The Crescent Moon Bear story reflects the process of healing that Opus Peace facilitates in its work with Soul Injury.
by Deborah Grassman
It was difficult reading; it was frustrating because my conscious mind was not trained in the metaphorical language of the unconscious; I protested with: “There must be another way!” Nevertheless, I persisted in understanding the story of The Crescent Moon Bear. I am oh so glad I did. In a fundamental, yet not so apparent way, it describes the tedious, perilous, and courageous inner work required to excavate peace in our souls. The myth highlights the trek taken to wrestle with our ego so that our hearts can be broken open. When we muster the honesty, courage, and humility to make this journey, we become liberated.
The Crescent Moon Bear reflects the process of healing that Opus Peace facilitates in its work with Soul Injury. “Opus” is a Latin noun that means “a work,” and is commonly used to describe a complex masterpiece. “Opus” is an old word that captures the ageless, artful complexity of creating a true “masterpeace” — pervasive peace that penetrates beyond comforting facades. The word “opus” reminds us that authentic peace requires work, courageous work, to heal scattered pieces of self. It also requires work to penetrate defensive, intimidating inner terrain that often prevents us from encountering our loving, grace-filled, compassionate self that hides its vulnerability in our depths. Once we are able to do this, however, we move from sole to soul.
This Japanese myth is from the book, Women Who Run with the Wolves, by Clarissa Pinkola Estes.
Knowing my love for the Crescent Moon Bear, Pat, co-Founder of Opus Peace, found this statue for my garden. It now sits prominently outside my window to inspire me in my personal Opus of Peace.
*The Crescent Moon Bear
There once was a young woman who lived in a fragrant pine forest. Her husband was away fighting a war for many years. When finally he was released from duty, he trudged home in a most foul mood. He refused to enter the house for he had become used to sleeping on stones. He kept to himself and stayed in the forest.
His young wife was excited when she learned her husband was coming home. She cooked bowls of tasty white soybean curd and three kinds of fish, and three kinds of seaweed, and rice sprinkled with red pepper, and nice cold prawns.
Smiling shyly, she carried the food to the woods and knelt beside her war-weary husband and offered him the beautiful food. But he sprang to his feet and kicked the trays over.
“Leave me alone!” he roared, and turned his back on her. He became so enraged she was frightened of him. Time after time this occurred until finally, in desperation, the young wife found her way to the cave of the healer who lived outside the village.
“My husband has been badly injured in the war,” the wife said. “He rages continuously and eats nothing. He wishes to stay outside and will not live with me as before. Can you give me a potion that will make him loving and gentle once again?”
The healer assured her, “This I can do for you, but I need a special ingredient. Unfortunately, I am all out of hair from the crescent moon bear. So, you must climb the mountain, find the black bear, and bring me back a single hair from the crescent moon at its throat. Then I can give you what you need, and life will be good again.”
Some women would have felt daunted by this task. Some women would have thought the entire effort impossible. But not she, for she was a woman who loved.
The next morning she went out to the mountain. And she sang out “Arigato zaisho,” which is a way of greeting the mountain and saying, “Thank you for letting me climb upon your body.”
She climbed into the foothills where there were boulders like big loaves of bread. She ascended up to a plateau covered with forest. The trees had long draping boughs and leaves that looked like stars.
“Arigat zaisho,” she sang out. This was a way of thanking the trees for lifting their hair so she could pass underneath.
She climbed till she saw snow on the mountain peak. A storm began, and the snow blew straight into her eyes and deep into her ears. Blinded, still she climbed higher. And when the snow stopped, the woman sang out “Arigato zaisho,” to thank the winds for ceasing to blind her.
She searched all day and near twilight a gigantic black bear lumbered across the snowfall. The crescent moon bear roared fiercely and entered its den. She reached into her bundle and placed the food she had brought in a bowl. She set the bowl outside the den and ran back to her shelter to hide. The bear smelled the food and came lurching from its den, roaring so loudly it shook loose little stones. The bear circled around the food from a distance, then ate the food in one gulp.
The next evening the woman did the same, but this time instead of returning to her shelter she retreated only halfway. The bear smelled the food, heaved itself out of its den, roared to shake the stars from the skies, tested the air very cautiously, but finally gobbled up the food. This continued for many nights until one dark blue night the woman felt brave enough to wait even closer to the bear’s den.
She put the food in the bowl outside the den and stood right by the opening. When the bear smelled the food and lumbered out, it saw not only the usual food but also a pair of small human feet. The bear roared so loudly it made the bones in the woman’s body hum.
The woman trembled, but stood her ground. The bear hauled itself onto its back legs, smacked its jaws, and roared so that the woman could see right up into the red-and-brown roof of its mouth. But she did not run away. The bear roared even more and put out its arms as though to seize her, its claws hanging like ten long knives over her scalp. The woman shook like a leaf in high wind, but stayed right where she was.
“Oh, please, dear bear,” she pleaded. “Please, dear bear, I’ve come all this way because I need a cure for my husband.” The bear brought its front paws to earth in a spray of snow and peered into the woman’s frightened face. For a moment, the woman felt she could see entire mountain ranges, valleys, rivers, and villages reflected in the bear’s old, old eyes. A deep peace settled over her, and her trembling ceased.
“Please, dear bear, I’ve been feeding you all these past nights. Could I please have one of the hairs from the crescent moon on your throat?” The bear paused. This little woman would be easy food. Yet suddenly he was filled with pity for her. “It is true,” said the crescent moon bear, “you’ve been good to me. You may have one of my hairs. But take it quickly, then leave here and go back to your own.”
The bear raised its great snout so the white crescent on its throat showed. Quickly, she pulled a hair.
“Oh, thank you, crescent moon bear, thank you so much.” The woman bowed and bowed. The bear roared at the woman in words she could not understand and yet words she had somehow known all her life. She turned and fled down the mountain as fast as she could. She ran under the trees with leaves shaped like stars. And all the way through she cried “Arigato zaisho” to thank the trees for lifting their boughs so she could pass. She stumbled over the boulders, crying “Arigato zaisho” to thank the mountain for letting her climb upon its body.
Though her clothes were ragged, her hair askew, her face soiled, she ran down the stone stairs that led to the village, down the dirt road and right through the town into the hovel where the old healer sat tending the fire.
“Look, look! I have it, I found it, I claimed it, a hair of the crescent moon bear!” cried the young woman.
“Ah good,” said the healer with a smile. She peered closely at the woman and took the pure white hair and held it out toward the light. She weighed the long hair in one old hand, measured it with one finger, and exclaimed, “Ah. Yes! This is an authentic hair from the crescent moon bear.” Then suddenly she turned and threw the hair deep into the fire, where it popped and crackled and was consumed in a bright orange flame.
“No!” cried the young wife. “What have you done!?”
“Be calm. It is good. All is well,” said the healer. “Remember each step you took to climb the mountain? Remember each step you took to capture the trust of the crescent moon bear? Remember what you saw, what you heard, and what you felt?”
“Yes,” said the woman, “I remember very well.”
The old healer smiled at her gently and said, “Please now, my daughter, go home with your new understandings and proceed in the same ways with your husband.”
*Estes CP. Women who Run with the Wolves. NY: Random House, 1992, p.347-350.
Books about Soul Injury and Mythology and Metaphor
You can read stories about the implementation of ceremonies and rituals in Deborah Grassman’s books, Peace at Last: Stories of Hope and Healing for Veterans and Their Families and The Hero Within: Redeeming the Destiny We Were Born to Fulfill.
Well-designed rituals are powerful because they access the unconscious; the unconscious can cultivate pervasive personal peace if we can open up to its honesty.
by Deborah Grassman
In my study of therapeutic ritual, I learned the importance of choosing symbols for rituals that have shared meanings for the individual or within the group. I also learned about the three stages of ritual: separation, transition, and integration, so that peacefulness can ensue. Well-designed rituals are powerful because they access the unconscious; the unconscious can cultivate pervasive personal peace if we can open up to its honesty.
The purpose of the separation stage is to acknowledge the problems and difficulties that make change necessary and to recognize the need for a person to separate from their former roles or identities that are interfering with peace. During this stage, there is a request to reframe unwanted change into an intention to change. For example, military rituals are formatted with highly evocative styles and symbols. Patriotic music and American flags activate unconscious images that motivate new identity and new will. Induction rituals help new recruits separate from civilian identity. Uniforms are issued, and heads are shaved. Recruits are sometimes ridiculed for their former immature, lazy, and civilian ways.
Many religious rituals might begin with a confession of sinfulness, asking for God’s help to let go of thoughts and actions that have interfered with more godly ways. Funeral rites or memorial services start with the acknowledgement of death and the reality of facing life without the loved one.
The separation stage is crucial in creating an effective ritual. In a grief-denying, “never say good-bye” culture, it’s tempting to skip the separation stage so that we don’t have to give adequate time and energy to articulating the need for change and separation. For example, modern funeral ceremonies often try to skip this essential stage by proclaiming, “This is a day to celebrate Joe’s life.” Unfortunately, this eliminates a safe space to grieve, the very thing the participants need. Not only that, if the need for change is not openly expressed, the silence reinforces fear of the problem, heightening the control it exerts. The whole point of a therapeutic ritual is to create a safe environment whereby the problem can emerge from hiding so its power can be diminished and the person’s empowerment to deal with the problem can be enhanced.
This stage is often the turning point for acceptance or rejection of the change that is being offered. Anxiety or resistance can be anticipated to be highest at this stage. Participants are asked to leave behind the familiar and anticipate a new beginning without knowing what a new beginning will require. Old identities are let go while new identities are not yet secured. Straddling two worlds, people don’t feel like they belong yet to either. The transition stage of ceremonies usually focus on educating the participants on ways to navigate the desired change.
In the military, the transition stage is used to indoctrinate recruits with a new world view that promotes warrior perspectives during several weeks of basic training. The transition stage in religious rites might include Bible readings and sermons that encourage change and living a more godly life. Funeral rites eulogize the deceased person during this transition stage of the burial ritual.
The final stage of a therapeutic ritual is the integration or incorporation stage. This stage seeks to instill hope for a future that promises growth. Thus, the ceremony is closed with a sense of renewal and confidence that change can be navigated and that peace will prevail. A symbol is often given that participants can take home with them. They are encouraged to let the symbol act as an inspiration to continue with the change – activating inspirational experiences from the original ceremony.
In the military, the integration phase culminates at the end of basic training with graduation ceremonies that symbolize the new warrior identity. In religious services, this phase might include celebration rites such as communion. In funeral rites, it might include a challenge to let the deceased person’s admirable qualities inspire others or assist in filling the gap the person leaves behind. It helps people let go of the world as it has been with their loved one in it. Then they can open up to a world without their loved one in it.
Books about Soul Injury and Ritual
You can read stories about the implementation of ceremonies and rituals in Deborah Grassman’s books, Peace at Last: Stories of Hope and Healing for Veterans and Their Families and The Hero Within: Redeeming the Destiny We Were Born to Fulfill.
Enacting rituals is an effective way to prevent and treat Soul Injuries.
by Deborah Grassman
The best way to treat Soul Injury is to prevent its occurrence. The best way to prevent its occurrence is to provide therapeutic support surrounding the traumatic event. Enacting rituals is an effective way to do this.
It’s tempting to erase a broken past, but the goal of a well-designed ritual is not to remove a painful past, (which would only serve to reinforce denial or other “flighting” behaviors), but rather to develop a different relationship to the past and instill confidence that the participant(s) can reckon with the past by using it to give their future new meaning. It encourages participants to redeem their suffering with new insight from lessons learned. As a result, their destiny is reshaped.
The stages of ritual also correspond to how we interpret time: past, present, and future.
The first stage of a ritual (separation phase) reflects a new willingness to abide with the past, acknowledging the specific brokenness that was incurred.
The next stage (transition) highlights the present, where a releasing of the past is done and there is a reckoning with the uncertainty and ambiguities of the present.
The last stage of integration expresses a decision that beholds hope for a different future.
Therapeutic Rituals for Professional Change
I have used rituals professionally when difficult transitions were needed. When our oncology unit developed the hospice program, we didn’t anticipate the strife and division it would cause the staff. Creation of new programs with different patients upset the usual pattern of care. Tension and arguments ensued as staff coped with the change. Staff were reluctant to let go of their identity as oncology nurses and expand into the identity of oncology and hospice nurses. The new identity was necessary for the unit to function successfully.
I designed a therapeutic ritual to promote the inward changes needed to incorporate the larger identity that was needed. During the separation stage of the ritual, each staff member recalled a cherished memory, said good-bye to “the good old days,” and acknowledged the difficulty and pain of doing so. Each proclaimed a desire to grow into a new identity that included hospice nursing. Each brought spiritual readings and songs that reflected letting go and saying good-bye.
During the transition stage, the anxiety of journeying into unfamiliar territory was acknowledged. Songs and readings that reflected a willingness to stay open to the uncertainty were articulated as well as a willingness to suffer required changes. Each person acknowledged the difficulty of changing and identified something they needed to do to make the transition into hospice nursing. A circle was formed with each person lighting a candle, saying, “A heart that is willing to suffer is a light to the world.”
The integration stage included receiving a small footprints pin with the words, “Know that your journey is sacred and that your footprints are holy.” Songs that appealed to the hope of living from our larger selves were sung; a final blessing dispensed.
There were many tears during this ceremony. There was also much change because there was no longer a need to fight or resist. Problems still arose, but they were dealt with openly and with understanding. I subsequently modified the ritual and used it at the conclusion of each “Living and Dying Healed” course I teach.
In my current practice of implementing Soul Injury programs, I have a particular passion for meeting the needs of personal and professional caregivers. I have witnessed the insidious Soul Injuries that families incur as they care for a chronically-ill loved one. The stressful demands of caregiving sometimes cause the caregiver to lose their own sense of self; fatigue and stress morph into Soul Injury. I have also seen this occur with Hospice staff. Working day in and day out with death and sorrow, they experience what is now known as “secondary traumatic stress disorder,” an occupational health hazard for people working in high-risk environments such as hospice, ICU, ER, trauma, foster care, etc.
When I began working in Hospice 30 years ago, there was much attention paid to the needs of the staff to grieve and release the accumulated sorrow that occurs when going from one dying patient/family situation to another. Healthcare delivery, patient/family expectations, and regulations have changed. It is no longer feasible to spend focused time on the bereavement needs of each staff member. As the Director of a Hospice program, I recognized that a well-designed ritual would be an efficient way to meet the needs of staff because it could be done with a large group of staff in a short amount of time. Thus, the Compassionate Caregiver Ceremony was born, which Opus Peace now implements for the insidious Soul Injuries that staff incur.
Therapeutic Rituals Surrounding Illness and Death to Prevent Soul Injury Development
Rituals are enacted at time of death on our Hospice unit. These rituals are especially important in our under-ritualized, death-denying, “we-don’t-need-a-funeral” culture. For example, a flag quilt replaces the blanket on the bed of the deceased, while family has time with their loved one’s body. The body is then transported to the morgue under the flag quilt. As the body passes down the hallway, people often turn toward the passing gurney and pay respect with a salute. The patient is also honored with a rose and footprint with his/her name and date of death placed on the empty bed. The six-inch footprints are made by staff from baked dough. When the dough hardens, it is painted. These footprints honor the veteran and also highlight their separation from us. Other patients see the footprint and anticipate that they, too, will be remembered and treated with respect. This footprint also acts as a trigger in the environment for them to anticipate and prepare for their own deaths. The footprint remains on the bed until another patient comes to occupy the bed. Then it’s moved to a wall in the hallway that depicts a rainbowed road with the inscription, “Together we walk, one step at a time.” The wall with all the collected footprints acts as another trigger in the environment for death preparation. In November, the footprint is moved to a holiday tree and later given back to the family members at a holiday bereavement program.
After-Death Ritual with Loved Ones to Prevent Soul Injury Development
Another important ritual occurs with the family at time of death. After a loved one’s death, an electric candle is lit with the family. The pain they are feeling is acknowledged. The courage to let go is affirmed. Family members are encouraged to tell a few of their favorite stories about their loved one. Each is then asked to write a message to their loved one on the back of the patient’s namecard, one more opportunity to address “unfinished business.” The card is placed on a stand in front of the candle. A prayer or reading that offers hope and support for continuing without the loved one is provided. Marianne Williamson’s book of spiritual prayers, Illuminata, is often used. It has one section devoted to prayers for use in therapeutic rituals. A pin with three footprints is then pinned on each person with staff providing a message of hope. “One footprint is yours. One footprint is your loved one’s. The third footprint represents all the people who are willing to help you walk this painful part of your journey. May each time you see these footprints, you know you are not alone. May you have the courage to ask for help when you need it.” As modern culture continues to devalue grief, as mourning is shortened from months to days, and as funeral services are eliminated, this ritual becomes increasingly valued.
We use ritualized formats that incorporate the three stages of change for other bereavement events. On Memorial Day, we use a ritualized format to provide bereavement care at a picnic. We also hold a Memorial service every four months to honor all the veterans who died in the Medical Center. Pat McGuire, Bereavement Coordinator for Opus Peace, developed an especially therapeutic program that we implement during stage 2 (Transition stage) of the ceremony.
She uses a cloth “pillow” shaped like a heart to symbolize grief. However, the pillow’s side seam is gaping and pieces of cotton stuffing easily fall out. Each wad of stuffing is labeled with common experiences that audience members might be having. When the heart is turned inside out and completely emptied of its stuffing, there are 3 long “heart strings” left:
(Pat) “When I look at all of you here today, I feel very grateful both for this opportunity to honor your loved ones and to be able to share with you in your grief journey. Gerald May, an authority on grief said that although grief may be the single greatest pain you will experience in a lifetime, it is a pure expression of love.
Love in our culture is frequently depicted as warm summer days at the beach without bugs or blowing sand. You all know that love is much more than that. In the circle of life, love is experienced as joy and happiness at times, familiarity and routine at other times, and painful bumps in the road at still other times. Each of these forces your love to resiliently change shape to accommodate. Sometimes these adjustments come so fluidly and imperceptibly that we hardly notice.
At the close of the circle of life, however, the transformation of love to grief is profound. This hospice team is privileged to have walked with many of you as your loved one’s circle reached completion. We are there as the very stuffing of the heart begins to pour out and the transformation begins.
[I begin to turn the heart inside out, spilling out stuffing labeled: denial, anger, jealousy, guilt, etc.]:
Denial – “This can’t be happening!”
Anger- “Why is this happening?!?”
Jealousy – “Why can’t my life be like ________?”
Guilt – “If only ______, this would not be happening.”
“Feelings we don’t want to feel begin to spill over as we fight the inevitable. Finally at the moment of death, the heart strings which are so entwined with one another are tugged and tugged until the heart that is left behind is turned inside out. Love has changed form to grief.”
[Pat holds the inside-out heart with it’s strings dangling for all to see.]
“I have spoken with many of you since the deaths of your loved ones. You describe the many symptoms that you are experiencing. You question your very sanity. There are many symptoms of grief.”
[Pat continues to pull out labeled stuffing. The final stuffing to leave the heart contains the physical, emotional, and spiritual symptoms of grief. Pat discusses each]:
Spiritual – doubt or anger at God
Emotional – depression, panic, anxiety, hallucinations
Physical – Pain, insomnia, forgetfulness, restlessness,
Lack of concentration, confusion
“Ok, your love is turned inside out, your tears are beautiful expressions of your love, and you are not crazy. But now, how do you adjust to the world without your loved one in it? How do you deal with this pain and loneliness? What will help you get through? Who can help?”
[Healing tools have been distributed in advance to staff and volunteers in the audience. When Pat says “who can help”, they begin to bring helpful stuffing forward labeled with things like: grief groups, tears, friends, etc., which I discuss while they place their stuffing back into the heart. Some of the things they bring (drugs, isolation, denying feelings) are on large, stiff pieces of cardboard that do not fit in the heart and actually prevent any of the healing components from getting through. Eventually, the heart regains its shape, it does not look the same, but it looks like a “Heart”].
Goodbye: It’s never too late to say goodbye. We say goodbye to the physical presence, not the love. (explain how to complete “unfinished business.”):
S.T.U.G.s: Sudden, Temporary, Upsurges of Grief
Healing Grief Groups: Free at most hospices
Gracious Receiver: People want to help, let them, tell them what you need.
Tears: The only bad tears are the ones you do not shed. Healing
Anniversary/Holidays: Hard to get through. Make a plan.
Memorial Services: Come together with others to honor/share pain
Forgiveness: Never too late to forgive. Letter writing.
Rest: Emotional surgery
Prayer and God: Crying in church
Small pleasures: Sunsets, candles, flowers
Good and bad days – let yourself feel good when you can
Friends and family: Double edge sword (choose who can help)
Precious memories: Those that hurt the most at first may be most comforting later.
THINGS THAT PREVENT HEALING:
Isolation: OK to be alone, but people need people. Flags for when the boundary is crossed
Denying feelings: Can’t heal what we can’t feel
Drugs/Alcohol: Prevents healing, by numbing. Keeps us stuck in grief.
Closing (Pat): “Grief will be different for each of you. It will take as long as it needs to take. It is work! Perhaps the goal of the work can be a tribute. The greatest tribute we can give a deceased loved one, is a full and happy life. You will never forget your loved one. A Native American medicine man once said, “If the dead be truly dead, why should they still be walking in my heart.” Love is resilient. Love transcends death and the love you shared will live on with you forever.”
Grief Recovery Group Rituals to Prevent Soul Injury Development
Bereaved group members finger paint a picture that reminds them of their loved one. One by one, they light a candle and explain the picture to the group. They also tell their loved one whatever they want them to know or they speak any unfinished business. Then they blow the candle out, while being affirmed that they can meet the challenges of a new world without their loved one in it.
When employees die, especially if it’s an unexpected death that leaves unfinished business, I meet with the employees on that unit. A candle is lit, and a memorial card with the person’s name and date of death is given to each person. They write their good-byes on it during the opening separation stage. During the transition phase, a picture of the deceased or some other object is passed and each person recalls a story about the deceased person. In the integration phase, each person identifies one quality of the deceased they are willing to let inspire them.
Books about Soul Injury and Ritual
You can read stories about the implementation of ceremonies and rituals in Deborah Grassman’s books, Peace at Last: Stories of Hope and Healing for Veterans and Their Families and The Hero Within: Redeeming the Destiny We Were Born to Fulfill.
Learn how Native American tradition of a Talking Stick can help others speak honestly and listen without pretense or judgmenet.
When they come to powwow, Native Americans pass a “talking stick” to everyone gathered within the circle. About a foot long, it is often adorned with beads and feathers. Two rules are observed: only the person holding the stick at that moment can speak, everyone else must listen; whatever that person says while holding the stick has to be truthful, no pretenses or coverups.
I recognized the power of this format to elicit deeper and more meaningful stories that can emanate from the hero within. The format also levels the playing field, equalizing the power for all participants regardless of position; no voice dominates, and no voice is excluded.
At our first meeting, we didn’t have a stick. A smooth, black rock was on the table, so we used that. It became our touchstone. I added two rules of my own: “We are free to pass the rock without speaking; no apology needed. Also, we must resist the urge to give advice or philosophize. Instead, we each tell a personal story or experience about the topic.”
Monthly sessions usually start by asking if anyone is seeking counsel. Someone identifies a need, and the touchstone is passed. Sessions have included multiple themes. One staff member spoke of a family death, and the rest of us responded with our own stories of recovering from a death or loss.
Another time a nurse said she was feeling “lost,” which elicited stories when others felt lost and uncertain. One nurse said she was having difficulties with a family member’s alcohol usage; the rest of us responded with our own stories of how alcohol had wounded people we loved.
An adult son moving back into a parent’s home prompted story-telling of lifestyle changes and boundary setting with older children.
One session responded to the need of a staff member whose young adult son had stopped any contact with her. All responded with stories of children (sometimes themselves) rebelling against parents. One staff member noted changes in health as she aged, realizing that she might need to consider retirement. The rock was passed to gather stories about our own experiences of aging and illness. It is not unusual for various aspects of Soul Injury to surface.
Sometimes the sessions might involve confrontation. Marie privately confronted Jane about Jane’s anger. Jane was surprised, expressing little insight into its cause. In a subsequent pass-the-rock session, Jane asked for stories about how the rest of us fight or flight anger. As a result, she realized that she camouflaged her anger with chaos and drama. Her journey to meet her shadowed anger is now depicted with a graphic on our Old Rugged Path. It shows a woman sternly pointing her finger, saying: “Hello anger. I’ve tried every way I know to ignore you. I prefer to get dramatic instead, saying I was ‘ruined.’ I’m reclaiming my power now. I wasn’t ruined. I was angry. I can say it instead of being defeated by it. Hello anger. You’re my new friend.”
We don’t always talk about personal issues. Sessions might address conflicting feelings about taking care of a difficult patient: “What inside me keeps me from loving this patient? What keeps me from responding graciously? What button is this patient pushing inside me and why?” Once there was a general climate of grouchiness on the unit. Staff chose to address it by inventing a “grouchiness scale.” Zero was mellow and 10 was irritable and grouchy. Then each of us was asked to address this further: “I’m a ____ right now. What I need to do to lower that number by one is ______.” Sometimes questions focus on issues our patients struggle with: “A time when I hid behind my stoic wall when it would have been better for me to come out is ________ ;” We also did “A time when I let my feelings misguide me rather than applying stoicism so I could accomplish my goal was _______.” And, of course the question we ask all our patients is most important to ask ourselves: “If I died today, what would be left unsaid or undone.”
Sometimes we work too hard; play gets stuffed in our shadow. That’s when we start a session with: “A story that always makes me laugh.” By the time we’ve all had our moment with the rock, we’re usually laughing so hard we have to choose between holding our bellies or wiping away the tears.
There has been little overstepping of boundaries. Self-controlled disclosure creates an atmosphere for safe and comfortable sharing. I’m thankful that Native Americans understood the wisdom of this powerful and meaningful forum for connecting and growing together, drawing out deeper insights from within.
The touchstone has collected hundreds of stories over the years. Wisdom is found in stories because stories have value beyond facts or biographical information. “The story is not told to lift you up, to make you feel better, or to entertain you. The story is meant to take the spirit into a descent to find something that is lost or missing and to bring it back to consciousness again,” writes Clarissa Pinkola Estes. She’s right. Stories are healing; they restore wholeness to our fractured selves. They help us find ourselves. There’s always room for each of us in a story, even though it’s someone else’s story. It reminds me of something I read: “We comfort others not from the foundation of our superior faith, but from the commonality of our mutual struggles.” A good story almost always has a “mutual struggle” that connects each of us in the “common-unity” of the community.
In times of uncertainty, loss, and change, therapeutic rituals provide a format for letting go of the old, and provides a map for a different, hopeful future.
by Deborah Grassman
The Power of Myth, a book by Joseph Campbell, awakened me to the value of myths and rituals and their relationship to the change and trauma recovery process. To my scientific mind, myths were untruths. Yet, here this brilliant professor was showing me how myths spoke truths about personhood and humankind. Just as parables (stories that are not “factual”) are used because words cannot completely embody truth, so too, do myths embody larger truths.
Myths use symbols that access the energy of the unconscious. Campbell reminds us that truth is often hidden in symbols, requiring nonphysical eyes to see it.
Campbell spoke similarly about rituals. Yet, for me, the word “ritual” meant a habit that was empty of meaning; it meant actions that were robotical, automatic, habitual. However, Campbell writes that rituals are just the opposite. They are filled with meanings that provide maps for navigating change. They provide order in the midst of chaos, helping things fit together. Their purpose is to transform the experience by bringing congruence to what was initially incongruent.
The ritual does not fix the problem, but rather opens us to a deeper interior dimension that allows us to be at peace with the changes that have occurred. Just as myths speak a larger truth of the unconscious, so do rituals.
The soul speaks a unique language. Symbols, myths, and rituals reflect the soul’s paradoxical, artistic, and intriguing expressions. If I was to better understand Soul Injury, I recognized that I had to better understand rituals. The more I learned, the more convinced I became of their therapeutic value. The more I let go of my preconceived ideas about what I thought rituals were, the more I became open to their effectiveness in reckoning with change. I realized that in times of uncertainty, loss, and change, therapeutic rituals provide a format for letting go of the old, integrating the uncertainty of change, and redefining a different, hopeful future.
I became so convinced of the value of rituals that I designed my graduate school master’s thesis on the relationship between rituals and hope. I embarked carefully upon the study of designing therapeutic rituals that could be used clinically to provide support, guidance, and hope for hospice patients and families as they faced the uncertainty of changes that accompany death.
For healing to be complete and heartfelt, the unconscious mind must be engaged. Rituals provide access to the energy of the unconscious. Once these rituals are valued, I hope that people will learn how to develop them to navigate important changes in their lives. When combined with integrative letter-writing, it becomes a powerful tool for abiding hardships and reckoning with the changes needed to create peace and healing.
Benefits of Therapeutic Ritual
A gaping hole in our society exists that would benefit from a therapeutic ritual. One example of this gap occurs when soldiers in combat are killed. Their surviving comrades are given no time or formum to grieve. Stopping to grieve would get you killed. Plus, “good” soldiers don’t cry. So where does their grief go? Mostly, the grief goes into the unconscious where it remains hidden until a later loss triggers its release.
The Opus Peace team developed a ceremony specifically for combat veterans so they can come forth to finally honor their dead comrades and honor their own grief.
Its origins stem from providing clinical consultation services to the staff at a State Veterans Home. I asked a Vietnam Veteran, “Is there anything from the war that might still be troubling you now?” The veteran, hardly able to talk due to severe COPD, nodded his head. Then he said, “My brother and I both went to Vietnam, but I was the only one who came back.” Tears slowly ebbed down his cheeks while we waited in calm silence. Then, he added: “I didn’t even get to go to his funeral.”
We suggested that we could design a ceremony to honor his brother and create space for his grief. We explained the value of unmasking his unresolved grief. The veteran’s face visibly lightened and he eagerly participated in the designing of the service.
That’s when we realized the gaping wound in many of the veterans at the State Veterans Home, so we invited all of them to the service to mourn their comrades fallen during battle. About 25 showed up! There were many tears as these veterans allowed themselves to confront the Soul Injuries they had been carrying for decades. Unmourned loss was liberated and healing begun.
Books about Soul Injury
You can read more about rituals and ceremonies and stories about how to apply them to navigate needed changes in Deborah Grassman’s books, Peace at Last: Stories of Hope and Healing for Veterans and Their Families and The Hero Within: Redeeming the Destiny We Were Born to Fulfill.
Veteran Memorial services, Memorial Day programs, and Veterans Day services help support the needs of bereaved Veterans’ families.
by Deborah Grassman
Ritualized formats that incorporate the three stages of change (separation, transition, integration) can provide effective bereavement care for Veterans’ families. Community Veteran Memorial services, Memorial Day programs, and Veterans Day services are just a few of the opportunities that agencies have to develop services that support the needs of Veterans’ families. The following are an example:
Consider offering a communal service designed specifically for families of veterans. Décor can be militarized and patriotic music played. The printed program cover might display military symbols. Posting of the colors, pledge of allegiance, singing the Star-Spangled Banner or America the Beautiful can enhance the military milieu.
Separation Stage of Ceremony: This portion of the service should acknowledge the problem: the death of the veteran and the family’s pain with the loss.
The Ceremony Host might:
Next: Read the names, but first prepare the audience. The goal is to help them connect with the part of themselves carrying their pain. Avoid trying to gloss over it or numb it: “In a few moments, your loved one’s name is going to be read while you stand to honor him or her. This may be painful for you. You might feel a lump in your throat. Don’t shove it back down. Instead, let it come out in tears. This is a sad time in the life of your family. Everyone around you also feels sad. Your grief is safe here. We are here to hold your grief with you.” Then, dim the lights. Formally and with a slight staccato style, read each veteran’s name; have their family stand; thank them for their veteran’s military service; light a candle.
(An effective way to provide the candle lighting is to have a stair-cased platform made of 2x4s and painted a dark color. Position tea-lights in such a way that the word “Hope” is spelled out. Have the candles draped before the service so that it is hidden from participants’ view. Four candle lighters can stand before each letter and the drape removed after the room is dimmed so that participants’ view remains blocked during the candle lighting. After the last name is read, THEN the candle-lighters step aside to reveal the word “Hope” ablaze. This always draws a collective gasp from the audience. See picture below)
Transition Stage of Ceremony: This portion of the ceremony should focus on educating the bereaved on effective coping strategies to reckon with their feelings of loss and creating a “new normal” without their veteran.
Pat McGuire, Opus Peace co-founder, has developed a metaphorical depiction of the process. She uses a large, pretty, cotton-stuffed heart that she displays while explaining all the “niceties” of love with its sentimental ideals. She also discusses the reality of love with its difficulties and shadows. Then comes a terminal diagnosis. She throws some stuffings on the floor: “Love starts getting messy.” More and more stuffings end up on the floor as Pat describes the usual disease trajectory that results in death. At the time of death, Pat reveals three heart strings on the inside of the heart (see picture above). “Love is pulling on your heart strings and you might feel empty with your stuffings all over the floor. Your world is now upside-down.”
Pat then shows how hope can be restored. (Before the service starts, she gave some people who agreed to help her out, a soft flannel swatch around cotton stuffing. Each swatch has a piece of advice about how to do the work of grief recovery. She instructs them to bring these forward when she asks with the words: “I can help”!) Now, she invites them forward with a “Who can help with this broken heart that’s turned inside out?” One by one, people jump up saying, “I can help!” They bring forth tips that help as well as things that don’t. The advice that can help is written on the soft flannel; the advice that doesn’t help is on large plastic cards that won’t fit into the heart.
By the end, the heart is re-stuffed and looks reasonably heart-like: “It doesn’t look quite the same and the stuffings are different, but it’s capable of beating again.”
Integration Stage of the Ritual:
This part of the ceremony should focus on integrating the pain that was brought out into the open. This can be done in several ways:
A closing song, blessing, retrieval of the flag concludes the service.
Memorial Day Program
Memorial Day is an opportune time to facilitate grief recovery with Veteran families. National Cemeteries usually have services on their property. You might coordinate a bereavement program to be held after the cemetery service is over. The program can focus on the specific ways to recover from their loss. Sending out invitations to Veterans’ families to attend both the Cemetery and the bereavement programs can help assure that bereavement needs are being met.
A program that I’ve participated in includes a picnic which allows interaction among grieving families of Veterans. The picnic follows a bereavement program held under the trees of the park. We bring the “Old Rugged Path” out from the hallway to hang from a branch of a large oak tree. The “Old Rugged Path” is a ten foot long path with captioned graphic figures along its way.
Each figure on the Path symbolizes a staff member and their story with the graphics and captions depicting our various struggles. Rocks along the way create barriers. Many stories symbolize feelings that have been shoved into hiding. Each staff person comes forward to read his or her story from the Path. Chaplain Dan’s graphic is a man peering out from inside a toilet captioned with: “I know I’m not the same person I was 8 years ago. I give the credit to God, a good therapist, and some Prozac. I had a lot of wounds to heal. It was hard work. Sometimes, it was painful. But, my-oh-my, the rewards! I’m free at last!”
I then talk about the relationship between grief and depression and the importance of getting depression treated. I then ask the audience if any of them can relate to Dan’s story. Many do, and are willing to share their experience, which encourages self-reflection for everyone else.
Pat shares her story of divorce. Her graphic depicts a car at the edge of a cliff with a frantic woman at the wheel. Road signs pointing different directions reflect her confusion. After Pat reads her caption, I explain how grief accompanies many losses, not just divorce. I emphasize how those “who grieve well, heal well” and the value of tears. I point out how the stoic culture of the military may have affected their family and how this can interfere with their grief recovery. Again, I ask for stories from the audience who have experienced confusion and grief from a loss and people always oblige, even seem eager to share.
I share my story of grief after my father died. Marie shares her story of coming back from Vietnam and the losses she felt. Sheila talks about her faith journey surrounding her agnostic quest. Shaku speaks about the estrangement she had with her son. All stories are different, yet all connect. After each person speaks, I briefly explain the bereavement principle surrounding the issue and go into the audience to solicit stories. The vulnerability of each staff person easily gathers them!
You can receive free pamphlets from your closest Dignity Memorial funeral home. Use them to educate Veterans’ families. You can also download the pamphlets below by clicking on them.
Sometimes, military culture can complicate the grieving process for the families of veterans who have died. This article by Pat McGuire explores those challenges.
by Patricia McGuire
Veterans and their families need the same things non-veterans and their families need when a loss is experienced: comfort, sympathy, emotional support of friends and family, knowledge, coping skills, time, and healing. The military culture, however, can create special grief needs as well. Complicating bereavement matters further, Soul Injuries tend to surface at the end of life for the entire family.
Stoicism, while a needed quality for an operative military, can be a hindrance in grief. Stoicism may cause grief to be hidden behind a silent or angry facade, cavalier humor, an attitude of bravado, or an “I’m fine” wall of denial. Stoicism not only affects veterans, it can affect whole family systems. One woman spoke of her friend who was married to a career Marine. She described the woman’s stoicism: “She is as much a Marine as he is. When her mother died, she was expected to grieve quickly and return to normal functioning in short order. She did.” Twenty years later, however, her mother’s death was reactivated when her husband died. This time, I gave her permission and encouragement to grieve and to take the time she needed to grieve both of these losses.
In addition to stoicism, “career-military” family systems may present special considerations. The family may have lived in numerous places for short periods of time, and this impacts family in several different ways. For example, at one veteran’s deathbed, his adult daughter identified for the first time where her bitterness for her father had begun: “It was the five different first grades I went to.” Because staff had been trained in veteran-specific issues, his daughter made this discovery as part of her anticipatory grief. She had the opportunity to work through this issue and the wall it had created before her father died. I acknowledged the patriotism and sacrifice that her entire family had made, which allowed the daughter to change her relationship to her past. This change helped her let go of some of her anger and open up to her father in a new way. Her grief after his death was facilitated by acknowledging the ways that this early loss affected her life and her perception of her father, which helped her deal with those losses prior to her father’s death.
Another issue which may arise with career-military families is that when there is a death or major loss, the family may find themselves far away from their family and support system. Because military families have not established roots, there may not be a network of support that facilitates effective grieving. On the other hand, because of these frequent moves, families of veterans may readily reach out for support because they have learned how to ask for help and form new bonds quickly. A Greek war bride from World War II cried at her husband’s death bed: “I have no family, what am I going to do?” I anticipated the possibility of complicated grief due to lack of support. An hour later, however, I found her in the hospice kitchen, with five lifelong friends from the Officers’ Wives Club. It was every bit a supportive family, just a different kind. Conversely, a young Vietnamese wife who barely spoke English said: “We did everything together. We are each other’s world.” This veteran’s isolation excluded everyone except his wife, leaving her unprepared for his death. She was at high risk for complications of grief and required extensive support to find her way materially and emotionally after his death.
Consider a third young American bride living in Germany while her husband served in Afghanistan. He was due to return in time for the birth of their first child. Unfortunately, the young woman went into labor early and their child was delivered stillborn. She was far from home, family, and anything familiar as she struggled with her overwhelming grief. Her husband returned to her as soon as possible, which in this case was a week later. He was grieving the loss of their child, feeling like he deserted his platoon, and struggling with symptoms of Posttraumatic Stress Disorder (PTSD). She was grieving the loss of their baby, the loss of innocence that she saw in her husband, and changes within her own body. This couple required intensive support as they faced their changed world. Their return to home was delayed due to legal issues related to transporting their child’s remains from one country to another. Plans had to shift to assist her parents to travel to Germany. This whole family system needed extensive support due to the complexity of the situation.
In her book, Peace at Last: Stories of Hope and Healing for Veterans and Their Families, Deborah Grassman explores the impact of military service on veterans at the end of life. She offers insight into some of the possible effects of combat on veterans and their families. Providing the book for family members to read helps them better understand the military influence on their loved one, their family, and themselves. This enhanced understanding can facilitate peaceful life closure and more effective grief recovery.
Veterans may gain a deeper appreciation of life by surviving combat and recognizing each day as a gift. Others may superficially integrate their experiences and carry on with their pre-war lives after returning from war. A third group may be changed by their combat experience and be unable to effectively cope. These latter two groups’ coping styles may adversely affect the family. Veterans in the last category may have struggled for years with bouts of depression, anger, nightmares, or from being overly protective or controlling. The veteran may have coped by using drugs and alcohol, or might have isolated himself in order to feel safe. Families living in this environment may have been abandoned, abused, or developed dysfunctional coping mechanisms to deal with these behaviors. This kind of lifestyle might precipitate divorce, creating multiple families by the time the veteran comes to the end of life. A common saying among Vietnam vets that overly simplifies this issue is, “Most veterans with PTSD have been married three times.” There may be three different sets of children at a veteran’s death bed. Perhaps their first family was abandoned when the veteran first returned home from war and he was unable to reconnect with them. These children may be angry. When the veteran remarried and started a second family, these children may have lived with abuse, drugs and alcohol, and developed dysfunctional coping mechanisms. After a second divorce, the veteran may have gotten into an addiction recovery program, as well as received help for his PTSD. A third marriage is often to someone who already has children. These children may reap the benefit of the veteran’s recovery and think their stepfather is very special. Imagine this veteran’s death bed with all of these family members present! Providing support for all of these family members with a wide range of forgiveness, estrangement, and anger issues creates a highly-charged environment for needed therapeutic work in order to facilitate some resolution. I strive to keep my heart open to all of these different family members and recognize each of the particular losses and relationships with this veteran. The past cannot be changed, but new understanding can help to change their relationships to the past.
When there are multiple families, judgments about one another are often passed. Guilt, shame, and blame are often the fuel that has been used to avoid the pain of the underlying loss of healthy relationships. This can negatively impact decisions that need to be made as the veteran is approaching the end of life. For example, the person who is legally able to make the decisions for the veteran may be someone from whom the veteran has been estranged. The current significant others of the veteran may find themselves disenfranchised at the time of the death, funeral, and burial. Another common contention after the death of a veteran with this kind of multiple-family constellation is: “Who gets the flag?” There is one flag provided for each veteran, yet there may be more than one person who feels that they deserve it. In these situations, it can be helpful to work with the VA’s office of Decedent Affairs, also known as the Details Clerk, to arrange for the provision of more than one flag.
Presentation of the flag in a respectful manner is of the utmost importance. Because many families today choose cremation, there may or may not be a funeral or memorial. In these cases there is not a formal presentation of the tri-corner flag to the next of kin. One VA nurse saw a family leaving the details office after their loved one’s death with a flag in a small rectangular box. He was upset by this “indignity” and called the team together to find a way to correct it. The solution was found when the Korean War Veterans Service Organization (VSO) agreed to use this need as an opportunity. The VSO provided education to a local Boy Scout troop about proper flag etiquette and flag folding. The Boy Scouts now meet bi-monthly with the VSO to fold flags. Together, they have maintained a supply of folded flags for that VA facility. The flag is now formally presented in a dignified way to the family at the time of death.
Other family members might have anger or bitterness about their veteran not getting a medal, service-connected disability, or pension. These feelings can interfere with effective grieving: “Dad was wounded in combat and he never received his Purple Heart. They lost his records.” This veteran and his entire family had chafed over this injustice for many years. After his father’s death, one son doggedly pursued his father’s records until the Purple Heart was awarded posthumously. This act helped the family begin to move through their grief. In a similar situation in which the Purple Heart could not be obtained, Deborah Grassman, their nurse practitioner, made a “purple heart,” ceremonially pinning it on the veteran while citing the heroic deeds that he had done. The bereaved family survey subsequently identified this act as extremely meaningful.
If PTSD is identified for the first time as a veteran is dying, the impact on family needs to be factored into their bereavement needs. Some family members feel relief: “I’m so glad to know it has a name. I knew something was wrong but I didn’t know what. Now this makes sense.” Other family members might feel guilty: “I wish I would’ve realized this sooner, I would have_________ (listened more carefully, gotten him help, been more patient and understanding, etc.)”
If the veteran had PTSD, physical or mental disability, or long-term illness prior to the death, the family member may be exhausted from providing care; they may not have the energy to grieve. In her book Chronic Sorrow: A Living Loss, Susan Roos (2002) writes about “significant losses with no foreseeable end” in the context of children with disabilities. Veterans and their families may share a similar experience. This may lead to frequent periods of sadness with no stable periods to allow time for grief and adjustment.
The family may have financial concerns near the end of life. For example, if the family has been supported by the veteran’s disability check, they may want extensive futile care because they do not know how they will survive without the veteran’s check. They may have provided care for the veteran for years and thus been unable to maintain work outside the home. It is important to acknowledge the reality of this practical consideration and recognize that the family’s questions about money may not indicate a lack of love, but instead may be a first step in providing the practical groundwork for their future welfare and their ability to grieve. Providing social work services can help the family with financial strategies and resources. The veteran may also be concerned about the financial plight of their family after he or she dies. This concern might cause the veteran to fight death so the disability check continues. One veteran lived for 40 years as a quadriplegic in a VA nursing home. He said, “My job is to stay alive as long as I can so my wife will have the money to raise our kids.” When he died, his family spoke of “growing up at the VA,” and there were as many staff mourners as family at the memorial service. Many such families have provided care and support for their loved one for years with little or no recognition. Acknowledgment of their patriotism and a word of gratitude for the sacrifices they have made may bring tears to their eyes. Those tears often represent the internal healing that is taking place. We developed a ritual that recognizes the family members who have been caring for veterans by pinning them with a small patriotic angel dressed in red, white, and blue. The family is thanked for their sacrifices and service to America by providing care and support to their veteran. A small card is given to them so they will remember the meaning behind the pinning. The card reads: “Caregivers are important too! Because we know you have also paid a price for our freedom, we honor you with this pin. It’s our way of acknowledging the many ways you’ve been impacted by the military and also the many ways you have provided care to our veteran. We are grateful.” (Go to “resources” tab for information about how to obtain pins).
Caregivers are 93% female. Most caregivers are spouses (72%) and parents (12%) (National Alliance for Caregiving, 2012). Today, there are more services for family caregivers than ever before. All VA medical centers now have Caregiver Support Coordinators (Johnson, 2012). They are experts on caregiver issues and are knowledgeable about VA and non-VA resources. They manage a menu of options to support veterans including in-home care service, respite care, needed equipment, home and automobile modification, peer support, and caregiver support groups. The VA also runs an interactive website for caregivers (www.caregiver.va.gov). The Primary Family Caregiver Benefits include a stipend (post-9/11) paid directly to the caregiver, which is centrally funded and managed. The caregiver may be eligible for health insurance through CHAMPVA (a health benefits program through VA), travel, lodging, and mental health services through VA or by contract. This kind of support allows veterans and their families to have more time and energy for their bereavement and emotional needs.
In addition to needing support when a veteran is facing illness and death, family members may also need help in understanding a veteran’s response to loss. A veteran’s inability to grieve someone’s death might be due to their fear of unresolved grief from comrades who died in combat, and this fear can sometimes cause the veteran to detach from grief. This was true for a veteran and father of four whose youngest son was killed in a hit-and-run motor vehicle accident. The veteran went through the formalities of identifying the body, arranging the funeral, and receiving the outpouring of support from his community; yet he remained impassive throughout the process. His wife and family were appalled at his lack of emotion. When the veteran came in for counseling, he reported being on a convoy in Vietnam 40 years earlier. One of the trucks hit a young Vietnamese boy. It was a dangerous area and they were under orders not to stop. This veteran was devastated by seeing this innocent boy left presumably dead and unattended. When his own son died in a similar manner, he could not allow himself to feel the grief for his own son until he had acknowledged the loss and grief of the parents of the Vietnamese boy. The latter was the focus of the bereavement intervention.
Another young soldier serving in Iraq was notified of his grandfather’s death; the Red Cross was prepared to bring him home for the funeral. The soldier declined to leave his troop, and the family was very upset with his decision. As bereavement counselor, I discussed with the family their son’s need for stoicism so he could face war every day. If he came home for the funeral, he may have felt that he had deserted his troop. He could also be opening himself up to an emotional bungee jump, bouncing from his feelings of his grandfather’s loss which could also trigger grief over deaths he was seeing in war, only to have to go right back into war two weeks later. Thus, the bereavement intervention did not focus on trying to convince the grandson of the need to return home, but rather on helping the family choose to validate the young soldier’s choice. Intervention also focused on planning a family gathering when the young soldier was home again and emotionally able to participate in working through his grief for both his grandfather and his fallen comrades.
Supporting Veteran Grief
As part of a focus on comprehensive care, unresolved bereavement needs of veterans need to be assessed when they are being treated for physical and mental health issues, homelessness, substance abuse, and PTSD. These needs can best be addressed by a clinician who has been sensitized to the special needs of veterans. In 2003, Wounded Warriors: Their Last Battle, a presentation developed by Deborah Grassman, was produced by the National Hospice and Palliative Care Organization (NHPCO) and distributed widely throughout both the hospice and VA communities. Her presentation sensitizes clinicians, veterans, and their families to issues that may otherwise be overlooked or misunderstood. (Click on “resources” on this website to view the updated version). The same stoicism that allows veterans to be the helpers of the world may prevent them from reaching out for help or support. Messages of “big boys and girls don’t cry” were learned as children and reinforced in the military. This message needs to be reframed by clinicians. When a veteran is talking about the pain of loss and attempting to hold back the tears, they can be reminded of the courage it takes to allow their feelings to show. It may be helpful to sit beside rather than in front of the veteran to allow emotional privacy. Alternatively, the clinician might bow their head and sit quietly when tears escape from behind a stoic wall. I let veterans know that tears are a normal reaction to pain and are welcome. I have a picture in the bereavement office of a face with a beautiful tear running down it. I ask veterans who struggle to externalize tears to study it and tell me what it elicits for them. The picture acts as a reminder of the beauty of grief expressed. I also use a prescription pad and “prescribe” crying in the shower, in the car, or wherever the veteran feels safe. Some veterans are more comfortable with humor and respond well to being told that I get a bonus if they cry. Everyone grieves in their own way, so there are not always tears. The gender differences between men and women have been studied for years and many men are more likely to express their grief by doing something active: planting a tree, building a memorial, or organizing a fundraiser for a needy veteran family. Tears may or may not be part of their grief journey (Doka and Martin, 2010; Golden, 2010).
In caring for veterans with PTSD, it is important to know that they may not trust easily. My initial efforts need to focus on gaining their trust. This can make something as simple as scheduling an appointment difficult. For example, when a veteran is identified for bereavement counseling, a telephone call is used to make contact. Not unusually, there is no answer and a message is left encouraging a call back. When this is unsuccessful, a second call is made and again a message is left. If the call is not returned, a condolence note is mailed to the home. Persistence often pays off at this point and the veteran may reconnoiter and peek into the bereavement office a few times. If I pass muster and seem trustworthy, the veteran will schedule an appointment to address his or her grief issues. A basic premise of passing muster is the understanding that “we serve those who first served us.” Veterans need to know that I am aware that veterans are trained warriors; they need to know that I value their service and recognize that freedom is not free.
These issues may also be apparent when a veteran is diagnosed with a terminal disease. The veteran may not want anyone “to see me weak.” They may go so far as to say, “When I can’t take care of myself, I’ll just go off into the woods to die.” I met one such veteran during his several admissions to the hospital through his illness. My interventions focused on encouraging him to be a gracious receiver. I educated him about Dame Cicely Saunders, founder of the modern hospice movement around the world, and what she said at a conference a few years before her death. Using a wheelchair for ambulation, she stated, “I used to think that being a giver was the most important thing. Now that I need help myself, I realize that being a gracious receiver is the most important thing.” He was encouraged to see how helpful his gracious receiving could be for him and for his comrades. As his illness progressed, he was able to make healthier decisions about his care. The veteran allowed his friends in the “Vietnam Brotherhood” to participate in his care and ultimately his death. Many of these men had only witnessed violent or mutilating deaths in the past. In combat there was no time to mourn the deaths of comrades. This veteran made a courageous choice to allow the brotherhood to come together as a group to grieve while they provided care and support to their dying comrade. They were dressed in their Vietnam Brotherhood jackets; many had long hair, ponytails, and tattoos. Although their tough exteriors were intimidating, they provided tender physical comfort by repositioning the veteran, giving him drinks of water and food, and even participating in circles of prayer. By relying on their camaraderie and overcoming their fear of vulnerability, they created a dignified death for their comrade and a new concept about death for themselves.
The Commander of a local chapter of the Korean War Veterans Service Organization (VSO) was asked about the impact of combat on the members. His eyes clouded over: “We all have PTSD to some degree. It’s just a matter of what we do with it.” He spoke of some members who self-medicated with alcohol, but of many others who channeled their pain into contributing to the community. Honor guards are one of the services this chapter provides. They are frequently at the local VA cemetery to honor their newly fallen comrades by providing military honors, an interment ceremony, and the presentation of the flag to the next of kin. He acknowledged that when he participates in these events, he is attending to his own bereavement needs by honoring the buddies he lost in service so long ago.
As many as 30,000 veterans live in State Veteran Homes and there are many other long-term care facilities caring for veterans. These settings can provide an opportunity to address unresolved grief from fallen comrades decades earlier.
One State Veterans Home in Ohio provides such a service. This was developed when Deborah and I were providing clinical consultation services to the staff so they would better understand how to care for the unique needs of veterans as they die. Deborah asked a Vietnam Veteran, “Is there anything from the war that might still be troubling you now?” The veteran, hardly able to talk due to severe COPD, nodded his head. Then he said, “My brother and I both went to Vietnam, but I was the only one who came back.” Tears slowly ebbed down his cheeks while Deborah and I waited in calm silence. Then, he added: “I didn’t even get to go to his funeral.”
We explained that we could design a ceremony to honor his brother and create space for his grief. We explained the value of unmasking unresolved grief. The veteran’s face visibly lightened and he eagerly participated in the designing of the service. Deborah and I then realized the gaping wound in many of the veterans at the State Veterans Home, so we invited all of them to the service to mourn their comrades fallen during battle. About 25 showed up! We also addressed the guilt that some of them felt — survivor’s guilt, guilt of killing other people, guilt of things done or not done. This launched a program called the Fallen Comrades Ceremony that has been done throughout the country for veterans of all ages and eras.
Veterans Need to Mourn the Deaths of Their Comrades
The source of the gaping hole in our society caused by the aftermath of war is unmourned loss and unforgiven guilt/shame from the deaths of comrades killed in war. The hole this leaves in surviving comrades’ hearts continues to exert its influence throughout their lives until the deaths are acknowledged, honored, mourned, and redeemed. We believe that our civilian society has a responsibility to help heal the Soul Injuries of our nation after war. Soul Injury ceremonies can help restore wholeness to our broken nation; we struggle together to heal the wounds of war.
Opus Peace has developed a Fallen Comrades Ceremony. The resultant service can be a model for other organizations to provide so that our nation can be healed of this gaping wound. If you would like to help heal our nation of the aftermath of war, please consider sponsoring a community event that invites combat veterans to come mourn their fallen brethren. Contact us and we will come help you. Don’t miss this opportunity to heal the aftermath of war in your community. Throughout the United States, there are Fallen Comrades ceremonies taking place. These can be healing to both veterans and their families.
Most VA Medical Centers offer memorial services honoring the veterans who died in their facility annually. These services should be formatted in a ritualized ceremony that acknowledge and promote effective grieving and the ceremony should have a military context. Many VAs provide bereavement ceremonies or events to provide support for the veterans and their families for Memorial Day, Veterans Day, Fourth of July, and other holidays. Community hospices and other long-term care facilities should be encouraged to participate in these events or to hold their own veteran-centric programs.
The military culture influences both veterans and their families. They may face issues that do not impact the general population. This is also true of veterans and families of loved ones dying on active duty; however, hospice services are not provided to families prior to an active military death. Bereavement care to the surviving family members should follow the above guidelines coupled with standard bereavement guidelines that focus on sudden and violent death.
There are two organizations that are uniquely equipped to provide bereavement counseling and support to active duty personnel, their families, and extended families: Vet Centers and Tragedy Assistance Program for Survivors (TAPS). Vet Centers provide individual, group, and family counseling to all veterans who served in any combat zone. Services are also available for their family members. TAPS is a national non-profit organization that offers extensive peer-to-peer support and education about traumatic death and the active duty military’s specific grief needs. Some hospices partner with these agencies to provide services. Other hospices partner with the Red Cross to offer bereavement services for active military deaths. It is important that Hospice staff receive specialized training in order to perform this task.
You can receive free pamphlets from your closest Dignity Memorial funeral home. Use them to educate Veterans’ families. You can also download the pamphlets below by clicking on them.
Soul Injuries are complicated. Quality of Life gatherings offer a forum gor giving voice to the suffering so that unmourned loss and unforgiven guilt can be liberated.
Quality of Life Gathering: A Forum for Healing Soul Injuries
by Deborah Grassman
Our hospice team consistently saw Soul Injuries surface at the end of life. The Soul Injuries did not always respond to the usual PTSD interventions that we provided. The Soul Injuries were sometimes complicated and required ferreting out its source. This required more time, energy, and skill than any single team member or consultant was able to provide. After much deliberation, contemplation, and trial-and-error experimenting, we developed a format of weekly Quality of Life (QOL) meetings with the patient and family where we gather at the bedside. The idea for the format of the QOL meetings evolved from a conversation I had with my colleagues. I had said to them: “Doesn’t it seem odd that no hospital in this country has a suffering team?” My boss thought so too when I mentioned it to her. Next thing I knew, I was designated to start one throughout the hospital!
Quickly I realized that neither patients nor staff would easily accept a “Suffering Team” on their unit; it just wasn’t good public relations. A patient suggested that we call ourselves the Quality of Life Team. “That’s really what you are doing,” he said. “You are helping us improve the quality of our lives.” The name stuck and for the next several years, staff throughout the hospital were trained in providing this quality-of-life service. The “QOL,” as it has come to be known, is one of the primary ways through which we provide spiritual care. We put casters on the legs of our chairs so we could literally “roll” to bedside, sitting at eye level so the power is equalized. The staff who “roll” to bedside include: physician, chaplain, nurse, social worker, and volunteer. We become a unified whole, stepping outside our professional roles unless specifically invited into that role by the patient and/or the situation. Rather, we come prepared to simply share the patient and family’s suffering; often that suffering surrounded a Soul Injury.
At the start of the QOL gathering, we reintroduce ourselves to the patient and family. The patients have met many people since they were first admitted, and we want to make sure they know the roles we play in providing their care. Then we explain the purpose of the meeting: “We’re here to listen to what might be on your mind or heart. We know this time can be difficult, and we want to listen carefully as you tell us what you are experiencing so we can respond to your needs.” Both patients and their family members usually respond easily to this open invitation to share their suffering.
We sometimes inquire about physical pain and symptoms to make sure we’re providing adequate treatment, but pain and symptom management is not the goal of hospice and palliative care; pain management is simply the vehicle to the goal; the goal is healing. I’ve seen people cured of illness without experiencing any deeper healing. Likewise, I daily witness people who experience healing even though their disease cannot be cured. We explore the emotional and spiritual aspects of their illness during the meeting. Our job is to vicariously experience whatever the patient says, abiding with whatever feelings arise and to connect with the part of the patient that is generating the feeling. We elicit stories so we can gain a sense of the patient’s past, their current struggles, and their hopes for a peaceful death. It’s often a time filled with laughter, tears, and cherished memories. We provide guidance about ways they can reckon with their illness. We explore the spiritual dimension so we can understand how to provide spiritual or religious care that is congruent with their beliefs. We ask if there’s anything we need to do differently to make things better. Not only does the question help us improve care, but the patient sees we’re open and willing to change; they feel free to speak about their needs. We also help them explore the impact of their military history so we are better able to identify its relevance to unfinished business or ways in which it might influence their death. We express our appreciation for their military service by thanking them and ceremonially pinning them with an “Honored Veteran” pin. We also thank their families for the impact the military had on family members and pin them with a military angel.
We offer choices for how to close the QOL session: “We can provide a spiritual reflection or prayer; each of us can offer you a hope for the day; we can tell a joke; we can sing a song; we can each tell you how your story has impacted our own lives; or we can just say good-bye. What would be meaningful to you?”
We’ve found this format to be invaluable for everyone who participates, including the staff. I asked Percy, a patient who had experienced five of these meetings, how he would describe the QOL gatherings. He said: “These meetings are God, man, and staff coming together to help patients feel happier and more comfortable. It helps assure that the patient’s goals are the staff’s goals. In the process, the whole organization becomes better and stronger.”
Morgan, the teenage son of Pat McGuire, co-Founder of Opus Peace, volunteered at the hospital one summer. He attended QOL meetings with patients. He witnessed the transformations patients often experience during their spiritual questing, and he called them “miracles.” Now, when his mother comes home from work, Morgan asks her, “What miracles did you see today?” His mother responds with stories of suffering she saw redeemed. She tells him stories of patients awakening to their interior hero so they could heal the Soul Injuries they had acquired.
I think our QOL meetings are like a story in the book, Kitchen Table Wisdom, by physician Rachel Naomi Remen. Remen attended a workshop for physicians by mythologist Joseph Campbell, in which he displayed a slide of Shiva. “Shiva is the Hindu name for the masculine aspect of God,” Remen writes. She explains that the picture shows Shiva dancing in a ring of flames while his hands hold symbols of the abundance of spiritual life. One of his feet is supported on the back of a little man crouched down in the dust, giving all his attention to a leaf the man is holding between his hands. “Despite the great beauty of the dancing god,” Remen continues, “all of us physicians had focused on the little man and the leaf, and we asked Joseph Campbell about him. Campbell began to laugh. Still laughing, he told us that the little man is a person so caught up in the study of the material world that he doesn’t even know that the living god is dancing on his back.”
In the midst of all the diagnostic and treatment modalities that permeate a hospital culture, we can likewise find ourselves studying leaves and missing the living god dancing on our backs and on our patients’ backs. The time we spend in QOL meetings with patients helps us create room for gods to dance.
Quality of Life Gatherings: Guidelines for Bringing Soul Injuries into the Open
The purpose of Quality of Life (QOL) gatherings is to support successful suffering as people encounter difficulties in their lives. Abiding and reckoning are the primary therapeutic processes used. QOL gatherings are especially meaningful when provided during critical transitions in peoples’ lives, such as changing jobs, teenage crises, or facing terminal illness. The following information provides a basic foundation to facilitate the QOL process in an inpatient hospice unit. However, the knowledge can be applied in any setting, situation, or relationship. The most important thing we bring to QOL is openness and willingness to do it, bearing witness to the Soul Injuries that surface as we do so.
QOLs are normally done with the team sitting at the patient’s bedside; however, they can be done outdoors or in area that is meaningful to the patient. QOLs should include all the people who are affected by the situation. If people can not be physically present, conference calls that include everyone can be made. The call is then placed on speaker phone so that everyone can participate.
QOLs are often verbally interactive, but they might not be so. With people who are cognitively impaired or comatose, quiet nonverbal presence may be more effective. Touching and singing also bring comfort.
You want to open doors without pushing people through. Pushing can do damage. Not opening the door also does damage. It abandons people and isolates them from talking about important issues no one wants to talk about, issues they may not even know how to talk about. We are often guilty of not opening doors because we fear pushing. It means we are putting our own comfort needs above the patient’s needs. It means we are more worried about making a mistake than learning how to respond to difficult needs of others. You have to have courage to make mistakes. When you do, apologize: “I’m sorry. I can see I overstepped. I apologize for not listening more closely.”
Setting the Stage
The opening of the QOL needs to acquaint the participants with the purpose of the gathering. It should also establish time boundaries as well as introductions of everyone present. Here are a few examples:
• “This is a 30-minute session when we come together to hear what might be on your mind and heart, a time for us to listen. We don’t have an agenda. This is your time. We’ll start by introducing ourselves.”
• “Sometimes we get so busy doing things to patients and for patients that we forget how important it is to just quiet ourselves and be with patients, to listen. So, we take these 30 minutes to just be here with you, to see how you are doing. We’ll start by introducing ourselves.”
• “We call these meetings our Quality of Life meetings. We don’t know what quality of life is for you. Our job is to take these 30 minutes together to listen so we will know how to respond to your needs, to find out what’s important to you so that your quality of life will be improved. We’ll start by introducing ourselves so you know who we are and what we do.”
Physical Pain & Symptom Management
Although we need to make inquiries into physical pain, the QOL should not stay focused on this dimension. If inquiries make you realize that more time needs to be spent assessing and alleviating physical pain, then the clinician can further assess this factor after the meeting is over.
• “How is the physical pain today?”
• “How are we doing getting the pain under control?”
Exploring the emotional dimension of suffering is one of the most important aspects of the QOL. Because several clinicians are present, different perspectives are provided. Because multiple family members and friends are present, alternative pieces of the suffering puzzle often avail themselves. I usually start out with a general question about change. Commenting on all the changes that they have experienced in recent days validates their suffering and also gives me an idea of how they are responding to it.
• “Your life has changed a lot lately.”
• “I would guess that you are reeling with all the changes you’ve had to go through.”
• “It’s not easy to have to go through all the changes that have happened in the past few months.”
• “You’ve been struggling with a lot lately.”
• “You’ve had a hard go of it.”
• “It takes a lot to go through what you’ve been through.”
• “You’ve endured a lot.”
• “I would guess you’re pretty weary with all that has happened.”
• “Tell us about the difficulties you’ve been having.”
• “Of all these difficulties, what is the hardest for you to deal with?”
Affirm and Validate Feelings
Engage the emotional component of the person’s experience. Help them to honestly feel whatever it is they are feeling. Take them into their emotions instead of away from them. Instead of helping them numb out or disconnect from their emotional pain, help them connect with the part of themselves that is carrying it. Clues about possible Soul Injuries are often uncovered at this time:
• “I know it can be hard for you to express feelings, but now is not a time to pretend like nothing is going on, that nothing has changed.”
• “It may be difficult to express the hurt you may be feeling. It may be tempting to try to hide it and act like everything is going on like normal. It takes a lot of energy to pretend.”
• “How’s your heart today, your inward heart?”
• “I can see you are comfortable talking about the pain. I’m wondering if there are ever times when you let yourself feel your pain?”
• Empowering silent voices: “If your _________ (anger, fear, cancer, liver, Deeper Self) could speak, what might it say?”
Many people would rather feel angry than experience vulnerable feelings. Anger keeps other feelings away. Anger often covers up hurt, fear, and helplessness, especially in men. On the other hand, many people have been taught that it’s “unlady-like” or ungodly to feel angry, in which case they need encouragement to acknowledge their anger. The approach to anger depends on which end of the spectrum the person is on.
Creating space with someone who tends to hide their anger:
• “I think I might feel angry if something like this happened to me.”
• ”I’m wondering where your anger is?”
• “I’m wondering why you’re not feeling angry?”
• “Sounds like you might feel a bit angry about all that has happened.”
• “What else makes you angry?” (This question takes them into a deeper level.)
Creating space with someone who uses anger to hide other feelings:
• “I’m wondering if beyond the anger, might be a bit of hurt. It can be very hurtful when ____ happens.”
• “I’d be hurt and sad if something like that happened to me.”
Creating space with patients who anger us. Approach patient when you feel calm and centered. (Remember the Samurai warrior never acts out of vengeance, only for cause.) Come bearing kindness:
• “I find myself angry with you sometimes because you treat me disrespectfully. I want our relationship to change, but I don’t know what I can do differently. It seems like nothing I do satisfies you.”
• “You look worried about something.” (Cite your observation.)
• “I would guess that this is a bit frightening for you.”
• “What else might be a little bit scary for you?” (takes people to a deeper level)
• “You look down today…” (observation)
• “You seem sort of heavy…” (observation)
• “I’m wondering if behind your hurt and tears, might be a bit of anger. Many people might feel angry when something like this happens.” (For people who hide their anger; women are often encultured to do so.)
• “Of course you are crying. This is a sad time.”
• “It’s good to see your tears.”
• “Your mouth is smiling, but your eyes are not.”
• “They say that the only bad tears are uncried tears.”
• “What else about this situation might hurt a little bit?”
• “It’s been a lonely road you’ve had to journey.”
• “It takes a lot of courage to let yourself feel lonely.”
Most people want certainty and a guarantee that everything will remain the same. Helping people accept uncertainty as part of life’s transitions can decrease their fear. At the heart of all fear of change is an unwillingness to let go of same and open up to different, that is, wanting things to go back to the way they used to be. Helping people let go of same and open up to different brings peace. Validate change and help them anticipate its occurrence:
• “Your world has changed a lot.”
• “Your world has really shrunk.”
• “Now is a time of uncertainty. Learning to be at peace with the uncertainty is hard.”
• “What else is difficult about the limbo that you’re in?”
• “I know that __________ (staying on top of things, being in charge, being able to take care of your wife, etc.) has been important. Things are changing now though. More changes might be coming. I’m wondering what things are important for you to let go of so things could go more smoothly?”
• “Would you consider letting _______ (same) go?” (cooking dinner every night, working 40 hours/week, putting up the Christmas lights, etc.)
• “What would happen if you let that go?”
• “How would things be different for you if you were able to let that go?”
• “You have given all your life: to your family, to your job, to your country. Now is the season of life when it’s your job to accept help from others. You’re in the cycle of life where it is important for you to learn how to receive.” Then, pin a “Gracious Receiver” button on them. The “Gracious Receiver” button is especially important for people who are stoic.
Don’t quickly dismiss guilt or minimize it. Give it time and attention. Be alert to “pseudo-forgiveness” which can be a way to avoid doing the work of forgiveness:
• “Sounds like you may feel a bit guilty about that.”
• “Sounds like you let her down when you did that.”
• “I’m wondering if you’ve considered asking for forgiveness about that?”
• “I wonder if you have forgiven yourself for having done that?”
• “Would you be interested in learning how to forgive and let that go?” (only after some exploration of the guilt).
Many roles are designed to protect, fix, do. Helplessness threatens all these. The goal is to become at peace with the helplessness.
• “Is there room for dependence on others in your new situation that you are now facing?”
• “Sometimes helplessness can make people feel angry. Is that the case for you?”
• “How difficult is it for you to let go, to relinquish control?”
• “I know you’re a doer and a giver. How are you about receiving?”
• “Are you the kind of person who can accept that things are changing and ask for help?”
• “If you don’t ask for help and you need help, what do you do?”
• “It can be very humbling to have to depend on others now.”
• “How might pride be getting in your way right now?”
• “What else are you feeling helpless about?” (Takes people beyond surface answers)
Point out Incongruities
Remember that only 10% of communication is verbal. Nonverbal communication is often more accurate. Stay tuned to it.
• “You’re smiling on the outside, but your eyes seem sad.”
• “I know you said you feel ‘fine,’ but you don’t sound like you really mean it. I noticed you sighed as you said it.” Beware of “fine” in unfine situations. (Fine acronym means Freaked out, Insecure, Neurotic, Empty)
After you’ve gathered a person’s story, they may provide you with clues that point toward a Soul Injury. Remember that the cornerstone of a Soul Injury is NOT the traumatic experience, it is when the traumatic experience diminishes their self worth. Often, just saying to someone: “It sounds like you might have a Soul Injury” is all that need be said. They resonate with the term and often even express relief to know it has a name. Others will query you after you use the term and you will need to provide further explanation.
• “A Soul Injury occurs when we get separated from our own sense of self. We start feeling worthless, or defective, or ‘less than’. Would you say something like that happened with you?”
Make sure you don’t just paint half the picture when explaining options to patients. Explain hospice care too so they can truly make an informed decision.
• “You know what medical care is like because that’s what we’ve been providing. The difficulty is that your needs are changing and medical care can’t help as much now. We have other things that can better help. Your quality of life is important. You might choose a more flexible environment of care like hospice. They will get you outside to smoke, get you a beer, let your family stay with you, go home on pass or out to restaurants, let your pets visit, put you on a motorized scooter so you can enjoy the outdoors, those kinds of things. They are experts at pain management and helping you achieve peace.” (Follow with a long pause.)
• “Pretend like you died today. What would be left unsaid or undone?”
• “What are your hopes so that you can achieve a peaceful death?”
Include Family Members
• “Do you all have the kind of relationship where you can speak openly to each other about what’s going on or do you all sort of try to protect each other so that the outside always seems fine and on the inside things are not so fine?”
• “You two have shared so much. I’d hate to think you are leaving each other alone and that you’ll miss this special time together. I can’t think of anything worse than spending the last few weeks lying to each other.”
• “It has to be difficult to even think about letting him go.”
• “Your world is going to be very different after he dies.”
Opening Spaces to Reckon with Grim Futures
• “I’m sorry. I wish I could do that” (when they’re asking for futile treatments).
• “Sometimes people think we are God, that we can fix anything, do things beyond our abilities.” (Long pause)
• “If there were any further medical treatments we could offer that would help, we would do it.” (Long pause)
• “In spite of everything we’re doing, your condition is getting worse.”
• “I’m worried about whether you’re going to be prepared for the end of your life. Tell me a little bit about what thoughts you have about getting ready for your death, whenever it comes.”
• “We can’t control the quantity of your life. We can control the quality.”
• “This is a very precious time of life because you might not have many days left. You might want to think how you want to spend these days, so that no day is wasted doing something you don’t want or distracts you away from what might be important.”
• “All of us need to be prepared for death so that when it happens nothing is left unsaid or undone. Whether you die today or 10 years from now, it’s good to be prepared.”
• “Some people worry that if they talk about death then that means it’s going to make it happen or it means they are thinking ‘negatively.’ If something is so fearful that we can’t even think or talk about it, then it has a lot of power over us; it occupies a lot of space and energy.”
Ultimately, the goal of QOL is to help people achieve peacefulness in spite of the turmoil and chaos of change that is occurring.
• “If you died today, what would be left undone or unsaid?”
• “Pretend like your loved one died today. Would you have any regrets? A year from now, would you look back at this time and wish you’d said or done something differently?”
• “Hopes change. Your hope has been in the physical dimension, hoping your body would get cured. Tell me about your hopes if that doesn’t happen – your hopes about the non-physical dimension.”
• Relationships: “What would you hope could happen between you?”
Seven Tasks of Living and Dying Healed
Ira Byock provides the first five steps of living and dying healed: forgive me, I forgive you, I love you, thank you, good-bye. I have added two more steps: let go and open up. I believe that the reason you do the first five steps is so you can achieve the last two. At the heart of successfully navigating any change is the ability to let go of same and open up to different. For palliative care patients, I make sure that the first four steps are addressed; for hospice patients, I cover all seven steps.
• “Sometimes people think there’s nothing that can be done. It’s true that nothing more can be done for you physically, but there’s a lot that can be done for healing, for emotional wholeness. There are seven things that will help accomplish healing. All of us have done things to hurt one another. It’s just part of the human condition. Now is a time to reflect on people you may have hurt and consider asking for forgiveness. Think about those who have hurt you, and any hurts you may be holding onto. Consider letting them go, offering forgiveness. Think about whom in your circle of friends and family may benefit from an expression of your love. Think about those people who have impacted your life who might benefit from an expression of gratitude for having touched your life. The next thing is the hardest, but probably the most important, and that is to say goodbye. Say goodbye to all those that you love and want to hold onto. Say goodbye to this world and everything in it and open up to the next world, however you conceive that world to be or not be. Say goodbye to all that’s been the same and get ready to say hello to all that is different. After you’ve done these five things, then your new job is to relax and let go. Open up to all that is new and different that is coming your way. If you are willing to do these things, you will be more peaceful. It’s a good way of living healed too. In fact, I practice this at the end of every day.”
Emotional Pain Scale
• “On a scale from 0-10 where 0 is perfect serenity and 10 is complete turmoil, where are you right now?” Patient describes what the number is. Get them to describe what this means to them. Then, “What needs to happen for that number to be a __ ? (Decrease the number that they give you by 1) What would be different?” (They are revealing to you what they need so they can heal.)
Vision for the Future
• “What hopes do you have for your death?”
• “What would a ‘good death’ look/be like for you?” (…and if that’s not possible? What else?”)
• “What do you need to do to get prepared for your death, whenever it comes?”
• “What do you think death is like?”
• “What do you think life after death is like?”
Power of AND
Try to gain both sides of a story. Invite completeness. Avoid either/or dualism.
• “He sounds like a saint. Can you tell me a little bit about his ‘not-so-saintly’ ways? (This approach counters the “canonized by death” syndrome.)
• “He sounds like a demon. Can you tell me about one redeeming quality that he may have had?”
• “Sounds like things are going great for you. I’m wondering about the times when things weren’t going so great.”
Make sure to distinguish between religion and spirituality:
• “Tell me a little bit about your faith life.”
• “How are you doing spiritually?”
• “Do you feel ready to meet your Maker?”
• “They say ‘there’s no atheists in a foxhole.’ Is hospice a foxhole experience for you?”
• “This can be a very important and productive time for exploring the spiritual dimension, a time to ask questions and seek answers. It’s a time of questing. Would something like that be meaningful to you?”
• “Sometimes religion hasn’t been important to people during their adult lives, but as they’re nearing the ends of their lives, it becomes more important.”
• “Would prayer or a nonreligious inspirational reading be meaningful to you?”
• Offer a hope: “May you have a deep sense of peace and understanding (based on whatever they need) this day.”
Find out what a situation or relationship means by asking questions that tell you the meaning it holds for them:
• “What difference did that make for you?”
• “How has that come to be important to you?”
• “What that tells me about you is that you have been _______ (conscientious, irresponsible, a good role model, a disappointment, etc.)
Distinguish between reminiscence and life review. Reminiscence therapy simply recalls stories; we recall stories automatically when we meet with old acquaintances. Life review therapy, however, goes beyond sharing memories. It adds the component of evaluating what the experience meant. So invite stories and then figure out how they mattered or how they made a difference.
• “Tell me how the two of you met.” After the story, sum up the meaning: “Sounds like he knew what he wanted right away, but you needed a little more time to know what you wanted.”
• “Tell me your favorite story about growing up together.” After the story, offer a meaning: “Sounds like you really looked up to your big brother, that he was your hero.”
• “What’s a funny memory that you will always have about _____?” After the story, sum up what it means to them: “Sounds like you had a good sense of humor, that you were able to laugh at yourself.”
• Comment on pictures in the environment. “It looks like everyone except that little boy on the side is having fun in that picture. He looks a little worried about something.”
• “What does your _____ especially love or appreciate about you?”
• “How has _______ been important to you?”
Affirming Qualities that Promote Healing: Honesty, Humility, Courage
Try to counteract pride, independence, and control by helping people value qualities they have which will transform their experience:
• “It takes a lot of courage to open yourself to your emotions and fears. I admire that.”
• “I appreciate your honesty with yourself and with me. It’s refreshing.”
• “You’re accepting life on its own terms now rather than trying to impose your own. It’s a humbling process. Humility is a good thing, an honorable quality I see in you.”
• “Tell me a little bit about how things went for you in the military.”
• “You probably saw a lot of ugly things in that war. Is there anything that might still be troubling you a little bit now?”
• “Some combat veterans have told me they lost their soul in that war. Did anything like that sort of happen with you?”
• Thank them for serving our country. Honor them with a flag pin.
• If family members have sacrificed because of their loved one’s service, honor them with an American flag angel pin.
• If a person is a Vietnam War veteran, have another Vietnam War veteran pin the Vietnam War beads on them (Go to “tools” section for more information).
Most Pressing Need
• “You’re struggling with a lot of difficulties, a lot of changes. What’s the most difficult?”
• “How can I help today?”
• “What can we do today to improve your quality of life?”
• “Is there anything we can do a little bit differently to make things better?” (Implies that you are open to change and willing to let him tell you his needs.)
Needing to Interrupt
• “I wish I could hear all of that story, but right now I’m wondering about _______.”
• “I hate to have to interrupt you, but I need to know about ______ right now”.
• Provide a warning of approaching time limit: “We only have a few minutes left. Is there anything else we need to know that you can briefly tell us?”
• “Is there anything we didn’t address that you wish that we did?”
• Offer choices for closing:
– Prayer: “What would you like us to pray for today?”
– Hope for the Day: “We can each offer you a different hope for the day. Your job is to just remain silent and absorb our intentions.”
– Tell you how you have impacted us today.
– “Just say good bye.”
General Guidelines for Implementing the QOL Format
Remember, the patient has never died before. They may not know how to do it or what their needs are. Our job is to open the door without pushing: to push damages, to not open the door damages. “Patient-centered care” does not mean that we do whatever the patient says and we’re not on the playing field. Also, we have to be careful that we don’t get prescriptive, thinking we know what this patient needs without their direction and lead. It’s a tension that we negotiate and navigate to get the best outcome.
• Want to hear him, join him. Sit down. Lean in. Have their affect reflect on your face. They should be able to see their words in your face.
• Share the questions. Don’t provide the answer. Make provocative statements and then let the statement hang in the air: “I would think this is pretty scary…”
• Be curious and with wonderment about their experience: “I’m wondering if you’re worried a little bit about what’s going to happen to you?”
• Couple ambiguous words (maybe, might, little bit, sometimes, guess, wonder, usually, possibly, etc.) with direct words that might be threatening (death, guilt/shame, etc.): “It sounds like you might be feeling a little ashamed about what you did…”
• Remember people usually get lots of affirmation for being positive and feeling happy. There’s not always a lot of people to validate their suffering. Validate it!
• Acknowledge any uncomfortableness, awkwardness, hesitancy, distraction that you might be feeling: “I’m a little hesitant to bring this up because I might be pushing into private business, so I don’t want you to feel like you have to answer this, but have there been times when you mistreated your children?”
• For patients that you’ve done several QOLs with, ask them for a question they want us to answer: For example, they might ask us, “What do each of you think about __________?” (life after death, how you would respond if you have to wait for death once you’ve accepted it and death doesn’t come, etc.)
– When to use silence:
a. Whenever the patient expresses feelings: Stop! Just experience the feeling with him/her.
b. After asking a probing question: Real answers take time. Also, a little anxiety in the air helps take the patient deeper into himself. Instead of a superficial answer, a deeper answer often emerges.
c. With older or impaired patients where it takes time to think and respond.
– When not to use silence:
Don’t use silence if it places an expectation on the patient to perform. Try to avoid putting the patient in that kind of situation, but if you do, rescue him from it. For example, you say to a patient, “Do you remember my name?” He might not and it can feel embarrassing or he might feel like he didn’t pass your test of name recall. Instead, say: “I know you meet so many people here and there’s no way you can remember all our names. My name’s Deborah and I met you last week when you were in the hospital.”
• With threatening topics, keep a solemn but light-hearted tone.
• Always reinforce expression of feelings by affirming the honesty, courage, and humility it takes to do so.
Books about Quailty of Life Gatherings
You can read about the lessons that 10,000 dying Veterans taught Deborah during QOL gatherings in her books, Peace at Last: Stories of Hope and Healing for Veterans and Their Families and The Hero Within: Redeeming the Destiny We Were Born to Fulfill.