the proposal. Informed consent was obtained from participants (see Appendix B) and copies of their transcripts were provided for those who were interested. Participants were given explanations of the study and their right to not answer questions, request that portions of the tape be erased, or withdraw at any time. Even though participants were informed of the topics for discussion, I was aware that talking about their experience of 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 mis- interpret 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 of 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 of the project, all identifying 99 information wi l l be destroyed. The data wi 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 of 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-in- view and was the path guided by the inquiry question? Narratives are fashionings of language which vary immensely in their degree of structuredness and of adherence to prescribed standards of form—which seek to make sense of and be adequate to experience, as it transpires over the course of 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 of 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 of hospice and Buddhist meditation. How that transition occurred is addressed in the following discussion of 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 of 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 of 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 of A I D S . . . . We do not study lived experience, rather, we examine lived textuality. (p. 33, parenthesis added) Lived texts are representations that are themselves embodied representations of 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 of 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 of representational discourse(s) and bring us to the limits o f language? The texts and generated 'data' were understood not as carriers of fixed meaning that can be recounted, but as sites of ongoing negotiation of meaning and possibility. A t the same time, there were terms and phrases used during the conversations that assumed some shared understanding of Buddhist philosophy and practice. The question arose, to what degree is this inquiry an 101 interpretation of meaning that is never fixed but embedded in a context of Buddhadharma that calls for 'translating' some of 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 of 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 of 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 of 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. Also , 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 of a seamless story is not at all reflective of the inquiry process or of life itself. The modernist narrative of 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 in 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 of 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 re- interpretations... 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' of the narrative. The intention of the first step was to develop a sense of the whole before fragmenting the narratives. 103 b) Finding a way to 'behold' the conversations in a space of 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 of dwelling in the midst of perceiving without interpretation, that is, "perceiving without thinking of anything1 '(p. 78, italics added). The Snow Man One must have a mind of 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 of any misery in the sound of the wind, in the sound of a few leaves, which is the sound of the land full of 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 of what is absent (the nothing that 1 0 4 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 of the 'unsaid' while trying to avoid the aforementioned traps of ascribing meaning or ignoring completely the absent. Anderson (1998) encourages incorporating intuitive processes such as meditation and alternative states of consciousness as aspects of analysis and although not always successful, the process of 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 of how participants responded to the inquiry question, 1 began 'content analysis.' Using coloured pens the transcripts were coded based on: a) history of 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 of analysis was made, I believe, because it was consistent with all of 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 of analysis. I found my attention constantly wandering with a feeling of heaviness and drudgery as I returned to the 'task' of coding. The vitality of the texts was lost and I soon abandoned this step. Gaining a sense of the aforementioned questions was more easily attained through simply 105 reading and re-reading the texts without dissecting them. Moreover, this line of questioning, although useful in the beginning, seemed to be a side-step. d) Identifying and dialoguing with themes Themes began to be noted. With a 'slow reading' of transcripts, a process of 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 of koans using a conventional format of 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 of the koan provided yet another interpretive form. Using a koan structure allowed both an 106 Eastern approach of privileging concepts by intuition, that is, beginning with what intrigued and interrupted, and a Western privileging of 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 of 'this' and 'that', 'me' and 'you ' , 'past' and 'future'. Cases or stories known to lead to such insights were posted publicly with the hope of benefiting others. Perhaps some of the best known one-line koans in the West are: "What is the sound of one hand clapping?" "Where is One?" "What is your original face?" Most koans are formed from baffling stories of Zen masters and are used today by meditation students to assist in going past conceptual thinking and opening one's heart- mind 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 of 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 of the koan, meditators engage their question with a concentrated introspection far beyond the reach of 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 of 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 of recorded koans, Roshi Philip Kapleau (1989) claims that the best koan is, " the perplexing inquiry that arises naturally out of 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 of mind where insight ensues 2 2; rather, the structure was adopted as a procedure for exploring new ways of thinking and languaging the existential issues related to living/dying and meditation. The metonymic texture of koans provides a space in which both conceptual and non- conceptual approaches to these inquiry problems could be explored. 2 2 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 2 3 were received during a course on Contemporary American Koans at the San Francisco Zen Center from October-December 2000. The Shallow Meaning is Enough K O A N C A S E 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 of life." Laughing, Roshi replied, "For you, the shallow meaning is enough." C O M M E N T A R Y 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? Maezumi Roshi points to our pride. V E R S E If you look for the deep you miss the shallow If you settle for the shallow you miss the mysteries of the Deep Perhaps Basho's frog is to the point S P L A S H ! 2 3 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. 109 Don't Lose Your Critical Intelligence K O A N C A S E Khandro Rinpoche was giving a set of teachings and a woman asked her: "What should we do with anger? How should we deal with anger?" Khandro sharply replied: "Anger is always a waste of 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!" C O M M E N T A R Y Khandro Rinpoche is one of the few female Rinpoches in the world of Tibetan Buddhism. Born in India in 1967, she is a teacher in both the Kagyu and Nyingma traditions. At Dharma Centers in the West, lectures, classes, and workshops that talk about anger often generate lots of interest. Expressing anger or suppressing anger are two popular modes but Khandro Rinpoche points us in a different direction. Do you push people away, do you deny what you feel? Perhaps there is another way. Don't lose your critical intelligence! V E R S E Boi l ing vats o f oi l 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 of the inquiry. This koan was selected because it directly addresses the broader questions underlying the inquiry and provided a starting place of perplexity. As 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 of empty spaces and places of self/no-self of birth, old age, sickness and death. Mindful of basic impermanence of living and dying, abiding in spaces of ceaseless transitioning F R U I T I O N 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 of 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 of logic. Other traditions, including Zen Buddhism, avoid what is considered excessively conceptualizing that which is non- conceptual and use heuristics such as silence, koans, and non-directive meditation practices to exhaust the logical into spacious clarity of 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 of non-conceptual heuristics. In Buddhist fashion, a middle way applying the structure of koan, commentary, and verse are used in this Fruitional dis/play. 113 K O A N C A S E 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 of 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 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 2 3 C O M M E N T A R Y Stan's comparison that parallels meditation and dying points to an interpretation o f dying that goes beyond conventional Western perspectives of locating death in the body within linear time. Rather than situating death at the end of a life-line, death is constructed as a momentary experience, occurring every mind-moment. This, according to Sogyal Rinpoche (1993) is the revolutionary contribution of 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 of mind and its role in living/dying provided the context of our discussions. A n attitude of 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 of life. Although fear and resistance were expressed during our discussions, death and dying also evoked 2 3 This case is a combination of quotations from two different participants. They are combined to more fully demonstrate a perspective of the relationship between meditation and dying expressed by several participants. 114 curiosity and interest as this koan case demonstrates. Before examining the central theme of parallel processes between meditation and dying, the notion of 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 of or in- between 2 4. To be interesting is to be neither fixed nor finite, but (-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 of liminality infers a bounded space of transitioning between these states o f being whereas liminality is used somewhat differently in this inquiry vis-a-vis living/dying. Here, oppositional states of living followed by dying are merged with an emphasis on the inseparability of living/dying in a liminal space of 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 2 4Hawkins, 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]'s an in- between 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. So it is an in-between phase...a liminal space (Gary, participant) 2 5 Hospice is seen as both a physical and mental space or as Seale (1998) describes, "an institutional construction of liminal space" and "a separate state of 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 dying and meditation as parallel processes?' The commentary begins with the g/round of how mind is re-interpreted within this inquiry, followed by thoughts on the path of mind as 'doubling' or 'interplay', and culminates with a fruition of meditation and dying as parallel processes How 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 of 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 of us are firmly ensconced in our ideas of reality and have difficulty conceiving other dimensions. In particular, participants situated in Buddhist views and practice, within a modernist society, articulated other ways of conceiving mind and its relationship with living/dying. Situating M i n d Although Nursing has a long tradition of philosophical inquiry into what it means to be human and engage with others in illness and death, the nature of mind and its functions are 'we 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 of 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 of thought since the Greeks, the understanding of mind has been approached through the means of abstract, theoretical reasoning (Verala et al., 1991). Although psychoanalytic theory comes close in turning away from reason as a means of 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 of dreams, that person is knowing the mind and commenting on it in an after-the-fact fashion, (p. 20) In other words, even psychoanalysis remains in the realm of abstraction. That is, when approaching mind, the tendency is to examine its contents of thoughts, symbolic referents, and feelings which is to explore its projections o f ideation and emotion. Rarely do we explore 'that' in which all of the contents of mind arise (Lief, 2001). We are often caught in the activity of 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 of perception" 2 6 (Thera, 1962, p. 30). Attention is understood as 'bare' because it relates directly with that which is perceived through the six senses without reacting, critiquing, or self-referencing with judgements of l iking or disliking. In other words, direct perception, including direct awareness of thought, is privileged over the dualism of thinking 'about' or discursiveness. Although the primary approach for 2 6 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). 118 understanding mind is through this process of raw sensory experience without conceptual commentary, theoretical models and descriptions of mind also abound. Participants varied in their interest and appreciation of the theoretical aspects of mind, be it Buddhist or otherwise, yet all participants were drawn to the practice of meditation and it was this direct experience of 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 of 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 of 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 of mind, concurrent with a way to examine mind directly via non- conceptual meditative experience. It is this combination of 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 of mind is seen as the most significant element in our experience of 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 of the World Trade Center in New York City and retaliatory measures in Afghanistan and around the world clearly demonstrate the repetition of 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 of our own mind (Thera, 1962); this advice remains timely. A s the primary object of investigation, [the] mind and consciousness are explored through various theoretical schemas in different schools and traditions of 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 of mind helpful in interpreting 2 7 See Kalupahana (1992), A History of Buddhist Philosophy, for a detailed discussion. 120 descriptions of awareness provided by participants2". Keeping in mind however, an old Zen saying that "as soon as you talk about a thing, you miss the mark" (Austin, 1998, p. 295), two aspects of mind and their interplay are offered as one of many possible interpretations of awareness that lays a g/round for exploring living/dying as a metonymic phenomenon.... The analogies of sky and clouds are traditionally used in Buddhist texts when referring to the phenomenon of mind. The first aspect of mind, known as sem (Tibetan), is often translated as 'conventional' or 'ordinary' mind (Sogyal. 1993; Trungpa, 1981). Likened to the formation of 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 of 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 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 2 8 '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. 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 of what is happening during successive moments of perception. It is important to note the subtle quality of 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 of awareness that goes beyond and yet includes oneself seems important as it mitigates self- consciousness or fixing awareness on ' s e l f as separate from one's environment. According to Zen teacher Dogen Zenji, "To 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 of 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 of mind is rigpa (Tibetan) that is more challenging to articulate and is described as direct, non-dualistic, ineffable awareness that is the nature of mind (Dalai Lama, 2000). Analogies o f boundless sky and unobstructed space are often used to depict the nature o f mind or rigpa. L ike space, it is said that rigpa is ever present, clear, without causation and accommodates everything. Rigpa 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 of the dissertation it became clear that my interest in the topics o f metonymy, dying, and meditation are manifestations of 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 of openness, we quickly lose track and return to our habitual patterns of 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 of 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 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 of us can identify with what ordinary consciousness feels like; we're in it. Ordinary sem functions through awareness of 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 of 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 of fear and uncertainty as he lets go of 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 of awareness revealed to Manuel an underlying sense of 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 of himself was directly linked to his narrative of 'other'. A s he stated, "I 'm me relative to this person"-- his identities of self and other were interdependent and temporary. In that brief pause, Manuel seemed to experience a metonymy of shared connectedness with his co-worker concurrent with a dissolution of 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 of 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 of meeting one's mind or mind-heart. The mind-moment of doubling exemplified in Manuel's story revealed a flow of experience that had been obscured by a priori perceptions of not particularly l iking his co-worker (or alternatively, it could have been a hospice resident, etc.). In stark contrast, 125 the sudden interruption of 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 of 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 of 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 of 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 of "falling apart." Why fear? Was this fear of groundlessness and no longer being certain? Was this fear of change and the unknown? Was this fear of death, death of the 'selves' that he had taken for granted? Manuel suggested that the unsettling of what had been previously known and assumed to be real was the source of his fear and then wondered i f this momentary experience was indeed 'naked awareness'—direct, non-conceptual experience? In understanding mind as a doubling of ordinary (sem) and non-conceptual (rigpa) awareness, was this a flash into the interplay of mind? A n d as is often the case (Epstein, 126 1995), did Manual quickly identify with the contents of his mind—his reaction of fear, and thereby obscure the open-ended quality of 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 of our projections. A s Stan shared regarding habitual patterns of 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]. Linking back to Manuel's story with his co-worker, he attributed its occurrence and his awareness of it to meditation practice. That is, he was developing new habits of awareness and attending to the subtle perceptions and emotional terrain that arise every moment. Meditation practice allows us to first recognize these moments of 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. So 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 provides meeting places with individuals we may be serving.... (Gary) In the open g/round of awareness, we can be receptive to whatever thoughts and emotions arise. Just as the sky absorbs storms and its plethora of cloud formations, we can learn to accommodate all manner of mental contents whether it is fear of death, 127 anger, compassion, bliss, or despair. Also , 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 of 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 of potential wakefulness wherein we can meet our mind directly. Doubling of life-and-death Re-cognizing mind as a play of ordinary and non-conceptual awareness avoids materializing sem and rigpa as ultimately separate aspects of mind. M i n d can be seen as a process of doubling that includes the content and functioning of ordinary thinking within ineffable awareness, while simultaneously generating something new. A s a generative process of life and death in a mind-moment, the birth of new beginnings arises. In the story of Manuel, he was going along 'as usual' when suddenly his train of 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 of previously held views, an open space of 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 mind' and is considered an open state of 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 in the in-between spaces o f awareness in each mind-moment. Rather than a bounded space between two illusory extremes such as birth and death, liminality is in this inseparability of birth-and-death that embraces and goes beyond these apparent oppositions into new possibilities. Like Manuel, we wander into and out of these spaces where predetermined narratives of the world are suddenly seen as translucent. Sometimes when these dis- ruptions are subtle, we pause briefly but usually carry on with our familiar behaviours without noticing the fluidity of experience. However, as one participant stated, some disruptions are not so subtle, such as a life-threatening diagnosis of lymphoma that "is like being whacked in the side of 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 of 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 of mind Inquiry participants used mindfulness meditation as an approach for understanding their minds and experience(s). A s in most Buddhist meditation practices, experiences of 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 of 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 of inspecting one's experience closely, whether it was the sensation of air entering or exiting the nostrils, or the sensations and movements of 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 of someone or some aspect o f mind being aware of something, this is theoretically inaccurate albeit experientially true for many beginning meditators (Wallace, 1999). That is, there is a sense of '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 of mindfulness is that ' i t ' is a process of 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 of 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 of something in particular, but is like an overall memory of or feeling about something. For example, with the experience of deja vu there is a vivid memory that something happened, of 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 of the happening but not necessarily the details. It is this experience of '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 of application in terms of growing yourself, but a process of undoing yourself. There is a sudden sharp jerk, a gap of undoing, ceasing to act. When you cease to act, the mindfulness enters into your system of being. That seems to be the basic meaning of 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 of ideation, sense perceptions, and emotional experience. This process of examining mind's projections and patterning is more akin to introspection or phenomenology. For Immanuel Kant, for example, phenomenology was the study of 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 of phenomena of experience (mental contents) while unmediated awareness addresses that 131 which is 'unknowable' in the sense that it is beyond concept— primordial awareness. z y 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 of awareness without discursive thought—simply perceiving as is....things-in- themselves. 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 mid- stream throughout the weekend workshop and asked, "Do 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 of 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 of 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 of each moment, in the stillness within action, and in the stillness of death. A l l stillness; the same and yet different.... Who is reading and experiencing this right now? Where are you? Where is . . . . 2 9 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. 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 of 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 of becoming familiar with death through their parallel processes. The degree to which meditation practice has shaped the participants' sense of intimacy with dying and whether such familiarity has an impact on levels of 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 of life is attributed to physiological changes and psychological factors such as feelings of chaos and approaching doom so that an individual becomes less wi l l ing or able to exert themselves as they once did. From a physiological perspective, signs of 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 of reflexes (Samaral). Notably, all of these indicators have a quality of 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 of this inquiry. Conventionally, in Western understanding of the self, we understand 'inward' as relating to feelings, thoughts, and imaginings and 'outward' as oriented to the physical world outside of oneself. However, in meditation practice inward is viewed in a radically different sense. Shear and Jevning (1999) explain, 135 [In meditation]... even awareness of 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 of one's mind's eye', so to speak, and ' inward' referred to here is intended to indicate a complete reversal of 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 of meditative awareness, but may also mislead in creating a false dichotomy through reifying the concepts of mental contents and awareness and presenting them as objective phenomena to be turned away from. Turning inwardly outward 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 of 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 of experience as it is happening without holding on— 'bare attention'. Attention is in-between inward and outward. One participant's description of 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 of directly experiencing successive moments of perception and subsequently shares how shifting in- between 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 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 3 0. Complete silence was maintained during specific times and in the dining hall for the first ten minutes of the evening meal. Silence provided a context for attending to both the active contents of mind and the inward stillness of 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 of additional silence, I impulsively escaped into conversation, back into the 3 0 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. 137 familiar world of speech where the terrain was comfortable and the discourse less edgy. Why is silence so often unsettling? This experience of 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 of silence is often to close-in awareness by not engaging and not noticing—or at least pretending not to be aware of 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 of 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 'now. ' The meditative element in these situations lies in first, recognizing one's discomfort (or whatever arises) and then not sliding away into 'trains of thought'—thereby limiting one's immediate ongoing awareness. With practice, one soon recognizes the transparent, transient nature of thought itself within broader awareness3 1 so that the allure of thoughts and images no longer closes off one's awareness into abstraction. The outcome of this kind of awareness, based on practice and 3 1 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. 138 interactions with long-term meditation practitioners, corresponds with Wallace's (1999) descriptions of the effects of samatha meditation that include: an increased capacity for concentration, cheerfulness and lightness of mind, increased mental and physical pliancy, and fewer and less intense afflictive emotions such as anger, craving, and fear. 3 2 In particular, participants described changes in responding to intense emotional episodes of anger, depression, and despair as an outcome of 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 of 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 Staying connected with the flow of experience and seeing what happens as we move in-between into somewhere (a)new.... Experiences of 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. j J The affective qualities of heaviness and angst did not necessarily go away, but a concurrent awareness of 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 of 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 don't need to wallow in 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; Kabat- Zinn, 1985). Fear of 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 of 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. By attending to the finely woven and uniquely patterned unfolding of momentary experience, we can learn to let go into the flow of each out- breath.... Great is the matter of birth and death, Quickly passing, gone, gone, Awake, each one awake, Don't waste this life. Zen Saying 142 Lett ing go Nobody wants to suffer and Buddhism re/cognizes the inherent suffering embedded in the experience of 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 wi l l always be dissatisfaction; this is part of the human condition and the im/possibility of sustained happiness. From this view, such suffering is a form of 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 of 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 of awareness or with the next breath. Mindfulness is learning to sit in that awareness without judgement, without speculating - simply being open and receptive to whatever is 143 arising in the unknown space of the next moment, and the next. Experientially, one's sense of 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. Like meditation, death is also stepping into an unknown of 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 of turning away from direct experience and thereby holding on to conceptualizations of 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 of discursiveness while staying connected with embodied experience as it unfolds unceasingly with each breath. This process applies to all aspects of experience, including dying and death. relates to death, dying and 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 of thought, feelings, and themes that constitute one's experience and sense of an experience?*. Instead of holding tightly to the dominant concept of a unified, essential self, we begin to experience self as a composite of thoughts and sensations arising moment-to-moment as solid identities 144 come into question. The grip of T am essentially' this or that loosens as meditation practitioners begin to see through and let go of 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'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 of 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 of '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 of 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 of identity loss (Wellwood, 2000). These experiences—momentary or prolonged, in-between the dissolution of one textured mask and the construction of 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 of Arthur Frank's (1997) and Shunryo Suzuki's (1970) perspectives on the experience of groundlessness illustrates differing interpretations of the role and benefits of letting go of narratives and provides alternative views on conceptual mind as a point of reference in situations of potential loss of 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 of 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 of 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 of agency the narrative affords the i l l person. For example, in the restitution narrative, the storyline is one of 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 of independence and individuality. Frank's sense of the transparency and possibility of 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 of meaninglessness is untenable from a Western perspective, this seems to be the crux of the matter. Even so, the point of departure between Frank (1997) and Suzuki (1970) rests in the centrality and importance given by Frank to the self-stories for people l iving 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 of tragedy and the reliance upon language in order to remain available to oneself where meditators in this inquiry, and Buddhist practitioners in general, differ from Frank's (1997) understanding of self and death. A s in Buddhism, Frank views the end of the self-story as a form of 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 of 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 of one's self-story as a 147 realization of self-lessness and therefore as an experience of liberation rather than tragedy. Yet, what of 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 of existential anxiety where the world as we know it falls away— an habitual Western response, as exemplified in Frank's approach, is to f i l l 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 of 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 of a predetermined self is seen as liberation from suffering rather than Frank's notion of tragedy. According to Suzuki, " in 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 of 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, in Zen practice, the beginner's mind is cultivated in all stages of life in 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 of 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 of 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 wi l l be. Letting go of 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 of ongoing narrating.... 149 Letting go of 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, in order to re-mind ourselves o f cherished moments o f the past. After al l , where is the fullness of life without dreams of the future or memories of the past? A n d yet Eliot (1976) teases, "to be conscious is not to be in time" wherein the poet introduces a notion of 'without time' and the possibility of situating between time and timelessness. Eliot invokes a metonymy in the midst of time-and-timelessness where, "only through time time is conquered." Conquering time in Eliot 's poem and in the context of 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 of 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 of abiding with whatever arises and passes away instead of pushing away or holding onto fixed ground. By interpreting time as a complex construction, one can see how 'letting go of time' is linked with the previous notion of 'letting go of fixed mind' where 'time' is a fixed concept. That being said, the metonymy of time/timelessness holds a particular 150 significance in this inquiry where a sense of time is not only an abstraction but a dynamic experience. In part, the significance of 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 of transitioning moments, 2) a privileging of present time or 'nowness', and 3) the disappearance of 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 of 'free time' or the taut constriction of 'running out' o f time, the symmetry of 'being timely' or the paradox of 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 of time that then becomes interpreted as our time. For example, our sense o f time shifts and changes depending on internal and external circumstances. On 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 of time are reduced and time is tailored to the wishes of the dying person. Consequently, perceptions of 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 of 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 of time that Geertz (1973) suggests have "an unbreakable internal l ink" 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 of 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 of 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 of human existence. Dr. Sherwin Nuland, a clinical professor of 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 l iving from dying and one must ask how viewing ourselves as finite entities that cease to exist with death might shape our perception and experience of 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 in its wake. He links this impossibility to our notions of 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 of 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 of thought are evident and the binary of life then death becomes problematic. In the preface of his Pulitzer Prize winning book The Denial of Death, Ernest Becker (1974) states what is echoed by many Western thinkers that the finality of death haunts us like nothing else, "it is a mainspring o f human activity—activity designed largely to avoid the fatality of death, to overcome it by denying that it has the final destiny of 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 of course prepared to maintain that death was the necessary outcome of 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 of 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 of 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 of life then death remains a universal principle in Western medicine and nursing, with a linear trajectory of our life-time eventually running out full stop. Cyclical time In contrast, the wheel of 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 of time. Time becomes linked with a circular image where birth and death refer to constructions, deconstructions and reconstructions of the sense of self rather than the dissolution of the physical bodymind. Even so, physical death is also seen as a transformation or re-cycling of the bodymind (addressed in the following section re: dissolution). 154 The materiality of time comes into question when the experience of ' 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 of self begins to destabilize and as this occurs in meditative experience, metaphors shift from spatial representations of 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 of change, who or what dies? How does this experience of self change one's perception and experience of death? According to participants, as we see more deeply into impermanence, we start to see the pervasive inevitability of change and that, according to one participant, diminishes fear. After all , i f we are change, then death is presumably another form of 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 of death simply because there is a sense of someone who can be threatened by annihilation. However, upon closer examination of this someone, an individual cannot be 155 found except in the form of constantly changing patterns of perceptual awareness in thoughts, feelings, sensations, emotions. 3 4 Rather than the finality of death—full stop, there is a quality of open, uncertain, movement. In a Buddhist context, death is not the end or final condition but is "one moment in a larger journey of 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? How is it that being in the moment is experienced as beneficial? For two participants l iving with H I V - A I D S , the tangible certainty of death makes l iving 'now' quite poignant. There is, after al l , no other moment, only imaginings o f past and future conjured up in the present. So-called l iving in the past or future is either planning or strategizing for the future or re-thinking 3 4 This type of analysis is conducted formally in Buddhist meditation traditions and is known as analytic meditation (see MacPherson, 2000). 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 Tulku (1974) instructs: It's possible to make thought itself meditation.... How 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 of awareness because you reject your experience and become separate from it.. .But i f our awareness is in the center of thought, the thought itself dissolves.... A t the beginning...stay in the thoughts. Just be there.... Y o u become the center of 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 of crack each thought, like cracking nuts. If we can do this, any thought becomes meditation (pp. 9-10) Judith L ie f (2001) speaks of 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 ie f suggests past and future breaths meet. A gap. Placing your attention on the sensations of breathing, what happens as your breathing is neither in-coming nor out- going 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 of perception. Without this kind of 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 iv ing 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 of direct sensual experiences. Directly perceiving one's life unmediated by discursive distraction was experienced as dynamic, vivid , 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 of human life and death became not just philosophical speculations, but aspects of participants' experiences. Some attributed being in the moment to a freshness and 'seeing for the first time' or seeing things differently in 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 of living/dying, training one's attention to letting go of thoughts of past and future, and abiding in present experience leads to unmediated experience. Disciplined meditators can directly perceive subtle impermanence and selflessness that puts them in touch with unique moments of reality as it is (Sogyal, 1993). Unmediated moments of sadness, despair, beauty, and delight allow one to see the fluidity of 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 of turning inwardly outward and letting go, the third configuration is the dissolution of bodymind at the end of 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, Gold Bond lotion, Vaseline and Gekkeikan sake. Small seedling of potted pine adorned with colourful bobbles, Red box of Cheez-its, salted cashews, bags of chocolate-mint wafers and chips. Left-over fortune-cookie prophecy, "you are about to change your line of work." Old poet snoring mouth agape, a gap long periods of silence long stretches of 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 of drugs and booze going places, staying still. Sti l l here. i i i 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 of night guardians, well meaning, yet inattentive... or unable to see? "Good 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. Are 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 of 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 of 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. Your rheumy gaze is fixed; one eye is neatly patched with white gauze while the other looks directly ahead drawing me into its vortex of darkness without bounds. "Oh Martin", she says softly, gently caressing your head. "He's gone". Wi th a twinge of 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 on . . . " and she bends down touching the crown of 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 of yellow and gray. 161 Except for the computer's hum and the soft gurgling of the fridge in the other room, the house is quiet. Silence is conducive to this process of imagining, re-visiting Martin, re/living the experience going deeper into mindscapes of remembering, evoking images, memories, andfeelings of yesterday. This recollecting has multiple-layers woven through by slowing down and leaning into the gentle swirls of imagining Looking out the window the drizzle of rain and subtle sway of branches catches my eye. The rains have finally come, much needed after this long spell of dry. I enjoy these wet, dark, days and allow my mind to wander, thinking of the maligning of rain by many urban dwellers. I think offarmers and firefighters at this time of year.... It's two o 'clock. The swish of tires from a passing car on the road brings me back; the computer hums softly. Martin's absence is felt. His 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 of 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 of caring brings intimacy and relaxation into the stillness. Quietly and with lightness we move through and into the curious edges of this inevitability that is death. 162 Dissolution of 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 of the universe into the four basic elements of earth, water, fire, and air. According to Stephen Hawking (1988/98) in A Brief History of Time, this division of 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 of 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 of 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 of movement. Thera (1962) suggests that by closely examining experiences into these elemental qualities, the actuality of phenomena becomes apparent; just as Michael realized, the 'idea' of pain did not exist in his direct experience even though a varied display of sensations arising and passing away were noted. According to Michael and Buddhist theory, this constant unfolding of sensation was interpreted as an interplay of elements— the constituents of experience. 163 Inner and Outer Manifestations of Elements Tibetan Buddhist teachers present an elaborate system of subtle psychophysiology based on the elements 3 5 and add a fifth element of 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 of thoughts, mind states, and emotions. For example (see Table 2), the inner elements of 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. Element Outer- sense perceptions Inner — mental states, emotions Earth - texture Sharpness, heaviness, pressure, etc. Eye- colours & shapes Arrogance, pride, equanimity, generosity Water - cohesion Fluidity, sense of continuity, etc. Ear - sounds Anger, aggression, clarity, wisdom Fire - temperature Burning, chills, warmth, etc. Nose - odours Desire, compassion, discriminating insight A i r - vibration Movement, shakiness, stretching, etc. Tongue- tastes Paranoia, envy, accomplishing actions Space - consciousness Awareness, concepts M i n d Dullness, confusion, ignorance, wisdom Table 2 Inner and Outer Manifestations of Elements 3 5 This discussion of the elements draws from both Theravaden and Tibetan Vajrayana perspectives (Goldstein, 1987;Thera, 1962; Thinley, 1998). 1 6 4 A basic understanding of the elements as an interpretive frame for experience becomes relevant when exploring the bodymind experience of dissolution in meditation and dying. What seems important to remember is that elements from a Buddhist view are primarily states of consciousness that dissolve from gross to more subtle levels o f awareness. Dissolution and formation occur in the constant display of ordinary phenomena, as Michael alluded, but occur more obviously, for example, when falling asleep (Varela, 1997), or while moving into subtle levels of awareness in meditation or with changing levels of consciousness when dying (Sogyal, 1993): 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 of interest here is how we might interpret Stan's experience of "disappearing at the edges" as a parallel process of 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 of dying. Despite this linear approach, the discussion of this section continues to be situated in the midst of liminal spaces where dissolution seems to occur, that is, in gaps of interruption, in melting separations of self/other, and in the transitioning o f dying. While processes of turning inwardly outward and letting go addressed bodymind from the aspects of awareness and conceptual mind, the process of dissolution also includes these and more specifically identifies the elemental qualities of the body in 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 or samadhi (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 o f 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 in 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 something" (Austin, 1998, 1998); and further, " Y o u don't let go of your 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 of the bodily s e l f (p. 142) and magnified awareness of awareness, or as Austin states, "expansion of 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 of elements provides one interpretation of Stan's comments. To demonstrate how this perspective might be applied in everyday activities, Stan described an example of 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 of his mind, being mindful of breathing, and trying to be present with the noise. It seems that rather than struggling against the dread or the idea of loudness, Stan adopted a stance of simply staying with the nuances of 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 of temperature, texture, cohesion, vibration, and awareness as they unceasingly arise and pass away. In summary, the framework of elements provides a way of 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 of one's bodymind is witnessed. A n d what of dying? Dying envisaged as a process o f dissolution o f elements is described with intricate detail in the Bardo Thotrol, written by Padmasambhava around 750 A D . 3 6 The English title, the Tibetan Book of the Dead, 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 of dying within a Tibetan Buddhist view. For example, bar means " in 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 of mind or realities characterized by deep uncertainty or groundlessness that may arise in everyday experiences and in the transition at the end of life. Although written in 750 A D , the descriptions of such mental states remain relevant. A s a basic part of 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 of 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 of 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 of suspension after we die but also suspension in the l iving situation; death happens in the l iving situation as well . The bardo experience is part of our basic psychological make-up. There are all kinds of bardo experiences happening to us all the time, experiences of paranoia and uncertainty in everyday life; it is like not being sure of 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. 3 7 Although all Buddhist traditions situate dying as a gradual "development of ever more subtle levels of consciousness" (Sogyal, 1993, p. 256), Tibetan teachers have described specific stages of dissolution for each element, or level of 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. 3 8 In brief, at first a feeling o f heaviness overwhelms the dying person 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 of cloudiness or smoke arise; we feel cool and are no longer aware of what is going on around us as fire dissolves into air and appearances of sparks arise in our mind's eye; the last feeling of contact with the physical world disappears as the air element dissolves into space; finally, a sense of white, red and then black light arises and the dying person is unconscious. When the blackness dissolves into the mind of rigpa or clear light, then death has occurred. Rather than death linked to exhalation, the appearance of clear light indicates death and the departure of consciousness (Freemantle & Trungpa, 1975; Lati 3 7 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. 169 Rinbochay & Hopkins, 1979). This usually occurs three days after breathing has ceased and is the beginning of the bardo or in-between transition 3 9. What happens afterwards is understood differently by different schools of 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 wi 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. And 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 of 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 wi 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 3 8 See Lati Rinbochay and Hopkins, (1979) pps. 17-19 for detailed explanation. 3 9 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. 170 life to another, T.R. Murti explains, "Rebirth does not mean the bodily transportation of an individual essence from one place to another. It only means that a new series of states arises, conditioned by the previous states" (cited in 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 of the body at the time of death, so too does psychic energy or consciousness transform into more subtle states that are determined by the condition (and conditioning) of the mind at the time of death. Analogies often used for rebirth are the transference of 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 of 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 of momentum in what is happening at every moment of consciousness better conveys the notion of rebirth. 4 0 Tibetan meditation masters suggest that the purpose of developing awareness of the dying process as laid-out in the Bardo Thotrol is to familiarize ourselves with this transitioning of consciousness as part of a natural psychophysical process. Through familiarity with groundless, in-between states of mind, it is suggested that during the dying process at death, we w i l l be better able to recognize the nature of [our] mind and be 4 0 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. 171 liberated. Fundamentally, the Bardo Thotrol points to recognizing our own projections and the dissolution of the sense of self as it arises in every moment until the moment of death. With extensive meditation practice in paying attention, the process of dissolution becomes apparent. It is interesting to note how western science has extensive descriptions of the physiological processes of dying that correspond to the dissolution of outer elements but is limited in knowledge concerning the transitioning from gross to more subtle states of mind. For example, in the Medical Care for the Dying (Victoria Hospice Society, 1993), consciousness is defined as follows: "To be fully conscious is to be aware of 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 of self and environment is not yet considered. Also , the potential for people to be aware of 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" of consciousness, to advanced confusion, delirium, stupor, and coma (p. 423). There is much to learn from ongoing dialogue between these traditions of 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 of 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 of caregivers— who ultimately, were considered in/separable from those whom they served. A l l the while, with the exception of silent meditation during shift changes, there was little talk of 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 l iving ones". Nevertheless, I wondered how care provided in a hospice steeped in mindfulness practice might be different, i f at al l , 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 of 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. And,. . . . I think that's the most important part. (Lauren) The practice of mindfulness included an intention of opening into spaces where dualities of self/other dissolved, separations of work life/spiritual life faded, and the solid binaries o f living/dying vanished. The intention of 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 of 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 of 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 of becoming yet another ' tool ' for relieving personal concerns alone? These questions w i l l be considered in more detail in 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 in 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. And,. . . . 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 see 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) Caregiving with a Unique View Caregiving in an environment like Zen Hospice was subtly unusual because questioning the substantiality of conventional reality was encouraged and valued as part of meditation/caregiving practice. I realized how among these caregivers, their questioning of how one comes to 'know,' as well as a genuine curiosity about how sensory perceptions arise and become transformed into conceptual interpretations of oneself and the world was not merely an intellectual exercise. Rather, being actively interested in how it is that the mind shapes experiences of suffering and joy for oneself and others was a reflexive way of being for participants. This curiosity was practiced— not by talking, philosophizing, or doing things differently - but was practiced through the 176 simplicity of paying attention to internal, external, and in-between layers of experience; that is, simply noticing spaces within experience, without ambition or goal. Such curiosity into the nature of mind was situated in an ontology of doubling, emphasizing a relationality of reality that leads to compassion. ...we start to see our commonalties...our common experiences as human beings as we begin to view our own turning the lens of mindfulness on ourselves. We start to see how we are created...if you will,.... as human 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 of sites of difference where identities of ' se 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 of how practicing awareness through mindfulness may have shaped participants' care. Where were the spaces of action? How did they know what to do? A s with other aspects of this inquiry, the realm of action was not seen as a binary separate from inaction. 'Doing ' was situated in a doubling of action-and-stillness, in 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 of 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 of meditation in hospice care, a challenge remains in providing specifics and direction without inferring solidity or immutable ground. " A n d what of doing?" she inquires, "Where is moving into the worlds of action?" "After a l l " , she points out, " Nursing is a practice profession, with an intentionality of action " easing pain providing comfort promoting wellness supporting human functioning. "Where is the action in the midst of this awareness?" she ponders... Engaging and 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 of 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 of 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 of 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 mind ' 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 of their availability to residents and one another. Liv ing 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". And 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-blah- blah. 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 of caregiving wi l l be discussed later; however, a notion of presence arising in a non-personal space was reflective of participants' perspectives and ontological views. A presence of'non-(self)-presence' or opening into a shared space without distinctions of '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 of 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 of engaging in situations without a script was seen as acting wholeheartedly based not on convictions of 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. And 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 of a situation and the intimacy of engagement amongst those involved. Being fully present and trusting the authenticity of 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 in 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 of 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 of momentary experience, which is all we ever have. Within the context of 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 of momentary experience also seemed to provide insights into the in/separability between caregivers-and-residents. Some participants saw this relationality of 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 of directness based in the sort of logic explained by Camilla: since we are interdependent, working for the benefit of 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 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 of 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 of vivid appreciation and beauty arose. One participant described this as noticing the beauty o f life that was constantly emerging. He also equated the elegance of a Japanese rock garden and Zendo (meditation hall) with a particular kind of 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 of caregiving at Zen Hospice. Simplicity and attention to details created opportunities to 'see' and 'feel' the flower-ness of a flower in space or the easing inward and dissolving of 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 of whatever activity they were doing was a meditative aspect of '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 in 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 of breathing in the pain and suffering of another in the form of black smoke and breathing back peace and ease in the form of 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 of the practitioner. Although he had not witnessed benefits for the recipients, he thought this practice might promote the development of 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 of altruism. Whether there was a direct impact did not seem as important next to the possibility of transforming even a small amount of suffering for another person. Again, intention seemed paramount. Real/izing Impermanence A s inscribed earlier in the commentary, meditation rendered cracks in participants' illusions of 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 of impermanence and mindfulness from moment-to-moment. Or, as one participant said prophetically, the only permanence is impermanence. Such embodied realization of transience was said to diminish fear and led to an understanding of dying as no longer tragic but a natural transitioning into spaces of unknowing. Death was seen by some as an opening for transformation that contributed to the view of hospice care as meditation in action. We 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) 1 8 4 It may be that experiencing the parallels between meditation and dying cultivated a level of 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 of 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. "Are you interested in what wi l l happen during and after death? How is it for you? What do you believe in? you have any spiritual beliefs? you believe something happens when you die?" (Lauren) In contrast, fear of death and social taboos were also evident as some caregivers recounted situations of closing off from residents and subtly not being available. What was unique, however, was the acknowledgment of 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) Making impermanence real, or real/izing the inevitability of death allowed space for entering into the shaky ground of fear. Fear manifested on many levels including the blatant example of a new volunteer who refused to engage with a resident's fear of dying on account of her own discomfort. When this incident was shared, one participant interpreted this volunteer's action as a form of 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 of the ongoing practice of meditation in action that is supported through formal meditation practice. 185 More subtle aspects of 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 of both hoping and fearing about the situation and to be completely available to what is happening for residents. To 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 wil l ing 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. And we don't necessarily do anything with the fear. We 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. You 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 of 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 wil l ing to shift, and be changed in the process. Communicating one's humanness in the ups and downs of this process was seen as an aspect of compassion and letting go. For example, ordinary actions like resistance to walking into a new resident's room was considered a practice of 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's qualitatively different. (Desmond) In sum, caregivers appeared to have a pragmatic approach in accepting a level of 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 of such impossibility. Action and inaction were doubled in a view of 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 V E R S E 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.... 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 of 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 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 Verse dying meditating , where are we in transitioning(s)? suddenly awakening into death, momentarily, into open skies of life complex, yet simply what is, staying with, abiding arising and passing away... minds meeting in/separable in spaces of unknowing abiding in thresholds where all possibilities await, at the edges 188 STRAND FIVE ~ DISCUSSION AND IMPLICATIONS Child 's Concept of 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 wi l l die one day maybe without knowing. Chogyam Trungpa D I S C U S S I O N The inquiry began with a question of how mindfulness meditation practice shaped the experience of living/dying for both caregivers and those living with life threatening illness. This fifth strand weaves a discussion of how the Fruition is inter-connected within a larger project of 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 of living/dying. Nursing has a long lineage of philosophical thinkers who have struggled with ontological questions from diverse perspectives. Such diversity can be seen as a healthy sign of debate or, as in some cases in nursing, as problematic diversions. The clarion call for metanarratives or a single, agreed-upon truth in nursing, is still heard. Kikuchi , Simmons, & Romyn (1996), from the Institute for Philosophical Nursing Research 4 2 , call for agreement on a conception of nursing truth which they feel is necessary i f the discipline of nursing is to flourish. They urge nurses to come to agreement about which kinds, measures, and expressions of truth are appropriate in nursing inquiry and in so doing, to begin conceptualizing a nursing truth in 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 of truth, nursing knowledge and development w i l l be scattered, resulting in the eventual demise of the discipline. Clearly, Kikuchi et al. value unity and congruence, and perceive the pursuit of incommensurate positions as not only problematic, but ultimately leading to the "demise" of the discipline: What would the pursuit of nursing truth entail? For one thing, it would require that we make up our minds about such basic matters as the nature of reality, the nature of human cognitive powers of knowing, and the nature of 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 of 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 of 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 of 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 of 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 in maintaining a healthy diversity in nursing dialogue within a plurality of 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 of 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. Like Indra's net, in/visible strands of ideas are inter-connected and can be recognized despite differing disciplinary contexts. A n example of these interconnections between nursing theorists and Zen Buddhism recently became apparent. This interconnectedness began arising while re-viewing some of the early nursing theorists including Paterson and Zderad (1976), Benner and Wrubel (1989), and Parse (1987). These theorists, more philosophically attuned to the concerns of this inquiry, grappled with existential questions of what it is to be a person and how nurses can engage with others in their health, illness, and dying. M u c h of 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 of self and of the other" (p. 3) in nursing literature. They introduced a mutual and transactional aspect of human existence where transaction inferred an "aware knowing" (p. 122) of one's effect in situations between persons. Although ' se 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' of 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 of his existence and understanding of its meaning. So, "all-at-once," while each man is unique; paradoxically, he is also like his fellows. His 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 of self and otherness"(p. 4) and a doubling that recognizes human capacity for sameness-and-difference simultaneously. 4 3 Although awareness of oneself and others transactionally is accentuated, the authors do not explore the phenomenon of 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' of nurses and their others" (p. 44, parenthesis added). Drawing on Martin Buber's (1958) notion of ' I -Thou ' , '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 in East Asian 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 of Taoist and Zen nonduality shaped his configuring of 'the between' that was later adapted into humanistic nursing theory: 4 3 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. 193 When I reflect on an act of mine (no matter how simple or complex) that I can unhesitatingly label "nursing", I become aware of 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 of 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 of "the between". However, occasionally, in beautiful moments, the interhuman currents are so strong that they flood our conscious awareness. Such rare and rewarding moments of mutual presence remind us of the elusive ever-present "between". (Paterson and Zderad, pp. 21-22) This perspective resonates closely with the intention of inquiry participants at Zen Hospice to serve through being mindfully open and present where mindfulness is ever- present—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 of conceptual and non- conceptual awareness. For example, in developing humanistic nursing, it is said to be essential to explore and describe the intersubjective character of 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 of participants in this inquiry who engage in mindfulness practice, both formally and informally, in cultivating awareness of shifting conscious awareness. In doing so, it was believed that moments of 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 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 of 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 of determinism, reductionism, and modernist positivism (Kim, 1999). In the academic milieu of the early 1980s, nursing was attempting to legitimize its position as a discipline of science privileging the natural sciences of 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-psycho- social-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 of Benner and Wrubel (1989) contributed significantly to the discussions of what it means to be a person, drawing primarily on Heidegger's (1962) work. Unti l then, Edmund Husserl (1859-1938), another German Philosopher (1859- 1938) and founder of been widely influential in constructions of 'person' Oiler, 1982; Ornery, 1983). due, in part, to his Cartesian Q. Are you weaving a story to contextualize 'presence' in nursing theorizing? A . yes.... you could say so... Q. Is this a metanarrative too? A phenomenology, had nursing (Benner & Wrubel; Perhaps this was views that assumed a stable, essentialized ego/self where mind, as a subjective consciousness, contained ideas 195 that corresponded, or not, to what 'factually' existed in the world. Based on these assumptions, one can sympathize with Kikuchi 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) 4 4, and subsequently adapted by nurse theorists including Benner and Wrubel (1989) and Parse (1989). In brief, Heidegger (cited in Payne, 1997) challenged the view of 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 of living. Further, when immersed in momentary happenings of life, a particular kind of knowing occurs that is nonreflective and beyond abstract, conceptual thought. A person has "an effortless and nonreflective understanding of 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 May 's (\996j45Heidegger's hidden sources: East Asian influences on his work, that examines these influences and Heidegger's close association with Zen Buddhism: 4 4 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. 4 5 1 would like to thank Dr. Ted Aoki for introducing me to May's (1996) text. 196 Heidegger's thinking definitely exhibits not insignificant similarities with East Asian thought. A n indication of this comes, again, from Hsiao, who writes as follows: 'much of what [Heidegger] has "brought to language" has...been said often in the same or a similar way in the thinking of the Far East'. While these kinds of thinking are gradually coming to the attention of Heidegger Studies in Europe, they are rarely given further discussion. Nor has there been much response to the astonishing fact that the reception of 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 of Heidegger's relations to East Asian thought (p. 5). . . . . Otto Poggeler has written that he [Heidegger] gladly acknowledged to visitors the closeness of 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 of Being, Nothing, and the complex relations with/in language, were influenced by his readings of Taoist and Zen texts and collaboration with some of Japan's foremost philosophers during the 1920s. This revelation becomes important here for several reasons. First, the interpretation of Heidegger (1962) and subsequently Benner and Wrubel (1989) and others, takes on a new spin and suggests the need for what May (1996) calls "transcultural thinking" that behooves us to devote ourselves "to non-Western thinking as thoroughly as to that of our own tradition"( p. 57). It also points to a false binary between Eastern and Western thought and reminds us of the in-between spaces of hybridity and Indra's net of inter-connectedness. A n d finally, it challenges the position of the uniqueness of disciplines in isolation from other sources of knowledge. It is in these hybrid spaces, rather than in opposition, that the following discussion of how re- 197 configurations of presence/absence, living/dying, and knowing/ unknowing are situated within nursing. Presence / Absence Although 'presence' is an important aspect of 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 in the recent Hospice Palliative Care Nursing Standards of Practice (Canadian Palliative Care Association—CPCA Nursing Standards Committee, 2001 ) . 4 6 Specifically, palliative care nurses are held to the standard of CONNECTION through demonstrating "a sense o f true presence by continual, unconditional acceptance and tolerance" (p. 15, italics added). Where does a reconfiguration of presence as mindfulness awareness resonate and/or disrupt current notions of 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 4 6 CPCA (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). 198 / 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.... example, in humanistic nursing, 'presence' involves knowing patients phenomenologically and co-experiencing their worlds (Minicucci , 1998) in the context of their health care. The difference between such perspectives and the fruition of this inquiry is both in degree and in kind. For example, in Minicucci ' s (1998) 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 of 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 of epistemic knowledge and knowing in modernist, Western traditions. The privileging of knowing and meaning often ignores the role and importance of unknowing—that is, resting directly in prereflective experience. Frank (2001) recognizes this hegemony of meaning in situations that are unable to be spoken. He describes his fears of health care professionals who would seek to explain (away) his suffering rather than encounter directly its groundless 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? 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 of recovery for all mourners. Similarly, mindfulness awareness moves beyond an hegemony of knowing, into spaces that equally acknowledge un/knowing, self/lessness and no/thingness. This leads to sites of 'self/other' or, T-Thou' that include our in/separability while maintaining the ability to continue questioning. Although humanistic nursing points in these directions, this inquiry lingers longer in these sites and spaces of 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 of Benner (1984) who identified presence, or 'being with, ' as one of 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 of 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 of se l f (Fuller, 1991; Mohnkern, 1992; Minicucci , 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 of a relational space and can lead to an instrumentalist view of presence as embodied in 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/presence- seeing 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 of openness and a commitment to stay in the moment with patients and families through the sometimes difficult process of 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 ' se l f is constituted, and subsequently, its role and relation to presence. A reification of presence is also noted in the typologies of Osterman & Schwartz- Barcott (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 of 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 of transpersonal space in nurse-patient 47 encounters. Overall, an instrumentalist view of presence as a tool or heuristic is questioned here. Whereas this inquiry emphasizes a dynamic space of awareness between caregiver and resident and a doubling of self/other, this engaged quality is not as evident when presence is 'applied' to situations. A s an intervention, nursing risks becoming the implementation of 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 of 'doing for' and 'knowing what we do' that leaves little room for what is not yet known or unknowable in each encounter. 4 7 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). 202 Knowing / Un/knowing Un/knowing, as a state of 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 of 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 of 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 of knowing are described by these authors in an example of 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 in 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 of knowing, adding to the ways of knowing reflected in Carper's (1978) Fundamental Patterns of Knowing in Nursing. Little response was found in the literature, with Heath (1998) supporting Munhall 's view of unknowing and integrating it into steps for reflective practice. However, although acknowledging the importance of 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 of de-centering or temporarily suspending the self as "the nurse allows the patients' subjective structure of 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 of 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 of 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? "Intersubjectivity is not a difficult concept to understand...What is Munhall (1993) draws on Atwood and Stolorow's challenging is practicing it in a wide-awake manner." (1984) notion of'intersubjectivity' as the interplay of one (Patricia Munhall, p. 126) organized verbal and non-verbal subjective world 204 encountering another. How 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 of liminality. Whereas Munhall acknowledges the challenge, although not an approach, of being awake to intersubjective experience, study participants practiced mindfulness to intentionally cultivate being wide- awake. Un/Knowing or how we can know yet not know or be unable to explain or define, are pertinent in our discussion of living/dying and caring for those in the midst of l iving their dying. By introducing possibilities of 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 of 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 of not knowing. Those who are chronically i l l , struggling in a space of uncertainty or dying may benefit greatly from nurses who value this ambiguous groundlessness of life that is always changing, and can be appreciated along with the security of certainty. In order to constitute and reflect knowledge(s) about that which is unknowable, indistinct, and ambiguous, nursing wi l l benefit from diverse philosophical sources. A s practitioners and inquirers we need to go beyond dualistic views towards a multiplicity of contexts that provide guidance for abiding in the midst of difficulty, in the midst of 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 of knowing in nursing. While human experiences of change, dissolution, illness, and suffering often resist articulation, the process of '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 of being with patients, i f one can abide there with ease, with the best interests of the patient in mind. Re-configuring death This inquiry suggests a re-configuring of living/dying that is different from Western perspectives where ' l iv ing ' holds hegemony over 'dying' . Death, re-interpreted in the Buddhist sense of participants, is also a momentary experience occurring each mind-moment; life is not necessarily privileged over death but rather is seen as a doubling of 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 of being/not being and ubiquitous change. In addition, mindfulness meditation practice is seen as a parallel process providing an embodied realization of this transience. Such realization is felt to diminish fear and open an understanding of dying as 206 no longer tragic but a natural transitioning into places of unknowing. In short, dying could shift from a discursive space o f tragedy into one of curiosity and inter-rest. However, most nursing literature on death and dying is grounded deeply in 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' (Mil ler & 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 of 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 of 'managing' cancer with mindfulness meditation. The perspective of 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 of what was happening to them. They reported less resistance to the natural cycle o f l iving and dying, appreciating both the pain and pleasure inherent in life, and feeling more 207 equanimity in facing mortality. Realizing impermanence was identified as the central phenomena of 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 of mindfulness meditation in this way. A s a 'strategy,' there is an undercurrent of 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 of 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 in a survey of 202 Connecticut nurse practitioners (NPs) that meditation was the second most highly recommended alternative 'therapy' referred by N P ' s with 11.4% of nurses providing meditation instruction in their offices. Meditation is rapidly entering the domain of nursing practice. Is meditation being co-opted into a system of (spiritual) materialism that wi 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 of the central tenets of hospice and palliative care is that dying is part o f l iving. While a terminal diagnosis often means the end of meaningful life from a medical standpoint, hospice philosophy conceptualizes dying as a stage in the human life- cycle, 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 of standardizing what 'growth' or developmental milestones are occurring in this life transitioning. Modernist penchants for categorizing have led to binaries o f 'good ' and 'bad' deaths (see Bradbury, 1999), and the double-edged sword, of developing new knowledge to better serve those who are dying, that cuts both ways. Attempts to create meaning and order out of what may ultimately be meaningless, nonsensical, and unknowable, may also be motivated by the wish to alleviate our ultimate lack of control and vulnerability of not knowing. Such efforts may add to our understanding of the dying process but never address the underlying conundrum of living well with the im/possibilities of death. Rather than asserting a position of 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 of meeting people where they are, and engaging without an agenda, has been part of the aspiration of 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 of 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 of being, a way of being present with people—where they are. And 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 of 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) of developmental landmarks, tasks for the end of life (Byock, 1996), and standardized norms of care ( C H P C A , 2002), such privileging of knowing vis-a-vis dying and death can too easily slip into discourses of 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 Fur ther 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 of 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 non- conceptual, everyday, raw happenings, by virtue of our presence with others during extra/ordinary experiences of forming and dissolution. This inquiry points to practicing awareness [of] these processes through mindfulness meditation, and an appreciation of conceptual and non-conceptual interplay that is continuously available. Moreover, the privileging of Western binaries of 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 of this inquiry is first in pointing towards these gaps In the gap between thoughts, non-conceptual awareness shines continuously Milarepa (cited in Welwood, 2000) 211 Integrating philosophical questioning and nursing practice This study also suggests a direction of bringing philosophical questioning, as a practice, into everyday nursing work —and particularly into hospice care. Where is living/dying happening? Where is suffering arising? Who dies? Where is reality? Such questioning is not idle intellectualism but cuts to the heart of 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 of life that renders a nurse open to a doubling of '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 of 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 of one's interpretation of 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 of response to engage existential fears of patients, families, and care providers.... 212 Enacting such 'noticing' by study participants was supported through short periods of silence, meditation, and reflecting on one's intention at the beginning and end of hospice shifts. Periodic retreats for staff and volunteers dedicated to meditation and contemplation acknowledged the importance of'suffering the questions' through non- discursive 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 of spiritual needs is becoming an expectation of nursing care, McSherry and Ross (2002) suggest that many nurses do not feel comfortable in this role, or with their skills, knowledge, and experience in this domain. Spirituality as it is being developed in health care is based on a Judeo-Christian version of 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 of 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 of action-and-stillness where abiding in-between is a skillful option. Engaging the mystery of dying and accompanying those during such experiences calls nurses who are wil l ing 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 of 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 of consciousness that transcends awareness o f self and environment is not yet considered in western nursing. Also , the potential for people to be aware of 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 pre- conceptions. Nursing requires skillfulness in moving back and forth between the nomothetic (universal) patterns of signs and symptoms and the idiographic (particular) of 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 of the interplay and relational space in-between self and other and the flow of 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 of 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 of 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 of administering pain medication in light of the new situation, taking into account his previous request to not be medicated. Interestingly the caregivers' awareness of 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 of the resident, provided another layer of understanding. Awareness o f the complexity of 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 of hospice shifts and attending to experiences of dissonance and conflict as they occur, allows for self- correcting behaviour at best, or at least an accountability of awareness o f what is happening, and how one is responding. Environment This study contemplates the role of 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 of these sites of tension and interplay as vital spaces of human 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 of human experience, nurses can open an environment of spaciousness that supports reintegration, deconstruction, letting go, or whatever is required during a person's dying process. I am aware of the dance between definitive and non- definitive 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.... 216 Is mindfulness meditation a recommendation for nursing practice? Mindfulness is only one way of cultivating embodied awareness. Although I am not suggesting meditation as a practice for nurses, this study signifies the importance of attending to non-conceptual experiences located in alternative discourses; finding ways to disrupt privileged views of reality while re-cognizing other possibilities of living/dying. Although Western nursing practices are re-turning to the elusive, non-material, and relational aspects of spiritual nursing practice, this study points to ways of refining awareness of nondual spaces in caregiving from non-theistic, non-modernist and non- western locations. Relevance for Nursing Education Mindfulness is configured here as a process of leading the mind back from theories and preoccupations, back from abstract attitudes, to the situation of immediate experience. Helping students to discern the edges of mindful presence and learning how not to f i l l in the gaps with busyness while leaning into the stillness of whatever activity they are doing seems an important aspect of nursing education. Awareness practices such as: moments o f silence; checking in with what physical sensations are arising; becoming aware of one's state of 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 of 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 of 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 of awareness and their ability to attend to the textures of situations. Reconciling the dichotomy of content and context and the liminal space in-between is an ongoing challenge in nursing education. Other implications include: • Questioning perceptions of time as commodity, and how these interpretations both help and hinder nursing care... • Are there ways we need to prepare nursing students differently regarding notions of time? How do those who are dying, and their families, think about and experience time? • Preparing nursing students from a location of 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 of living-with-dying and hospice care. Continued engagement with approaches and discourses that open up assumed views of reality are required as the diversity o f patients and health care environments continues to expand. The path of this inquiry is a beginning effort in moving outside of conventional structures without rejecting these forms, and calls for greater experimentation in embodying ways of articulating indistinct and liminal spaces of human experience that both 'shows' the phenomenon being studied and demonstrates through its explication. Further inquiry is needed into ways of articulating and approaching non- conceptual 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 of caregivers-and-residents. Some participants saw this relationality of 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 of change, death and dying, and health and wellness, is needed. Suggestions sparked by participants also calls for further investigation: • How does regular meditation affect death anxiety amongst caregivers? • Is there a relationship between quality of life and meditation practice for hospice caregivers, and those l iving with chronic or terminal conditions? 21 • How can awareness practices be incorporated into approaches to educate health care providers in providing effective support for existential or spiritual concerns of patients and families? • How can Tibetan Buddhist typologies of consciousness inform Western understandings of mind and consciousness and existential concerns at end-of- life care? • What is the experience of liminality amongst non-meditating hospice nurses and residents? • How is spirituality understood by those in non-theistic, non-existentialist traditions? Although volunteer caregivers comprised the majority of participants in this inquiry, the role of volunteer service in hospice care was not addressed per se. However, the high degree of 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 of questions including: 4 8 profiling hospice volunteers and the knowledge, skills and experiences they bring; what is the impact of 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 4 8 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. 220 adequately utilized?; what is the impact of hospice volunteering on the volunteer?; what is an effective training model for retaining and challenging volunteers?; and what innovative models of volunteer service exist that address non-traditional settings or special populations? Finally, potential benefits of meditation in 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 of '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 Tzu1 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 of Chuang Tzu has been the joy and impossibility of this dissertation journey; texturing a life-world that tarries in-between the 'writable'/the 'non- writable'. Sometimes the voice is that of the 'writable' (perhaps more often than necessary), and sometimes 'un-writable' spaces seep through (an effect I cannot 'direct'). With 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 in order to contribute to disciplinary knowledge, but suggest that this motivation is only partial. According to these authors, the purpose of inquiry is also for inquirers to be able to make sense of their worlds, to see what works, and for the endeavor to be an aspect of 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 of 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 of human experience at the end-of-life is being called for. Exploring complexly layered experiences of 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 in the forefront when I first arrived, they soon became a vital part of my experience: many of the young patients I cared for were dying, the life expectancy for Bangladeshi adults was 45 years, and the radical assault on my understanding of the world, uncovered an abyss of groundlessness—a free fall from reference points. Immersion in a culture and way of 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 of literature and philosophy. Although I couldn't articulate what it was I was looking for, there was a sense that I would recognize ' i t ' when encountered. Various writers including Wi l l i am 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 of that curiosity into what it is to rest in a space of living/dying, knowing/unknowing, where things are simultaneously not what they seem, nor otherwise. How do we recognize these spaces? H o w do we rest? 224 What does it feel like? Are these deathless spaces, as one participant intimated? Are these sites where compassion abides, as another participant suggested? Are 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? A n d A o k i ' s metonymic gaps? Can these questions be answered? Yes and no ? What is it to tarry in a space of living/dying? What is it to write from the writable / non-writable? It's a bit scary. There is a lot of 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 of an experience of 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 of 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 of thinking of aporia, one perhaps more enduring, (p. 13) Aporia points to a place of 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 of 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 bi- negation 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 chal lenge- 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 bi- negation 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 of science and Buddhism. In this way, the inquiry has attempted to reflect Bhabha's (1990) 'third space', a space of 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 of the perceived benefits and outcomes of using this form of 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 of applying a technique to relieve symptoms. ! '. embedded. For example, what distinguishes Buddhist meditation is its premise of nonduality that immediately calls into question the limits of language, or at least the possibility of language taking us to its limits. This has been more challenging, as some textual habits are deeply ingrained. Even so, as practitioners and been important to inscribe non-representational discursive spaces in which Buddhist thought is Therefore, in exploring mindfulness, it has also We can never finally determine what things mean. However, we can open up spaces that show meanings as partial, open to questions and always changing.... 230 inquirers we need to experiment and go beyond dualistic views towards a multiplicity of conltexts that provide guidance for abiding in the midst of difficulty, in the midst of 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 of 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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S Can you share with me what brought you to do this kind of service? •S Can you share with me a story of 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 of 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 of 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 in 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 Can you give me an example o f a time here in hospice when mindfulness took on meanng for you? •S How has your experience working at Z H P changed over time? •S How has your practice (of meditation) changed over time? •/ Have you gone through periods when you think about leaving Z H ? Why? 249 S In general, I 'm wondering how mindfulness influences our reality of living-and-dying, especially for those who intentionally cultivate awareness through practicing it formally. Do you have any thoughts on that? meditation/sitting practice fosters an awareness of living-and- dying? Is such an awareness helpful? Why? S In the buddhist sense, there is a view that each moment is a moment of 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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