Alternative Therapies in Health and Medicine, May 1996, vol. 2, no. 3
by Frank Ostaseski
Frank Ostaseski is the Founding Director of the Zen Hospice Project, a nationally
recognized programme of conscious care for the dying in San Francisco. Inspired
by the 2,500-year-old Buddhist tradition of contemplating sickness, old age
and death, the Zen Hospice Project encourages and supports a mutually beneficial
relationship between volunteer caregivers and individuals facing death. This
innovative model of conscious care provides a spectrum of collaborative volunteer
programmes, residential care, and training which aim at cultivating wisdom and
compassion through service. Founded in 1987, the Zen Hospice Project is the
oldest and largest Buddhist hospice in America.
A long-time Buddhist practitioner, Frank uses his knowledge of both Buddhism and Western psychotherapy in his work of de-mystifying the care-giving process.
The following article is based on a talk given by Frank Ostaseski at the Munich conference on Death, Dying and Living in November 1996.
This afternoon we are going to explore our intention in service, and I think it's helpful to start with the basic, but true premise that real service does not happen unless both people are being served. At an installation ceremony at the Zen Centre, a student asked the abbot, 'What can the Dharma teach me about serving others?" The abbot answered, "What others? Serve yourself!" The student persisted, "How do I serve myself?" To which the abbot responded, "Take care of others."
Every day I work with people who are dying, and some of these people are very tough. They may have been living on the streets for some time, or be angry about their loss of control. Often they have lost their trust in humanity; turning their heads to the wall, they withdraw. Most of them don't care beans about Buddhism. These people don't trust easily and if I am going to be of any use to them at all, I have to be particularly clear and honest about my intention; if I'm not, they will quickly sniff out my insincerity and sentimentality.
Some of the individuals I work with blossom, and the way in which they die will be a great gift; they make reconciliations with their long-lost families, and they find the kindness and acceptance they have been looking for their whole lives. It can be quite wonderful to be around these people. But I don't do this work because it can turn out so well. Chasing such rewards brings exhaustion and ultimately leads to manipulation because we're so busy trying to create the conditions that lead to a reward. In so doing we miss the current situation. I do this work because I love it and because it serves me. I try to see myself in each person that I serve, and I try to see them in me. Those I work with know and trust that, in fact they come to rely on it. They understand we are in it together.
You see, at the very heart of service we understand that the act of caring is always mutually beneficial. We understand that in nurturing others we are always caring for ourselves, and this understanding fundamentally shifts the way we provide care. I'm not the good guy coming to the rescue; I have no white horses. Instead we become what I call 'compassionate companions'. 'Compassion', when literally translated means ' suffering with others' and 'with' is the most important word, because it implies belonging. 'Companion' is 'one who travels with another'. So in this relationship there is no guide, there is no healer and no one healed; we simply accompany one another. And as my friend Reb Anderson says, "We are simply walking through birth and death holding hands."
If we are paying attention as we walk into the room of someone dying, we immediately understand, in a visceral way, just how precarious this life is. As we understand that, we also come to see how precious it is. When we keep death close at hand, we become less compulsive about our desires, we take ourselves and our ideas a little less seriously, and we let go more easily. We become more open to generosity and to love. Paradoxically, working with the dying will make us kinder to one another. In the face of death everything we normally identify with ourselves will either be stripped away by illness or given up gracefully-but it all goes. 'I'm a father', 'I'm a mother', 'I'm a hospice worker', 'I'm a sexual deviant'-whatever our notion about our identity, it will go.
On the surface, the lives of the people I work with seem to be very different from mine: they're black, I'm white; they shoot heroin and have AIDS, I don't; they're homeless and alone, I pay a ridiculous amount of rent and I have four teenagers. It would be easy to convince myself that we are separate, after all a few months ago we might have just walked past each other on the streets. But the wonderful thing is that now, in the hospice, we are thrown together in the most intimate of circumstances. And suddenly in the midst of all the activity, in the details of service, we find a meeting place. We find that we belong together.
Prior to any action of the body, thought, or speech, there is a moment of intention that we need to be aware of because clarity about our intention gives us choice about how we can proceed. A moment of contact with our intention can break our habitual patterns and keep us from operating on automatic pilot.
In the Zen tradition there is a practice called dokusan. It is an interview with the teacher. The student is instructed to wait outside the teacher's door, where they must gather themselves completely into the moment. They have no idea what is waiting for them on the other side of the door, they have no idea what their teacher will ask them, so they have to be ready, flexible and open. Going into a dying patient's room is like going for dokusan. Ideally, our bodies and minds should enter the room at the same time. Sometimes that's not the case, is it? We leave our minds way behind sometimes we even leave our bodies behind! Or we enter the room days before we ever got there.
There was a volunteer I know who did this. He went to a patient's bed and the patient got very excited saying, "Oh I'm so glad you're here. I finally have someone to talk with about my dying." The volunteer got very excited and said, "Yes, yes, yes. I'm going to get books by Elisabeth Kübler-Ross and Steven Levine and I will be back next week and we will talk all about it." Of course the next week he came back with piles of books and the patient said, "Yes. We're watching the football game on TV, please come in. Watch the football game with us."
Too often in care-giving, we're not so much looking to see what serves but to confirm some idea we have about ourselves. We want to be somebody. We say, 'I work with the dying/ with the emphasis on 'I', and invest in the role, not the function. I sometimes call this 'helper's disease', and it is a much more rampant epidemic than AIDS or cancer. We try to set ourselves apart from other people's suffering. We set ourselves apart through our pity, our fear, our professional warmth and even our charitable acts. This work has nothing to do with charity.
A few years ago a woman at our hospice was just a few days from her death, and she was quite sad and depressed. This seemed natural to me; she was dying. But a nurse suggested that we start her on Elavil, which is a medication used to enhance people's moods and usually takes about three weeks to start working. I asked the nurse, 'Why do you want to prescribe this medication?" She replied, 'Well, she's suffering, and it's so hard to watch her suffer." So I said, "Maybe you should take the Elavil."
This attachment to the role of helper is old in most of us; helping others provides a needed sense of power or respectability that we collect at the end of the week like a pay cheque. But if we're not careful, this identity will imprison us as well as those we serve. After all, if I'm going to be a helper, somebody has to be helpless!
My friend Rachel Remen, who runs the Commonweal Cancer Centre in California, speaks very beautifully about this. She says:
"service is not the same as helping. Helping is based on inequality, it's not a relationship between equals. When you help, you use your own strength to help someone with less strength. It's a one up, one down relationship, and people feel this inequality. When we help, we may inadvertently take away more than we give, diminishing the person's sense of self-worth and self-esteem. Now, when I help I am very aware of my own strength, but we don't serve with our strength, we serve with ourselves. We draw from all our experiences: our wounds serve, our limitations serve, even our darkness serves. The wholeness in us serves the wholeness in the other, and the wholeness in life. Helping incurs debt: when you help someone, they owe you. But service is mutual. When I help I have a feeling of satisfaction, but when I serve I have a feeling of gratitude. Serving is also different to fixing. We fix broken pipes, we don't fix people. When I set about fixing another person, it's because I see them as broken. Fixing is a form of judgment that separates us from one another; it creates a distance.
"So, fundamentally, helping, fixing and serving are ways of seeing life. When you help, you see life as weak; when you fix, you see life as broken; and when you serve, you see life as whole. When we serve in this way, we understand that this person's suffering is also my suffering, that their joy is also my joy and then the impulse to serve arises naturally - our natural wisdom and compassion presents itself quite simply. A server knows that they're being used and has the willingness to be used in the service of something greater. We may help or fix many things in our lives, but when we serve, we are always in the service of wholeness."
Caring for those who are suffering, whether or not they are dying, wakes us up. It opens up our hearts and our minds. It opens us up to the experience of this wholeness that I speak of. More often than not, though, we are caught in the habitual roles and ideas that keep us separate from each other. Lost in some reactive mind state, busy trying to protect our selfimage, we cut ourselves off and isolate ourselves from that which would really serve and inform our work. To be people who heal we have to be willing to bring our passion to the bedside; our own wounds, our fear, our full selves. Yes, it is the exploration of our own suffering that forms a bridge to the person, we're serving.
This is how it works. A few years ago a very, very dear friend of mine, someone I loved very much, was quite sick with AIDS. I had known him for many years. In just one afternoon he lost his ability to speak, hold a fork, stand and to formulate a coherent sentence, and it happened during the afternoon that I was taking care of him. It scared the hell out of me. Me! 'Mr. Hospice'!
I did everything I could to take care of him. He had enormous fistulas and anal tumours, and constant diarrhoea. We moved incessantly from the toilet to the bathtub and back to the toilet again. It went on all night. I was exhausted and all I wanted to do was get him to bed so I could sleep. I tried every trick I knew. I was cajoling, I was manipulative, I was paternalistic. I changed wardrobe more often than Madonna.
In the middle of one of these moves from the bathtub to the toilet, he spoke. From his garbled mind he said, "You're trying too hard." And indeed I was. I stopped right there, sat down beside the toilet and started to cry. It was the most exquisite meeting of our whole relationship. We were completely helpless together. No separation. No professional warmth.
If we're not willing to explore our own suffering, then we will only be guessing as we try to understand our patients. It is the exploration of our own suffering that allows us to serve others. This is what allows us to touch another person's pain with compassion instead of fear and pity. And we have to be willing to listen, not only to the patient but to ourselves.
We must pay careful attention to what's immediately in front of us. A year or so ago a very tough, eighty-year-old Russian Jewish lady was in the process of dying. As I walked into her room I saw that she was gasping for air. The attendant sitting by her bed said to her, "You don't have to be frightened, I'm right here with you." The woman replied, "Believe me, if this was happening to you, you would be frightened." I just watched. Then the attendant said, "You look a little cold, would you like a blanket?" The woman replied, "Of course I'm cold! I'm almost dead." If I was going to be able to help her, I knew that I would really have to listen. I really had to pay attention to what she was telling us.
She was struggling with her breath, but she wanted to be dealt with honestly-she didn't want any bullshit. I said, "Adèle, would you like to suffer a little less? Would you like to struggle a little less?"
"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?"
Now remember, this was one rough, tough Russian Jew with absolutely no interest in Buddhism or meditation. But she did want to struggle less. So for a few moments she tried this and, as she did so, I saw the fear in her face begin to wash away. She took a few more breaths, and then died quite calmly.
If we are going to be of service we have to pay attention to what's immediately in front of us, act with minimal intervention, and bring to the experience the same attention and equanimity that we cultivate on our meditation cushion. The degree we are willing and able to live in this ever-fresh moment is the measure of our ability to be of real service. When the heart is open and the mind is still, when our attention is fully in this moment, then the world becomes undivided for us and we know what to do. Each of us here can do that, we .don't need twenty years of Buddhist practice. Each of us has the capacity to embrace another person's suffering as our own. We have been doing it for hundreds of years-we've just forgotten how, and so we have to remind each other.
When our hospice first opened, one of our volunteers, Tom, was helping a patient with AIDS to move from the bed to the commode. As they began to move the patient fell, causing chaos: his pants fell down around his ankles and the commode tipped over-it was like a small Hiroshima. This is what care-giving is really like. Anyway, Tom fumbled through it all and got the patient back into bed. Then he called me. "Frank, I want you to review with me the techniques we learned in the training about positioning people in bed." I said, "OK, let's just do this: the next time you go to move J.D., before you start just check your belly. See if your belly is soft. If your belly is not soft, don't do anything."
'Don't give me that Buddhist stuff. I want to know what do I do with his knees?" "Just check your belly and call me back later."
It was a bit like saying, 'Take two aspirins and call me in the morning', but he did call back a bit later.
"Frank, it was the most amazing thing. I went to move J.D. and my belly was hard as a rock, so I stopped. I took a few breaths, my belly softened and the next thing I knew, J.D. was in my arms like a lover or a small child. It was no trouble at all."
We all know how to do this.
Buddhist practice includes this notion that we have all been born many times before and that we have all been each other's mothers and fathers and children. Therefore, we should treat each person we encounter as if they are our beloved. As we inquire into the heart of service, we see a pattern: common to all habits that hinder us in our work is a sense of separateness; and common to all those moments and actions that truly seem to serve is the experience of unity. Einstein wrote about this, and Sogyal Rinpoche quotes it on page 98 of The Tibetan Book of Living and Dying:
"A human being is part of a whole, called by us the 'Universe' a part limited in time and space. He experiences himself, his thoughts and feelings, 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."
When the heart is undivided, everything we encounter becomes our practice. Service becomes a sacred exchange, like breathing in and breathing out. We receive a physical and spiritual sustenance in the world, and this is like breathing in. Then, because each of us has certain gifts to offer, part of -our happiness in this world is to give something back, and this is like breathing out. One friend calls this 'simple human kindness'. Our work, I think, is to get out of the way of our own innate wisdom and compassion-that simple human kindness-and allow our inborn ability to see what another needs, to serve the dying and the living.
Quotation by Rachel Remen from Noetic Sciences.