Enduring the Edge State of COVID-19

We certainly are living through interesting times.

The level of despair and anguish being experienced is like nothing that has happened in decades. For most of us, not in our lifetimes. Urban hospitals all over the world are being converted into mass casualty triage tents previously only used in active combat zones. There is so much uncertainty, anxiety and stress everywhere. It can feel completely overwhelming.

For the past 20 years, I have helped people going through cancer treatment and their loved ones navigate the strange new landscape of uncertainty a life challenging diagnosis can bring. This process is now repeating itself on a planetary scale. The entire world-- billions of people-- have been very quickly taken from the familiar into the unknown. The economic toll is just beginning to be felt, but the human toll is already rippling out all over the world.

It was from Roshi Joan Halifax that I first learned the term "Edge State". This refers to the boundary between the known and the unknown. For all of us, the world we knew is gone. The world that we will make out of this is still to be determined. We are in the in-between-- the Edge. What Tibetan Buddhists call a "bardo".

Edge States are not easy. There are some tips and coping skills that are helpful. But I don't know if they can "solve" the Edge. The Edge is something we have to be at home in, like living in a hut on the lip of a smoldering volcano.

I don't think it's an exaggeration to say that for many of us, certainly all of us in health care, this is a traumatic time. It's a slow motion, serialized trauma that will unfold for weeks, probably months. There is only so much one can do to be ready. Of course, in our happiness based society, the goal is already targeted to be "resilience", but that may be more for economic wishful thinking than for emotional health.

I believe that before we speak of resilience, we have to experience what is happening with the best available tools in our toolkit. What we are experiencing is grief for the world we knew, the people we love who will not survive this experience, perhaps already for so many who have succumbed. We are also grieving the lives we thought we were going to live. We all had plans and roles that have disappeared, crumbled and changed.

How do we experience this in as healthy a way as possible?

My work with people going through cancer treatment, when life becomes a prolonged Edge State, has  taught me a few things:

1) Accept that this is happening. You don't have to be immersed in the news all the time, but stay informed just enough to guide your daily decision making and daily choices.

2) Structure your time. If you are now working from home, or not able to work, set up a schedule. Most humans find safety in routines, even if they are annoying routines. Wake up and go to sleep at the same time. Eat meals at the same time. Exercise if you are able to.

3) Find your breath. Mindfulness has become increasingly popular, but with its popularity have also come a bunch of unfounded claims. I believe that mindfulness is a mind-body technique to improve the human stress response through breath awareness. This may be helfpul to watch. Practice breath awareness as often as you can, especially after watching the news.

4) Try and keep a clear mind. Avoid alcohol and other intoxicants. If you smoke anything, quit. There is growing concern that inhaled smoke in any form makes people more susceptible to increased complications and death from COVID-19.

5) Do the best you can. This is a global pandemic. The world is grieving what it knew. The horrors of this time will be told for years to come. This doesn't need to be the most productive time in your life. You may not make the best decisions every day. The goal is this: be a loving friend to yourself. Treat yourself and others with kindness. That is surprisingly difficult for most of us in a slow moving trauma like we are all experiencing. Do the best you can. That may be hard enough.

Meditation: The Inside Scoop

The most common reason people give to be unable to meditate is to say "I can't turn my mind off". For some reason, there's this assumption that meditation requires the supernatural ability to clear the mind in order to be performed. This is absolute rubbish.

Everything we do requires practice. If the prerequisite or goal of meditation practice was to empty the mind, the best meditation teachers would be those who could perform lobotomies. I can assure you this isn't the case.

I've maintained a daily meditation practice for about 18 years. I thought I'd share with you all some of what happens when I sit down to meditate to assure you that a quiet mind is in no way a requirement for a meditation practice. The following took place in an idyllic location while on vacation in Catalunya a couple of weeks ago. I sat down one afternoon while everyone else in the house was gone to watch my breath. I assumed the meditation posture, and focused my mind on counting my exhalations, one at a time, while allowing my mind to unfurl.

"What a beautiful spot. I can't believe how blue the sea and sky are. I should have sat down to meditate a while ago.

It reminds me of what I thought of earlier, once you decide to sit down to meditate, everything outside of the sitting session is resistance. How long have I had this meditation practice? I used to say 16 years, but I think it's 18. Wow. Mind still very much on.

This spot is high up. I'm pretty sure it will survive the ice caps melting. Who knows how many feet that will be. I hope it's gradual, although that one researcher said it's more likely to be sudden and catastrophic. Those methane reserves in Siberia are being released, that's really bad. It will all come down to timing. I hope we're all together when it happens. I can't imagine the drive out of south Florida. What will I take? Glad I backed up the hard drive and put it in a Ziploc in my office. That's going to be a crazy traffic jam. We'll have to head north. I hope I can get a job in another state easily. I wonder if the flood will bring down the global economic system.

Wow, that's the most uncomfortable tangent. I hate that topic. Government is so broken. Taken over by demonic forces. Ancient forces that brought down Rome, too. So evil the way the way they're treating the earth.

Why all the judgement? Meditation is about love, after all. Ok, let's think about love. Let's send love to the politicians and greedy oil executives.

Wow, what a nice spot to sit. I can't believe how relaxing this is. Seems like a bubble while the rest of the world turns to shit. So many dead in Gaza, Syria.

Breath tight. Release the belly. There. The most helpful thing is always to release the belly. Got to remember that. Love the chattering parts of the mind. How many parts of my mind are there? Wait, who's keeping track? Is that part of the mind, too, or something outside of it. Does mind emerge? I'm really appreciating that emergent hypothesis. I wonder if I can incorporate that into the Toronto workshop somehow. The slides are all done. Those used to make me so much more nervous.

The run this morning was awesome. I wish we had mountains and trails in Florida like that. Makes me miss living in California. I don't think my Achilles' tendon can take two runs a day, but I would love to if I could. I wish I had run more in my late twenties. Grad school sucked for that stuff.

Soften the belly.

Oh wait, that was a shimmering moment. Love that. Let's do it again.

Nope. But that was nice.

Ah, it happened again.

Hmmm. I hit my goal. But I want to keep going. Ok, another 49 breaths. I hope I have time. Is there anything else I should be doing?

Oh, nevermind, this is nice. 'The Buddha's enlightenment is vast, it encompasses all experience'. He's been here, each moment is a footprint of his enlightenment.

If only people knew how much chatter remains, even with meditation practice, they'd be less intimidated. I should totally blog out this session. "

So what's your experience like?

Seven Tips for Professional Caregivers

This past weekend I was in Toronto as part of a series on Contemplative End of Life Care put on by the good folks at the Institute of Traditional Medicine. My area of focus was grief, specifically the approach I use and have highlighted in my books. It occurred to me that I've been taking care of the dying and grieving for over 15 years. I feel like I just got started and nowhere near burned out. I was asked several times in different ways what's worked for me in being able to sustain high intensity mental health care.

When I'm discussing end-of-life care and grief therapy with other professionals, I like to point out that we need to tap our own inner resources of compassion in order to be able to help others. To do this, we have to build up these inner resources in the first place.

The way to do this is fairly straightforward to describe, but harder for many to put into practice. We'd much rather take care of someone else than ourselves. If we listened to half the advice we give others about how to take care of themselves, we'd be twice as healthy.

What works? In 2014, there's very little mystery in answering this question. Here's the list, again, culled from decades of health and well-being research (done by others) and my own personal experience: 

1) Treat yourself as a whole person. This means balance different aspects of your life-- body, mind, spirit.

2) Eat right. What's that mean? Science is telling us more and more how important it is to eat plants, use common sense portions and avoid processed foods. For me, this means going to the grocery story to buy ingredients rather than meals to re-heat.

3) Exercise. If you can do an hour a day most days of the week, wonderful. If not, 20-30 minutes 3-4 times a week of moderate cardio exercise is a good goal.

4) Meditate. This doesn't mean read about meditation or enjoy spending time in your garden or playing with your pet. It means cultivate a daily sitting practice. It's the purest way I know of to nurture heart and spirit.

5) Create a community. If you work in health care, start talking about self-care. Give hugs to tired colleagues. Spread the word that we matter. You don't want to become the nagging missionary, but better yet, let the changes you're making be their own example. People will notice you're doing something different. If you work as a solo practitioner, reach out on social media or try to arrange meetups in or near your community to find like-minded people that can help you feel connected. The key to preventing burnout is feeling that you're part of a bigger whole, a tribe of fellow caregivers moving in the same direction with the same priorities. Don't wait for a community to form spontaneously, change the system to be one you like.

6) Limit your reliance on alcohol, television and other drugs. We joke a lot in health care about happy hours. But there's no evidence to suggest people who drink regularly are more emotionally resilient or spiritually centered than those who drink very little or not at all.

7) Don't be afraid to grow into your potential. Many of us started out working as professional caregivers with mentors or teachers we looked up to. Mentors aren't born, they're made out of experience. Don't be afraid to make changes in how you work and how you live so you can become an expert at what you do. Remember the gratitude of others as a guide to keep you going. What helped your patients the most? Keep doing that.

We are blessed to do what we do for a living, but chances are no one has taught us how to be in it for the long run. Health care providers who are balanced and healthy can provide better care for others. My goal in caring for others is to be able to do it for as long as I can and stay healthy in the process. I hope you can, too.

5 New Year Resolutions Worth Keeping

At the end of every year, we do the same old song and dance. Hours of TV on which celebrity did what, slept with who, went to rehab, got into a fight, married, divorced, had a kid. Who lived, who died, all smushed alongside the most memorable videos of the year. This year I'm sure will be filled with the likes of Miley Cyrus, Duck Dynasty and a host of other characters I would be embarrassed to explain if I was every abducted by aliens.

And then there's the shallow media hype of the mythical New Year's Resolution. You're supposed to wake up January 1st to a new you, start shedding those holiday pounds, quit smoking and do otherwise obviously healthy behaviors on the endless list of shoulds. Some of you will stick to your plans. Some will become sidelined and fall into the familiar embrace of guilt and shame at the end of this year, only to repeat the cycle until life hits you over the head with a sledgehammer as to why these healthy behaviors were a good idea in the first place.

Here's my advice to you on what would help all of us. Some of it has a research-base, others are just common sense I've picked up from the past 15 years of end-of-life care. It's a good idea to have these as general lifestyle choices, not just for the first few months of the year.

1) Seriously, exercise. It's the best medicine. Start out slow. Your goal should be about 20-30 minutes of moderate exercise 3-4 times a week. This is the therapeutic dose that has positive effects on your heart, mind and emotions. More is fine, less is not as good. If you don't exercise, see a doctor first to make sure you don't have cardiomyopathy or something like that. Don't wait.

2) That meditation practice you've heard and read so much about? Guess what? It really works. You'll be hearing more and more about it this year. Stick to it. Spend some time every day meditating. The therapeutic dose is about 20 minutes twice a day. Few people can do that if they haven't sat down to meditate before. You can find some guidance here on how to get started. You have time for all the stress and worry in your life, you might as well squeeze some stress management into it.

3) Say "I love you" to everyone you love more often. Say it every day. Love is powerful, way more powerful than any of our individuality. When you're in a hard emotional place, a loving companion, be it a spouse, partner, child, friend or parent can usually make it all better just by being there. If you don't have direct companionship, use social media. Reach out and get connected.

4) Listen to music. Turn on music every day. Use it in the background. It can structure times of great stress and uncertainty. If you're grieving, it's a much more wholesome way to drown out the silence of your home than the jarring sounds of television.

5) Laugh every day. Find something funny to read, watch or listen to. In all the commotion about self-care, laughter is often left out. The best way to transcend hardship sometimes is to laugh at the absurd predicament we're all in. Emotional pain isn't funny-- what's funny is the nearly comical way we go about our lives, obsessed with what turn out to be the tiniest, most insignificant details. We lose the big picture. Can't find something to laugh about? Here's a start.

The most important thing to remember about your resolutions: you're more likely to stick to them if they are about what you want to do rather than what you don't want to do.

Seven Tips from the Edge

For the past 15 years, several hours of each work day for me involves seeing the world from the perspective of someone who is dying. I don't know exactly how it is or what it is in me that chose to do this for a living, but I feel very strongly it's a big part of what I was put on this planet to do with the life I have.

It's not for everyone to do, and I don't think it makes me all that special. I can assure you that when my car makes a funny noise, I'm clueless as to what to do about it and glad that there's a mechanic who is doing what he or she was put on this planet to do, and fix my car. I can't do that. That makes the mechanic way more special to me. I need my car.

I've written elsewhere that recently for an 18 month stretch, I knew a steady stream of 2 or 3 people who died every week. I knew some of these people for days, others for years. That streak got interrupted for a few weeks, but seems to have returned in its brutal predictability.

Being in such close and regular contact with death, of having people gravely ill, dying, frozen in fear or radiating peace, them and their loved ones asking me what this whole gig we call existence is about... Roshi Joan Halifax refers to this space as an "edge state", way out on the horizon where the known and the unknown meet. I believe this horizon is what the existentialists refer to as "absurdity", the quest for relevance and meaning in an otherwise indifferent world that cares little for our individual existence.

Out on this edge of absurdity, I've had these flashes of insight lately as I go about my day that the whole gig is a giant inkblot. We see patterns where there maybe are none, we see images where they may be only empty space, we impose rules where chaos reigns, we see connection when we are really flying alone by the seat of our pants. And it's probably okay to do that.

Our intelligence and capacity for insight gives us choices in what patterns we see, what decisions we make, which rules of the game we choose to abide by. For many of us, religion saves us time and effort, offering us a template of guidance. For many of us, we find our own way.

For all of us, I think the most important facts to keep in mind are these:

1) None of us are fully in control of anything, no matter how much power, wealth, fame or status we accumulate. Pink Floyd sang it best years ago, "all the iron turns to rust, all the proud men turn to dust."
2) The whole inkblot nature of reality does not make violent or mean behavior acceptable. On the contrary, we should treat each other, and all life, lovingly, as we would lost and scared children that showed up at our door. That's really what we all are-- lost animals trying to find our way into the comfort of each other.
3) We waste a lot of energy doing stupid things to keep the crushing absurdity of being alive out of sight. Rather than focus on self-destructive vices like gambling and drugs to indulge our insatiable appetites for fleeting pleasures, we should bear mindful witness to fleeting moments of awe that surround us every day that go un-noticed. We're often too lost in our internal chatter to notice awe, to the point where we often can't dwell in awe.
4) Respect the body. See #3. Our choices should nurture our meat suits, not destroy them. We don't have our body for as long as we would like. It begins to age and fall apart just when you're getting used to it. Don't grease the wheels towards achiness.
5) Find what soothes you that is healthy, and what soothes those around you that is healthy. Create opportunities for soothing regularly. We're all lost children, we want security blankets. There's nothing wrong with that.
6) Structure the ambiguity of our absurd existence with self-disciplined progress towards goals. Exercise, meditation, healthy eating and sleep hygiene form a powerhouse of security and inner resources to ride through waves of suffering and anxiety. I've written about this extensively in my books. You actually have to do these things, though, not just read about them.
7) Live a life that others would want to grieve. This sounds strange to our pleasure driven society, but grief is often a sign that you got close to people, that people got close to you. Grief is healthy, and it's essential. Live a life that people would want to celebrate after you leave. You might not know how to do it now, but if you embrace absurdity with love, you're probably going to find out how.

Buddhism and Grief, or Why I Write

A couple of months ago I was giving a workshop based on my first book, Grieving Mindfully. The book is based on the practice of mindfulness and draws heavily from Buddhist teachings and approaches to suffering. It's by no means a "Buddhist" book, and I've come to learn over the years that atheists and churches have all used it with benefit.

One of the participants at this particular workshop shared a story. They were at a teaching being given by a Buddhist lama in the Tibetan tradition. A distraught attendee had recently lost a spouse and asked the lama how they should manage their grief. The response they received in this moment of pain was something to the effect of "your spouse is dead, there's no sense thinking about them. Move on."

Horrible.

Two thoughts came to my mind. The first was a story I recount in the book of a woman whose baby dies. She goes to see the Buddha to ask him to bring the baby back to life and thereby end her grief. The Buddha agrees, on the condition that she brings him a mustard seed from a house death has never visited. She goes all over town, unable to find such a house. With the realization of the universal nature of grief, she takes comfort in meditation, takes refuge with the Buddha and ultimately (according to legend) becomes fully enlightened. This is a very different approach than what this lama said. The Buddha has this woman meet the entire city at their common pressure point-- loss. She must have heard hundreds of stories of loss, been given comfort by others feeling her pain, and comforted others suffering her same pain. Quite different from being told there's no sense in thinking about her baby anymore, or to just get over it.

The second thought I had was a reminder, it's generally a good idea not to ask lamas for advice on relationships, especially marital advice or issues related to grief. They don't participate in family life. The comment the lama made was a reminder of this. It would have been more helpful for the lama to say "look, I have no idea what that kind of pain is like. It sounds absolutely awful. You should ask someone who is trained in this. I can teach you to meditate, maybe that will help."

Thankfully the participant who shared this story was commenting that a mindfulness-based approach to grief, one that trains people to endure the ups and downs of emotional pain, seems much more compassionate than the advice the lama gave. This isn't meant to put down the lama at all, but to point out how diverse Buddhism is and what a wide range of approaches all belief systems have to grief. I've heard variations of the lama story many times over the years. I am glad to contribute a small piece to counter-balance what I think of as an unhelpful attitude towards grief, be it from Buddhism or popular culture-- you suffer for a little while, but then you'd better dust yourself off and move on. It's the same unrealistic and simplistic advice many of my cancer patients get-- think positive and you're as good as cured.

I wish!

The truth is much, much more complicated. The science tells us that roughly one third of us do seem to dust ourselves off and "move on", whatever that means. The rest of us have a very different experience. For another third of people who experience grief, some very intense emotions show up for a very long time. It's for this population that I write, and this population that needs all the tools they can get. It's not a sign of any weakness or deficiency to suffer for a long time after loss. And not everyone agrees on what "too long" is. I think grief carries a potential that can be harnessed, sometimes deliberately, sometimes by accident. Like the grieving mother who goes to the Buddha, grief can carry us forward into some very, very dark places, but also-- often unexpectedly--become a catalyst for growth.

My new book comes out in a couple of days. I hope it helps steer readers towards that kind of growth.

Thoughts on Mindfulness

You hear more and more about mindfulness meditation.

The word "mindfulness" is getting very over-used. It makes writing a blog about mindfulness kind of awkward to do, much less write books about. Mindfulness is very, very old, but it seems that it's gone through some predictable and repetitive cycles in its spread across cultures and time. A couple of nights ago I was reading Miyamoto Musashi's "Book of Five Rings" when I came across this quote: "The field of martial arts is particularly rife with flamboyant showmanship, with commercial popularization and profiteering on the part of those who teach the science and those who study it. The result of this must be, as someone said, that amateuristic martial arts are a source of serious wounds."

That was written back in 1643. The same can be said of meditation in general and mindfulness in particular. The word is over-used. It's become something of a status symbol among the spiritual elite. Surely you must have trained with so-and-so, done this-and-that, etc. What winds up happening is that too many people feel like they can't anywhere in the practice without the proper "credentials". But there is no substitute for a daily practice. Plenty of people have spent hours of one-on-one time with some very famous and gifted teachers and walked away without any change in their meditation practice- or lack of.

You don't have to go to India or some exotic location. It all starts with your breath wherever you are.

What happens when "unconditional, present-centered awareness", as Jon Kabat-Zinn calls it, becomes commodified? I recently came across a headline that said something like "mindfulness can make you more money". In the words of Tony Montana, "is that what it's all about?" Is that what the Buddha taught? A marketing tool? A researcher has recently sparked controversy by assembling a study of mindfulness among military personnel. While this heal their pain or make them more efficient, focused killers?

The truth is, our culture and our time are not new to these sorts of questions. The context of mindfulness has not always been the pristine monastery in a tranquil countryside. Even in the Buddha's own time, brutal war and genocidal conflicts raged all around him. So did charlatans, con artists and frauds. During his many frequent travels, he often returned to a place he had been before and found the local populace practicing a degenerated form of his teachings under the spell of a charismatic teacher.

This has all happened before, and I believe the antidote stays the same. The goal of any mindfulness practice must be compassion towards self and other and service towards those less fortunate and suffering. This comes about by being simply present. Don't bother with showmanship-- learn the instructions, then just practice, practice, and practice. There will always be someone who has practiced longer than you, with more famous people, in more exotic locations. There will always be those whose altars and meditation areas are just perfect, those who have really spiffy meditation accessories, and those whose libraries are more interesting.

None of this matters.

These are all distractions. Mindfulness is not meant for pristine conditions. The Buddha practiced in clothes other people had discarded alongside dusty roads under frankly miserable conditions. Pabonka Rinpoche once told a story about an old lady who learned the mantra "Om mani padme hum" wrong. Yet she repeated it unceasingly, meditating on compassion. She was enlightened even though she got the words wrong due to her motivation, intention and practice.

So never mind the hype. Practice, practice, and practice some more. Just breathe.