There is a Grace that happens—a moment when you see that breaking of the spell of the ordinary. It is a moment of both simplicity and complexity mashing together to create something glorious. Grace.
What is Grace? I spent the past year pondering this question as I fumbled my way down a path of self-compassion. I do not take the word Grace lightly. I mean it in all its multilayered majesty. Grace is our presence in the world. Grace is that wondrous balance of existence that when we reach it, we smile knowing that all is right and good and as it should be. Grace is worth. It is the value of each of our human lives in the larger intertwined universe. Grace is our talent and our offerings to the world. Grace is kindness and goodness and patience and mercy. One might call it soul or inner spark. To me Grace is the core of what makes us human. Galway Kinnell tells us in his poem “St. Francis and the Sow” of each thing flowering from within of self-blessing, of each thing having its own loveliness. That’s Grace.
Each of us is filled with Grace. We see glimpses, but rarely believe what we see. It is more common to go through life blind to our own Grace even though we are likely to see it in others, especially those we love. I think each of us travels our way searching for our own Grace, not knowing that we already have it. Self-compassion practice helps us find the Grace already residing deep within each of us.
I think I have spent a good portion of my first fifty years searching for Grace. This past year has been particularly fruitful. I discovered that all along Grace was deep inside me waiting to be noticed and nurtured by no one other than me. I only had to open my heart to reveal it and set it free.
I read an interesting article recently that recommended changing the Triple Aim in medicine to the Quadruple Aim. Let me provide a little background. Don Berwick and colleagues first described the Triple Aim as a way to optimize health system performance. (I know this sounds painfully dry, but bear with me.) It proposes that health care institutions pursue three performance parameters: improving the health of populations, enhancing the patient experience of care, and reducing the per capita cost of health care. This sounded brilliant and has been widely accepted and implemented. This apparently has had the unintended consequences of increased workplace stress for physicians and their teams as well as quality reductions and cost increases. This is one of those situations where something sounds reasonable and practical on paper—a win-win as they say—and then in practice it fails miserably. How could this be? The Triple Aim didn’t take into account a fourth factor, which is the well being of the people implementing the first three aims. Physicians and their health care teams started experiencing burnout, which in turn threatened the viability of the first three aims. The whole system is then at risk of collapse. So the Fourth Aim delineated in the article involves improving the work life of those who deliver care.
I find it so completely fascinating that the concept of the Triple Aim never took into account that the folks implementing the three aims might have actual feelings and needs. This strikes me as an essentially corporate way of approaching medicine. The thing is—patients are people. Doctors and their staff are people. We all have feelings and needs. For everybody to be happy and functional a certain understanding of this balance is necessary.
I recently taught a workshop on mindfulness for physicians, and this need for harmony and balance in the workplace was palpably evident. Under the current system, doctors are not happy people. We all go into medicine with altruistic goals. We want to help people. We want to have meaningful and enduring relationships with our patients. We want to do the right thing. We don’t want to sacrifice our own well being and the well being of our families in the process. That is often what happens.
Mindfulness is not the panacea; it is not the cure. It is the means to recognition that the Fourth Aim is important and should be honored. It must be honored or our whole health care system is at risk. In my humble opinion.
Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff (Millwood). 2008; 27 (3):759-769.
Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med 2014; 12:573-576.
How did I get involved in all this mindfulness and self-compassion stuff? As a physician, compassion is one of those qualities I should have in abundance. And I do, but. . . . . Compassion is about being present for another person’s suffering and having the desire to ameliorate it. The problem is that if you don’t have much compassion for yourself, it’s hard to truly have it for others. Like the airlines say, “Put your own oxygen mask on first before assisting others.” As a physician I’ve seen a lot and been through a lot. Without going into the details, I basically came to a point in my life where things were very out of balance. Trying to juggle full time work as an Ob/Gyn, a husband and a small child, the business, the call, and malpractice issues took its toll. I was looking for a better way. This search led me to integrative medicine and mindfulness. I’ve never looked back. Leading a good and happy life is completely about finding the balance that’s right for you. There was a lot of guilt and shame, distress, anxiety, doubt and general freaking-out before realizing that I actually had some modicum of choice in all this mess. Mindfulness has really led me to these conclusions. It is the “head” or mind part of the balance equation. But all that drama takes its toll, and hence there needs to be another part of the equation. That’s the “heart” part—compassion. And it begins with self-compassion. So I am doing a little research project and adding this to my daily mindfulness practice. I see huge potential to help both patients and physicians alleviate stress and add joy to life. I’ve seen the benefits of mindfulness practice for myself and those I’ve taught. Now I want to see if self-compassion practice takes things to the next level—a deeper, more enduring and heartfelt practice that can affect everyone around you and beyond. Stay tuned. . . .
We all live in a stressful world. There are numerous demands on us coming from all different directions. We can feel like a hamster on a wheel until we just run out of gas eventually. The way to keep this from occurring is to realize that “we cannot nurture others from a dry well. We need to take care of our own needs first, then we can give from our surplus, our abundance.” (from Jennifer Louden) Self-care about giving attention to the physical self, the spiritual self, the mental/emotional self, relationships and lifestyle. It’s about finding equilibrium. The biggest challenge facing most of us is how to live a balanced life. This does not mean a life containing no ups and downs, but one with resilience to change. Resilient people are better able to gather their strength and resources in the face of adversity. We are most able to do this when we are physically, emotionally, spiritually, and interpersonally supported and nourished. This is where the “integrative” part enters the picture.
The “integrative” mindset comes from integrative medicine (IM) where the orientation is toward wellness rather than disease or illness. IM focuses on the body’s natural healing capacity and aims to enhance mind, body, and spirit. This is really about looking at the whole picture. It’s about taking a holistic (and I don’t mean just natural or alternative) approach toward health. It’s about looking at the whole person, in all their uniqueness and complexity, not just their diagnoses. This leads to the question: what is health?
The word health comes from the Old English root word hal, which means heal, healthy, whole. It is interesting that in Western culture and medicine, this is not how we define health. The Oxford Dictionary defines health as “the state of being free from illness or injury.” There is a more global and inclusive definition that comes from the World Health Organization. The WHO defines health as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity.” According to this more integrative view, we begin to see a bigger picture—that health is about wellness, well being, thriving, flourishing. It’s about wholeness—however that is defined by the individual. This inspires the ultimate question—what make’s you whole?
The word health comes from the Old English root word hal, which means heal, healthy, whole. It is interesting that in Western culture and medicine, this is not how we define health. The Oxford defines health as “the state of being free from illness or injury.” There is a more global and inclusive definition that comes from the World Health Organization. The WHO defines health as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity.” According to this more integrative view, we begin to see a bigger picture—that health is about wellness, well being, thriving, flourishing. It’s about wholeness—however that is defined by the individual. This inspires the ultimate question—what make’s you whole? The integrative mindset offers a very different way of seeing health and wellness that can impact your life in a profound way. It bespeaks that healing can be found in the way we live our lives. Balance is truly the foundation for wholeness. It emphasizes addressing all the components of our life; they are all important, interconnected and interdependent. The Wheel of Health from Duke Integrative Medicine illustrates this well. It shows how integrative medicine attends to health issues, nutrition, exercise and movement, sleep and rest, lifestyle, the physical environment, relationships and communication, spirituality, and the mind-body connection. At the center is mindful awareness, which involves mindfulness and self-compassion. Mindful awareness is the core element upon which everything else is built.
Mindfulness is defined by Jon Kabat-Zinn as paying attention in a particular way: on purpose, in the present moment, and non-judgmentally. Mindfulness is about knowing what you are doing while you are doing it. It’s about seeing that good stuff and bad stuff come and go in life without necessarily reacting or letting it take control of your life. It’s about being able to take a step back and put some space between you and your thoughts and feelings. It is a mindset that allows you to find pause and equanimity among the waves of life.
Self-compassion is comprised of mindfulness plus self-kindness and a sense of common humanity, according to Kristin Neff, PhD. Compassion is an inherent human response to suffering that is not often directed toward oneself. We all share suffering as part of normal human experience. Being able to direct kindness toward oneself as well as others is fundamental to well being. Being kind to yourself in all the aspects of health and wellness, not just emotionally, is true self-compassion. Self-compassion and self-care are really flip sides of the same coin. Understanding this leads to a more integrative holistic view of life where all the parts are important and necessary to make up the multifaceted whole.
There was a time in childhood when we understood this in a very fundamental way. Young children have no qualms about kissing their own reflection, hugging themselves, or demanding care for a ‘boo boo”. We love ourselves unconditionally as children and receive compassion from both others and ourselves. This changes as we grow older. We lose that sense of self-kindness. Regaining this sense of self-compassion is true self-care. We can best care for others if we care for ourselves first. We need to put our own oxygen mask on first.
Do you know what self-compassion is? Perhaps this sounds like a contradiction in terms. How can we have compassion for our self?
Compassion comes from the root words “com” and “pati,” which together mean “to suffer with.” Merriam-Webster defines compassion as “sympathetic consciousness of others’ distress with a desire to alleviate it.” It is about allowing ourselves to be with the emotional discomfort of someone else’s suffering with the hope of lessening it. Most people naturally resist this discomfort, but feel empathy for another person’s distress. We all feel compassion; it is part of being human. How can we not have feelings toward another being that is suffering? Why can’t we offer that same kindness to our self?
The concept of self-compassion comes out of the Buddhist tradition of loving-kindness meditation where words wishing health, happiness, safety and peace to oneself and others are repeated as a meditation. These words are felt to create a benevolent connection to oneself and to the rest of the world as a force of good will.
Self-compassion amplifies this idea. Kristin Neff, PhD and Christopher Germer, PhD write about the three components of self-compassion. The first is self-kindness. This is just what it sounds like—being kind to yourself. This may sound simplistic, but our culture places emphasis on kindness to others, not to self. The second is common humanity. This is the idea that we are all in this great “world soup” together—we are all interconnected. Thich Nhat Hanh refers to this as “interbeing.”
The third component is mindfulness. This is about paying attention on purpose and in the present moment without judgment. It is awareness of awareness. It is a means to experience each moment of our lives as it is happening—and to know we are experiencing it.
These three parts taken together can lead to increased resilience and well being, to an experience of wholeness and intimacy with all the parts of our life.
A human being is part of the whole called by us “universe,” a part limited by time and space.
He experiences himself, his thoughts and feeling as something separated from the rest—a
kind of optical delusion of his consciousness. This delusion is a kind of prison for us, restricting
us to our personal desires and to affection for a few persons nearest us. Our task must be to free
ourselves from this prison by widening our circle of compassion to embrace all living creatures
and the whole of nature in its beauty. Albert Einstein
Integrative Medicine has its origins in the whole system concepts of Ayurveda and Traditional Chinese Medicine. These non-western approaches do not separate the body into parts, but rather look at the patient as an integrated whole including mind, body, spirit and community. The Arizona Center for Integrative Medicine at the University of Arizona defines Integrative Medicine as healing-oriented medicine that takes account of the whole person, including all aspects of lifestyle. It emphasizes the therapeutic relationship between practitioner and patient, is informed by evidence, and makes use of all appropriate therapies. This approach intuitively understands that humans don’t exist in a vacuum, and neither do their parts. Everything in our lives—what we think, how we feel, what we believe, our habits, our movement, our diet, our environment, our jobs, our relationships, our community, our spirituality—everything affects our health and well being. I am waiting for the day when medical culture really acknowledges this fact. It is the key to not only achieving individual wellness, but also the key to societal change in the health patterns currently taking their toll like obesity, diabetes and heart disease.
I’ve been thinking a lot about this word lately—on several levels. In English, aware means knowing, conscious, mindful, informed, perhaps wise. Strangely enough, however, there is a Japanese concept spelled the same way in English, but pronounced “ a-wa-re’ “. I first learned about this term at a retreat where the speaker defined it as meaning “happy-sad.” I found this to be a fascinating concept and one for which we have no parallel in our language. Apparently this term comes from a certain historical period in Japanese literature. I have researched it a bit, and it seems to really mean the poignancy of life. It is the emotional realization that everything in life is transient and impermanent, which makes it all very sweet and sad at the same time. As a parent, I would compare it to watching your child take his first step, and then he is walking and running and soon he is grown up and leaving. You know each stage is fleeting as it is happening, and there is both joy and sorrow in this. This word aware’ touches me deeply. I think it defines the human condition. It is the enigma that we all struggle with—how to be happy and how to deal with sorrow and suffering.
This all became even clearer to me this week when I participated in a Tonglen meditation. Tonglen is a Tibetan meditation known as a Giving and Taking meditation. In this particular style, we were guided to inhale the suffering and grief of others (the “stuff” of life, as Tara Brach intoned) and to exhale space and openness. We were guided to note the feelings in our body as we did both. I had the remarkable realization that the bodily feeling associated with sadness, anxiety and grief was actually the same as that associated with happiness, joy and spaciousness. This knowing that happiness and sadness are inextricably interwoven became palpable to me. It is certainly something I understood on some level already, but this was truly more visceral and beyond words.
So essentially, awareness of your breath with compassion, daily, leads to equanimity and freedom.
This has been an interesting few days here in Bend. Fire is truly a living capricious thing. From the moment I saw the two first plumes trailing into the bright blue sky, concern set in. I stood on my deck with my camera and binoculars watching the fire quickly progress. It was both scary and amazing. After an hour or so I started seeing a spotter plane and then later helicopters and tankers. All evening into night we watched the fire spread, becoming an orange flaming glow on the horizon. Remarkably, the “Two Bulls Fire” is now mostly contained. I am so grateful to the firefighters for working so hard to quickly get the fire under control. Only a charred swath of smoldering ashes and wispy smoke remains.
The Heart Center Meditation is a lovely practice I first encountered when I was doing an Integrative Medicine fellowship through the University of Arizona. Ann Marie Chiasson, M.D., an integrative physician and energy healer, taught this meditation of repeating four mantras. It struck me deeply at the time, so much so that I wear a Navajo ring with four different colored gemstones to signify the four parts of the meditation. I feel that these four qualities define the healer.
The Buddha taught that practicing the Four Heavenly Abodes or Sublime Attitudes leads to liberation of the heart, which is love. Also known as the Brahma Viharas (in the original Pali language of the Buddha), they are lovingkindness (metta), sympathetic joy (mudita), equanimity (upekkha) and compassion (karuna).
Dr. Chiasson modified these slightly to be unconditional love, healing presence, inner harmony and compassion. She teaches the meditation by recommending that you place your left hand over your heart, and then place your right hand over it with your thumb tips touching. Close your eyes and repeat the four attitudes silently, one with each breath. Compassion is first invited into your heart. She describes this as limitless and oceanic compassion. With the next breath inner harmony is invited. This is balance within leading to balanced action. Next is healing presence, which is the desire for healing in the self and in others. She defines this as love in action. Last is unconditional love, which is reverence, awe or love while seeing things as they are.
This all sounds so simple, but repeating this meditation for five minutes daily can lead to a more open heart.
Dr. Heather's musings about medicine, mindfulness and life.
Heather Krantz, M.D.
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