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Psychodynamic Psychotherapy
By Linda Gill, MD

Linda Gill is a MD, psychiatrist and a diplomat of the American Board of Psychiatry and Neurology. Linda completed her BS in Biology (with a minor in physical anthropology) at the University of Pennsylvania in 1992, MD at the Medical College of Pennsylvania in 1998. Her residency training was a combined Internal Medicine and Psychiatry program at the University of Rochester, Strong Memorial Hospital and was completed in 2003.
Dr Linda Gill

 

Holding the Sacred Space; The Healing Power of Unconditional Presence in the Human Encounter

Part One

This article is by no means a comprehensive exposition on the topic; nonetheless I hope it can offer some assistance to those seeking to alleviate the emotional suffering that often accompanies the end of life process.

Facing and integrating difficult, painful events and emotions is central to psychotherapy, and there are psychotherapeutic principles which can offer real help to those facing and those who work with terminal illness, bereavement and death. Of course death is also an existential fact of life with a profound and often painful impact on all those who must grapple with it – and we all must, sooner or later.


What is Psychodynamic Psychotherapy and How Can It Help?
Psychodynamic psychotherapy holds that much of human suffering is caused by seemingly overwhelming and irreconcilable emotions and intrapsychic conflicts associated with past wounds and traumas, as well as the difficult existential realities we all must face. Many of these wounds stem from childhood experiences and no life is without them as invariably one’s caregivers are human and imperfect, and unfortunately in some instances outright abusive or neglectful.

Likewise, each person will experience existential angst over the limitations and frailties of human reality, including impermanence, ageing, illness, death and loss. Ideally the indomitable and resilient human spirit can utilize these experiences as a crucible for growth, maturation and deepening compassion. However, when the intensity of the emotions and conflicts overwhelms our coping mechanisms, resources and available support, then the suffering human defends against the pain by submerging it into the unconscious and by using various defence mechanisms such as denial, projection, splitting, and the like.

Alas, the experience nonetheless continues to live inside the unconscious of the person, and to colour their present interactions and experiences in an unhealthy and painful way. It is also easily observed that the unresolved past seems to repeat itself as a theme or pattern in one’s life, causing further misery. Therefore, psychodynamic psychotherapy has the premise that human suffering and dysfunction can be relieved by making the unconscious conscious, and in such a way that the past painful experiences and emotions can now be tolerated, digested, and integrated into a more accepting and cohesive, if at times bittersweet, life pattern. In other words, by having the opportunity to face the unconscious material one can now make peace with the past and with difficult existential realities and begin to live more happily and productively in the present. The individual is then freed from the need for rigid and dysfunctional defence mechanisms and a repetition of patterns based on the past, leading to a more open and flexible life stance.


The Importance of the Therapeutic Relationship
To this end, the therapeutic relationship between the therapist and client serves as a vehicle for observing and exploring the phenomena within the client’s psyche and life, and also within the therapeutic relationship itself. For inevitably, a person’s intrapsychic experience will find itself reflected in their external experience, in their relationships – and the relationship with the therapist is no exception. But here the therapeutic relationship differs from other relationships in that its express purpose is to courageously and compassionately explore its own dynamics and the intrapsychic life of the client in a setting of safety and emotional honesty. Good psychotherapy is an art, a science, a spiritual endeavour, and above all, a human encounter.

The therapeutic relationship is thus of central importance in the healing process, and the therapist’s interactions with the client must cultivate an atmosphere where it is possible to safely acknowledge, allow, experience, tolerate, explore, digest, and integrate those overwhelming events and emotions which could not be assimilated previously. The therapist must hold the sacred space, the container, in which the work of psychotherapy can occur successfully. Likewise, the sacred space can also be of great help to those psychologically healthy persons facing the often overwhelming end of life experience. The tasks of transition (for the dying) and of bereavement (for their loved ones) are made more bearable and manageable with such a resource available. Some of the components of this container are obvious and have already been alluded to: safety, trust, respect, emotional honesty and genuineness, non-judgement, compassion and kindness, courage, and willingness for the task. I will speak now in more detail of some other elements of a healing therapeutic alliance.


Presence or Deep Listening
Of paramount importance, presence is the sense that the therapist is energetically and emotionally with the client, here and now, available, attentive and listening. So often in human interaction the parties are distracted by their own internal thoughts, worries, obligations, etc., and are also busy with any emotional reaction triggered by the interaction itself, so that a full attention to the other is not possible. In other words, one is more present with oneself, one’s own internal reactions, than with the other person. As the joke goes: “Are you listening, or merely waiting to speak?”

Indeed, it is a sad fact of human life that mostly people are not truly present in the here and now because of this internal preoccupation. In the healing relationship, the therapist makes an effort to give her full focus and attention to the client. Of course, it is not possible to stop all one’s thoughts or reactions – and the therapist indeed must acknowledge and monitor their own reactions – but these are put aside to focus on the client and are not acted upon in a reactive way.

This presence leads to what I call “deep listening”, because what is heard from the client can be much deeper than what is heard in “ordinary” conversation. It is clear that every human being can sense genuine presence and finds it profoundly nurturing and healing. The healing comes from several sources – firstly, to be truly heard and seen, is something needed. To be able to tell one’s story in detail, and have it received, brings the experience of connection and validation. Also, the telling of it can help clarify it in your own mind and heart. The naming of experience acknowledges it and makes it less amorphous, allowing one to grapple with it more effectively.

Sadly, sometimes therapy is the first place where a client experiences presence and deep listening. In the case of those confronting death, this is such a difficult experience and society is generally so ill-equipped to deal with it, that often those around the dying and bereaved don’t feel they know how to speak to them, or feel unable or unwilling to do so because of their own discomfort about death. So, to have a space to honestly air feelings is a real gift to the dying and bereaved.

Additionally, the therapist’s ability to maintain consistent presence indicates that she can, indeed, tolerate and receive the client’s story, as well as their intense feelings or “affect”. This gives the client permission to be open, to be relieved of any guilt that their story is a burden, or fear that it will trigger rejection, criticism, or retaliation, or shame that their story is not permissible. The continuous presence of the therapist also inspires the client to believe that presence with their pain is possible for them as well. Finally, the experience of being truly present is healing for the one who is present – it quietens the mind and heart. The therapist‘s ability to be present can be “contagious”, encouraging the client to also be more present.


An Unconditional Quality to Presence
It is important, for obvious reasons I think, that the presence of the therapist be perceived as benign and unconditional. By unconditional, I mean that the therapist’s motivation in being present with the client is: 1) to be useful and helpful to them, and 2) having (hopefully) cultivated the capacity for presence in their own work and life, this tends to be a habitual state for the therapist.

The therapist is not offering their presence with “conditions” or stipulations, or in exchange for fulfilment of their own need and agenda, as is so often the norm in human relations. Indeed, care must be taken that even the “agenda” of helping doesn’t become an unhelpful insistence that the client get “better” to alleviate the therapist’s anxiety or frustration, and to reassure them that they are a good therapist and a good human being. This unconditional quality allows the client to trust the therapist, and to believe the therapist is benign and has their best interest at heart, and frees the client to be frank and open and pursue the healing work in earnest. Likewise, in the setting of working with the dying and bereaved it is important to cultivate unconditional presence and to be clear about one’s own motivation and agenda for helping. It’s also important to respect the individual nature of the grieving process and not to push the bereaved into rushed resolution of their grief to alleviate our own discomfort.

Part Two

Healthy Boundaries
Note, however, that “unconditional” and “without agendas” does not translate into a lack of boundaries in the therapy relationship. The therapist does not help the client by tolerating inappropriate use or abuse, such as verbal lashings, repeated daily telephone calls or other intrusions into the therapist’s life, lying, etc. Tolerating inappropriate behaviours (which are dysfunctional attempts at coping) only serves to enable them, and are better served by having clear and consistent boundaries from the outset, and by treating the behaviours as simply one more thing to be openly and honestly explored in therapy.

Indeed, the setting and keeping of boundaries is a necessary component of a safe, effective healing space, and can also serve as a healthy model which can translate into the client developing healthy boundaries in other settings. Of equal importance is the negative effect lack of boundaries has on the therapist – it leads to resentment and professional burnout, among other things. One cannot hope to work effectively or enjoyably in the helping professions if one does not take adequate self-care, which includes knowing our limits and needs. When working with psychologically healthy persons coping with death, the issue of inappropriate behaviours is less prominent, yet in times of crisis the suffering person can overtax their support systems.


Emotional Honesty and Genuineness
Emotional honesty and genuineness is a pre-requisite for the work of psychotherapy, since one cannot face and integrate that which is not seen and acknowledged. There can be many barriers to this openness, including fearing a negative response to one’s admissions, not feeling one has permission for disclosure, wanting to avoid overwhelming, shameful, or otherwise unpleasant phenomena, a lack of conscious awareness of the phenomena, and not having the habit or know-how of naming and acknowledging things. The therapist can be and do a number of things to facilitate the client move through these barriers.

Firstly, the therapist can embody and model emotional honesty and genuineness themselves. This would be sensed by the client and foster their trust. Also, this shows the client that honesty is welcomed, permitted, and valued in the therapy setting. It can also show in a practical way how one names and explores intrapsychic phenomena. One way the therapist demonstrates honesty is to be willing to broach and ask the client about topics in their life which are usually avoided as impolite, “bad”, taboo, painful, delicate, etc. If this is done openly, non judgmentally, gently and respectfully – without forcing the client to speak and experience things they are not yet able or willing to – it can help them be more open.

Also, the therapist can themselves name and mirror to the client: 1) their observations of the client and the therapy interaction (“You seem tense, angry, sad, etc.”, “I notice we spend every session discussing what you think your mother would do, have you noticed that? What do you think about that?”), and 2) existential reality (“Everyone will sometimes feel angry towards those they love”, “Change is unavoidable in life, but this isn’t always easy”).

In selected instances, disclosure of the therapist’s own reactions and emotions can be helpful, but only when this has a rationale in facilitating the therapy and is not done to alleviate the therapist’s own discomfort, or to criticize and punish the client. For example, it can normalize an emotion for the client if the therapist admits “I sometimes feel angry too”, or it can help to identify an interpersonal pattern if it is identified in the therapy relationship: “You told me you crave nurturing and feel you don’t receive enough of it, yet just now you’re pushing me away.” It is also critical that the therapist is willing to acknowledge their own errors, limitations and failures of empathy. Honesty and openness can also bring relief to those encountering death, because death and the pain it brings is difficult to talk about and is usually avoided.


Willingness
Without a willingness for the task of psychotherapy, no healing can occur. The difficult task of observing and exploring one’s intrapsychic life can seem daunting and overwhelming, so that willingness fails. A sense of non judgement, courage (even in the face of fear), and curiosity can be great aids in increasing willingness.

An approach which encourages the discovery of useful and interesting information, information about experiences that all humanity shares (and which are not shameful or abnormal), is also helpful. Psychotherapy is a journey of healing and self discovery, with the client and therapist acting as explorers, looking at the client’s intrapsychic life with interest, musing about its significance and purpose, experimenting with viewing and experiencing it from different vantage points.

The ability to experience the humour, awesomeness, richness and poetry of life’s tapestry also makes the task more bearable. Offering hope -- that the work is possible and will bring understanding and relief to suffering -- also increases willingness. However, enough misery, a realisation of the futility of one’s previous strategies for coping, a sense of being “sick and tired of being sick and tired”, also allows more willingness to try new approaches and to bear with a difficult task.

It’s helpful for the therapist to both acknowledge the difficulty and seeming enormity of the task, while also reminding the client of the resiliency and even heroism they possess which allowed them to survive their past traumas, and which can now be recruited to help them succeed in the work of therapy. Those approaching death, or experiencing the loss of a loved one, may find that those qualities which increase willingness can help them persevere when the grieving process seems endless and unbearable.


Tolerating Affect
One of the major tasks of psychotherapy is to increase the client’s capacity to tolerate their own intense feeling states or “affect”. Suffering is caused by painful thoughts and emotions, as well as ineffective strategies used to try and cope with, or avoid them. The suffering person does not know how to bear their thoughts and emotions, or how to work on them effectively, to integrate or release them – but, in fact, these things can be learned.

One can practise gradually being more present with thoughts and feelings, and to gain detachment and perspective on them (which is not the same as denying them), and indeed thoughts and emotions tend to have their life and then dissipate, when they are allowed to actually do so. Once the client begins to expand their affect tolerance and to experience that their emotions actually do move, shift and transform, then they feel relief, renewed hope and more enthusiasm for continued intrapsychic work.

It is only because they lack any experience that such things are possible, or any practical know-how as to how to accomplish them, that they are left with their pain and their failed attempts at coping.

Therefore, the therapist and the healing space act as a container to hold the client’s affect as the client learns to do this for themselves. This is not the therapist “taking on” the client’s pain, but rather the therapist demonstrating an ability to be with and tolerate the pain, which serves as both a model and as temporarily borrowed ego strength for the client. Indeed, the therapist, while attentive and compassionate, does not take the client’s thoughts and feelings personally and remains non-reactive. This in turn allows a client to feel safe in opening up, as they will neither harm the therapist nor risk their punishment. They also learn that they are not harmed by the experiencing of affect themselves; despite feeling vulnerable and uncomfortable, their emotions do not destroy them. Likewise those facing death will feel relieved and comforted to have a place where their grief can be held and tolerated.


Holding Life’s Paradoxes
Existence, relationships, and intrapsychic life all include many troubling and confusing paradoxes, and psychotherapy must find a way to encompass these if it hopes to succeed. For indeed, a work of psychotherapy consists of facing and integrating all components of one’s self into a cohesive, healthy, fluid whole, and this necessarily includes finding a way to acknowledge and accept the reality of both poles of life’s paradoxes.

One paradox, which was already discussed, is that of acknowledging both hope and a possibility of healing, while simultaneously realizing that life will always include pain - that some existential hardships are unavoidable (such as change, death, etc.), and there are limits to any human endeavour including therapy.

Another important dialectic is the importance of validating and normalizing the client’s painful experience, while balancing this with encouraging the client to look at their experience in new and different ways: to reframe and change their relationship to their experience and perhaps let go of it.

Other paradoxes include: simultaneously loving someone and also feeling negative emotions (even hate) towards them, having seemingly contradictory traits or emotions (such as being both weak and strong, both kind and cruel, etc.), experiencing life as both beautiful and ugly, etc. Likewise the end of life experience can trigger many contradictory and paradoxical emotions and thoughts, and making sense of and peace with these is part of the grieving process.


Respecting the Process
The client’s healing in psychotherapy is a process which takes time, occurs in stages and layers, and is unique for each individual. This must be acknowledged and respected in order for psychotherapy to be successful. The grieving process is similar in this regard. Distinct stages to healthy grieving have been noted: shock and denial, anger or protest, bargaining, despair, and acceptance or detachment. Those working with the bereaved should be sensitive to this process.

The Therapist should also be aware that unhealthy grieving means that the client may miss out or “get stuck” in any one of these stages. For example, the client goes immediately to a state of detachment/acceptance. On learning they have terminal illness, they say “I’m fine, I can deal with it“, and yet have no feelings of apparent protest or anger about what has happened i.e. “Why should this happen to me. It’s not fair, I have so much more that I want to experience in life”, etc. Then the Therapist needs to sensitively work with the client to see what feelings may be too painful to explore.


The Importance of Self-Support
Finally it is essential that therapists do their own work (perhaps, but not necessarily, through having therapy themselves), to obtain adequate professional support and supervision, and to maintain adequate self-care.

It should be obvious that therapy will be limited by the degree to which the therapist has successfully grappled with their own emotions, past wounds, paradoxes, etc. For how can the therapist tolerate such exploration in the client if they’ve found it too painful or unmanageable themselves? Modelling such skills as affect tolerance, presence, emotional honesty and the like is not possible without their own inner work.

Of course, at the same time it must be acknowledged that the therapist is human, imperfect, and that inner work is ultimately an ongoing, lifelong process. Therefore because all therapists will have limits, “blind spots”, and will sometimes be “stumped” or need a fresh perspective, it is highly recommended that the therapist engage in regular professional supervision. “Supervision” refers to having knowledgeable and competent colleagues with whom one can review one’s work with clients and receive feedback and fresh insights. Lastly the work of a therapist contains many rewards, but also many challenges and one cannot hope to work effectively or enjoyably if one does not take adequate self-care. All of this advice holds true for those working with the dying and bereaved, for this is also rewarding but demanding work.

Summary
While the preceding discussion is not comprehensive, nonetheless I hope it will provide some taste of what the psychotherapy process is and of the factors which facilitate its success as a healing endeavour, and that these insights will be useful to those working with the end of life issues. Whilst psychotherapy and helping someone through the grieving process are by no means identical, they do have in common the need to confront and work through difficult experiences and emotions
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Psychological Insights
By Sri Dhira Chaitanya

Sri Dhira Chaitanya practised for years as a child pshychiatrist in New York and later he studied and taught Sanskrit and Vedanta. He is therefore able to address both the psychological and spiritual issues involved in death and dying with a special insight. He has kindly permitted Ganga Prem Hospice to reproduce parts of his book on Bereavement and Final Samskar in Hindu Tradition.

Sri Dhira Chaitanya

Attitudes toward Death and Dying

Emotional Reactions
A person deals with one’s own impending death in a variety of ways. The kinds of responses that one has are influenced by one’s culture, beliefs, personal values and personality. Upon becoming aware of one’s impending death, it is natural and quite common to become anxious. Every individual cherishes his life. So, the real likelihood of its coming to an end is an unwelcome thought that one does not want to entertain. Often a person’s initial reaction is one of denial. The anxiety in such a person’s mind does not permit him to accept the reality and inevitability of his own impending death. There is an apprehension in talking about death or dying, expressing one’s feelings, planning for the well being of one’s family and taking care of one’s personal affairs. Initially the person talks and behaves as if everything is as usual. Denial is not a conscious, deliberate decision not to talk. It is an unconscious protective mechanism of the mind to cope with a highly anxiety provoking situation at a particular time. The period of denial may be transient or remain with the person until his death. Denial may at times lead to a feeling of invulnerability, even leading to reckless behavior.

Sometimes a person does not deny the inevitable but avoids dealing with it directly. This is done in order to protect himself or others from the unpleasant and difficult emotions associated with death. Such a person may preoccupy himself with mundane matters that are unconnected with the fact of his death and thereby spare himself and others the agony of painful feelings.

Fear is another common emotion experienced by a dying person. The possibility of impending death evokes a fear of the unknown. No one knows for sure, what would happen after one’s death. The continuity of one’s very existence is put to question. And, no one is ready to die to find the answer. Additionally, there is the fear of loss of one’s family and friends. These are the people who have been the source of support in one’s life and have helped one deal with many difficult situations in the past. However in this particular instance, when death is at one’s doorstep, they are as helpless as oneself in doing anything to prevent it. Often, there is illness associated with dying which gives rise to fear of pain and suffering. Quite often, one has ideas of the process of death that are dramatic and frightening, because one may have witnessed a traumatic death, or have been influenced by what one sees in the media.

An individual who is aware of his impending death often experiences sadness. He worries, his sleep gets disturbed and he may lose his appetite. He is unable to enjoy anything pleasant. He may cry and appear morose. Any experience of loss or the possibility of loss evokes sadness in an individual, even when it is the loss of oneself due to death. To begin with, there is the concern that one would cease to exist and thus be lost forever. Even if one were to continue, it certainly would not be in the current shape and form, as one has to necessarily give up one’s body at the time of its death. Whatever complaints one may have about one’s body, it is the only one that one has had and is familiar with. The thought of losing it forever naturally evokes sadness. Besides experiencing sadness, one may go through a process of mourning for the impending loss of oneself, much the same as one goes through bereavement process after any loss. Sometimes, one can become melancholic and withdrawn to the extent that one isolates oneself from one’s own loved ones emotionally and/or physically.

Individuals may also experience guilt in varying degrees. One starts recalling a lifetime of acts of omission and commission. In retrospect, one realizes that there is much that one would like to have done, and maybe much more that one could have avoided doing. This is not only in regards to one’s personal pursuits, but also in one’s relationships with others. Knowingly or unknowingly, one invariably becomes instrumental in causing hurt in another individual, either by one’s action or by one’s words. No individual wants to maliciously and deliberately hurt someone he is related to. Thus, one experiences guilt and given a chance would like to make amends for all the hurt that one may have caused. Guilt can cause considerable fear in an individual who has grown up to believe in the prospect being punished after death for eternity, with varieties of horrible experiences for not conforming to prescribed codes and dogmas.

Anger is another common emotion experienced by the individual facing immanent death. Anger arises when one perceives oneself as a victim of an act of injustice that one has been subject to. It also arises when one feels helpless in a given situation. Even though death is an inevitable fact of life, it is also true that one does not willingly accept its occurrence. Moreover, a significant part of ones time is devoted to maintaining one’s life and extending it as long as one possibly can. Even if one acknowledges that death is bound to occur one day, the timing of it’s arrival always seems premature. One wonders, “Why am I the chosen one at this time, I am not ready to die, to leave my loved ones” and so on. These thoughts make one feel helpless and give rise to anger. Sometimes, sadness is also expressed as anger. Thus we find that a person facing impending death becomes irritable, easily angered and may even unreasonably blame others such as family, friends, doctors and sometimes even God for what is happening to him or her.

In conclusion, some individuals are more accepting of the inevitability of death than others. Even though they feel a certain degree of sadness for various reasons such as loss of their loved ones, they have essentially reconciled to the fact that they are dying. They can articulate their thoughts, feelings, and fears, seek and gain comfort and support from those around them. Their beliefs and traditions provide them with strength, reassurance and comfort.

For one who ascribes to Hindu traditions, one’s beliefs and the basis of the Hindu religious and cultural traditions become a source of strength, reassurance and comfort. Hindu tradition emphasizes that the occurrence of birth underscores the certainty of death at some point.

Know that for the individual who is born, death is inevitable indeed.’

The Vedic tradition places a certain value on dispassion, vair¡gya, in regards to the world and the people one encounters in one’s life. This attitude is based on an understanding of the ephemeral nature of the whole universe. Vair¡gya is not viewed as a fatalistic attitude that impairs one from functioning in the world and relating to it appropriately. It is an appreciation of the truth of it’s nature, which in fact makes one relate to the world as it is. It permits one to make the most of one’s association with the world and the people one spends one’s life with.

The following verse highlights the attitude of vair¡gya based on the transient nature of the world:

‘One’s possessions are left behind at home and relatives (left behind) on the cremation grounds. The body is consumed in the funeral pyre; only punya ( merit) and papa (sin)accompany (one).’

Vedic tradition also enquires into the ontological status of the world of experiences, and the relationship between oneself, the universe and it’s cause. An understanding of these matters helps an individual deal with not only himself and others, but also with life and death.

Bertrand Russell eloquently described death as a concluding episode of one’s life and an integral part of existence. Using a metaphor he said that an individual’s existence should be like a river –small at first, narrowly contained within its banks, and rushing passionately past boulders and over waterfalls. Gradually, as the river grows wider the banks recede, the water flows more quietly and in the end, without any visible break, it becomes merged in the sea and painlessly loses its individual form.

Reactions in Family Members
The ones who are close to a dying person also have to deal with a variety of emotions of their own. They too get anxious about what is happening around them. They may be engaged in the medical and nursing care of the person that can be tiring and overwhelming, not to mention confusing. They feel a profound sense of helplessness because of their inability to prevent what is happening to their loved one. They feel that they are letting him down.

Their profound sense of helplessness sometimes evokes anger at others for not doing more than what they are doing. This anger can get directed towards other caretakers, such as doctors, nurses or other family members. It can result in petty misunderstandings between family members that in turn, evoke guilt as one feels embarrassed at one’s own reactions. Anger can also get directed towards God, who is seen as being responsible for causing them pain and not responding to their prayers to spare the one they love.

They experience fear of losing someone they love and perhaps rely upon. The possibility of never again being able to see and live with a loved one evokes both fear and sadness. They begin to imagine what it would be like to live without their loved one. Ruminating over the future is the way a person’s mind tries to prepare itself for an undesirable experience that it anticipates and fears.

Families also feel pressured to maintain an appearance of normalcy in front of their dying member. They are afraid that if they reveal how upset they are, the person may not be capable of handling their distress. Thus, they avoid showing their feelings, which does not really serve any purpose, as people who are close to each other can usually sense each other’s unexpressed feelings. Thus, their attempt at protecting one another in this manner does not usually work.

There is no ideal way which would be universally applicable, in order to cope with the difficult situation of impending death in a family. Every individual affected by it, deals with it in the way he knows best and in the manner in which his mind is comfortable and capable. However, one can say that, in general, it is advisable to be as communicative as one possibly can. When a person does not know what another thinks, they start guessing what might be in the other’s mind. Very often what they imagine is not only inaccurate, but also exaggerated and worse than it is. Additionally, it is generally easier to deal with something that one knows than with the unknown. This is so even with respect to dealing with another person’s thoughts and feelings. Protecting one another in a difficult situation that involves death, only compounds one’s sense of helplessness as one is unable to change what is happening and also unable to prevent other’s agony. Sharing one’s thoughts, feelings, concerns, fears and so on, is comforting, even though it may be difficult to do. People discover a tremendous amount of strength from each other during difficult times. When faced alone, a difficult situation looks impossible to overcome. However, a seemingly impossible situation becomes manageable when endured along with people one trusts.

Conclusion
In relating to individuals facing death, it is best to remain one’s natural self. It is not necessary to act as if nothing is happening. Doing so, only gives a message that one does not wish to deal with the difficult issue at hand. It prevents the dying individuals from expressing their wishes, and sharing their feelings. It places an added burden on them to deal with death alone and leaves them feeling unsupported. By encouraging them to express themselves to the extent they are comfortable, one can provide them with a lot of support. One needs to make them feel that they have someone, who though incapable of changing the inevitable, is willing to be by their side until the very final moment of their lives.

In order to help a loved one who is facing immanent death, it may become necessary to put aside for a while one’s own sadness and feeling of deprivation at one’s impending loss.

During such a difficult time one’s religious traditions and beliefs become a source of strength and comfort, for both the dying and those closely connected to him or her.

Coping with the Final Moments
There are occasions of impending death, when both the dying person and those connected to him know that death is inevitable and immanent. There is a fear of the unknown. There is fear of annihilation. And, there is fear of losing all one is familiar with. One may be overcome by a sense of helplessness. There is also sorrow at separation from all that one is attached to and one loves. Very often, those that one is connected to are also very sad. Both the dying person and his family try to protect each other, and may pretend that everything is as usual and fine. It is very difficult to suggest how one should behave during these times. People tend to do what is most comfortable to them and what may be appropriate in case of one family may not be so in case of another. When one is able to, it is very helpful to share one’s thoughts and feelings with those one is close to. To talk to a loved one about one’s feelings and fears is very comforting to both. Even if what one speaks causes sadness, when sorrow is shared with a person one loves, it is easier to experience.

It is a rare gift to be able to express oneself and share one’s thoughts and feelings with one’s loved one who is dying. This is so because, very often death comes unexpectedly, or a dying person may be incapacitated or in pain. It is a very common experience for people, to feel that they did not say what they would have liked to say to a person who is no more, and they live with this sense of incompleteness for the rest of their lives. It is in such difficult times that one’s Religious convictions and spirituality become a source of great solace.

Generally, Hindus recite verses from the Vedas such as Purusasuktam, the Bhagavad Gita, Ramayana, and Visnusahasranamam. It is believed that what one’s mind is attuned to at the time of death, determines one’s gati, direction of onward journey after death and also one’s next birth. Therefore, the family and friends of a dying person provide an environment of spirituality and comfort during the final moments of his or her life.

In Bhagavad Gita, (Chapter 8, Verse 5) Lord Krishna assures Arjuna of the following:

The one who gives up his body remembering me (the Lord) during his final moments reaches me. Of this there is no doubt.

Unless a person has lived prayerful life it is difficult for him to remember the Lord during his final moments. People everywhere have their own beliefs about what happens to an individual after death. But there is no one, who has seen a dead person come back to report to those alive about their experience, in a manner that can be verified by them with certainty. There are however, innumerable cases investigated, reports documented and available that have been verified indirectly to a greater or lesser degree about after death experiences and reincarnation. Most people do accept that there is an entity in addition to the physical body that survives death and remains in some form. However, not knowing for certain makes the unknown future frightening.

There is also a sadness that comes from the knowledge that one will never again see those that one loves and has spent one’s life with. Moreover, no one can take with them any of the possessions that they have accumulated in their lifetime and have to leave behind all that they are attached to. There can also be a fear of possible pain and suffering associated with the process of death itself.

Process of Bereavement
The human mind being complex as it is goes through intense and at times overwhelming reactions during the process of bereavement. Bereavement is defined as a reaction to the loss of a loved one and separation from those upon whom one depends on for comfort, sustenance and sanctuary. Even in the animal kingdom, it is striking to see the reaction of an animal to the death of one of the members of their family or group. For a moment or longer an animal will remain around the dead member as though perplexed at it’s lack of responsiveness, and the animal’s behavior implies an uncertainty or confusion about what has happened. Sooner or later it appears to leave reluctantly and continue with its life.

A human being reacts to any loss with grief and mourning. Grief is a normal and a common human experience, as no one is spared from the experience of loss, or from events that cause sorrow in one’s life. Mourning is a process by which a person experiences and resolves his grief. Most people go through a series of normal feelings and reactions during their bereavement.

Upon losing a loved one, a person often goes through an initial state of shock and feelings of numbness or bewilderment. The person is in despair and may react with disbelief over what has happened, by thinking or acting as if the deceased person is still present. Thus the initial response may be one of denial or anger. His distress and suffering is evident in crying, sadness, loss of appetite and difficulty sleeping. It is not uncommon for the bereaved to feel guilty and blame themselves, for acts of commission or omission towards the deceased person. There is a yearning for their presence, an inner restlessness and a preoccupation over the events leading to the person’s death, or of the final days or the past. A human mind deals with any trauma, whether minor or major, by ruminating over it. This helps a person get over the traumatic experience. Death of a loved one is a major traumatic event in one’s life, and it takes a length of time to adequately get over the trauma.

The circumstances of death also affect the bereavement process. When death is sudden and unexpected, the initial reaction of disbelief is intense. It is difficult for one’s mind to accept the fact that a person, who was very much alive and part of one’s world, is gone in an instant. The experience of losing a loved one abruptly makes the uncertainty of one’s own life very evident, and one becomes very much aware of the ephemeral nature of one’s own existence. The void felt within oneself is very deep.

When a person dies after a protracted bout of illness or after a prolonged age, and his death is anticipated, the bereaved usually have some time to adjust to their inevitable, impending loss. In such an instance, one’s mind starts imagining what it would be like to lose the person, how one would manage their affairs and the feelings one might have. However, one is unable to truly anticipate what will happen until one actually lives through the experience.

After numbness and disbelief, comes the feeling of anger. Anger is born out of helplessness. The bereaved may express anger by blaming others for the death of their loved one. They often blame the medical personnel who had been involved in the care of the deceased. They may also blame other family members for not doing enough. Some of this blame is due to their own guilt, at perhaps not doing all that they could have done, to save their loved one. It is not uncommon to see misunderstandings between family members of the deceased. As each one attempts to deal with their own conflicting emotions, they take out their frustrations on one another. Sometimes people blame God, who is seen as having the ultimate responsibility for everything that happens in the universe. The average person understands God as someone who gives what one desires when prayed to. And, their experience tells them otherwise, because their God did not grant their wish for their loved one to survive. Thus, even a normally devout person may get angry and reject religious traditions that could have been of comfort to him.

Eventually the grieving process results in an acceptance of the reality, that is, the irretrievable loss of a loved one. One gets resigned to the reality of the loss, as one has no choice in the matter. Over a period of time the intensity of sadness lessens. One is able to participate in and enjoy pleasant things in life. The void that is created by the absence of a loved one is filled by his memories.

Sooner or later most people come to terms with their loss and are able to accept the reality that their loved one is gone from their life physically. Reconciliation of this loss permits them to continue with their own lives. To this end, they may identify with some of the characteristics of the person they have lost, thereby gaining strength and security from the person they cherished. The acuteness of pain and sorrow diminishes and the person feels like returning to their normal life.

It is important and necessary for an individual to go through the process of bereavement. Only by doing so, one is able to overcome the trauma of one’s loss, such that it allows one to continue with one’s life in an emotionally healthy manner. Sometimes, one has difficulty acknowledging one’s feelings because they are unpleasant and difficult to bear. In such instances one denies to oneself the reality of the emotions one experiences. Thus there is an inner contradiction in what one feels and what one allows oneself to experience. When one allows oneself to experience emotions that occur naturally in one’s mind, and is able to acknowledge them to oneself, one is more in touch with one’s nature and is able to grow from the experience, however unpleasant, difficult or painful it may be.

In current times, when families are scattered all over the world and separated by distance from their loved ones, one may have to deal with the death of a family member at a distance. Because of Hindu traditions, the initial ceremonies involving disposal of the body of the deceased, are performed immediately after death and one is not able to participate in it by one’s physical presence. In these instances an individual may wonder whether it is necessary to travel the long distance since “everything is over”. However, one need not minimize the importance of participating and being physically present for the remainder of the ceremonies during the grieving period. Being with one’s bereaved family, sharing the common loss, expressing one’s feelings to those who can relate to it intimately because of their relationship, are all important to the process of bereavement. Therefore, unless there is an unavoidable reason, it is advisable to physically participate in the ceremonies and be with one’s family during the prescribed period of mourning.

A loved one who is deceased is always remembered. There is no such thing as “completely getting over” or “resolving” the death of a loved one. There are recurring occasions in one’s life when the absence of a loved one is felt, with varying degrees of sadness. However, one is able to experience this feeling without much discomfort and continue to live happily.

There are rare occasions when a person is unable to overcome the grieving process. His sadness becomes more instead of less. He is incapacitated and unable to take care of himself fulfill his responsibilities. The passage of time does not seem to help and he becomes unable to function. When this happens, such a person may need extra help of a professional to help him overcome the intense reaction to the trauma.

From Bereavement and Final Samskara in Hindu Tradition
By Sri Dhira Chaitanya
Published by Purna Vidya Trust, Tiruvannamalai

 
 
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