understanding emotion in death and dying understanding emotion in death and dying
TRANSCRIPT
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
1/18
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
2/18
condition The doctor was quite aware that this was contrary to the patients wishes. His efforts
continued successfully even after a coronary occlusion which complicated the picture. He fought it
as successfully as he fought the pneumonia and infections. When the patient began to recover from
all the complications, the question arose---What now? He could live only on the respirator with
twenty-for-hour nursing care, unable to talk or move a finger, alive intellectually and fully aware of
his predicament but otherwise unable to function. The doctor picked up implicit criticism of his
attempts to save this man. He also elicited the patients anger and frustration at him. What was he
supposed to do? Besides, it was too late to change matters. He had wished to do his best as aphysician to prolong life and now that he had succeeded, he elicited nothing but criticism (real or
unreal) and anger form the patient. We decided to attempt to solve the conflict in the patients
presence since he was an important part of it. The patient looked interested when we told him of
the reason for our visit. He was obviously satisfied that we had included him, thus regarding and
treating him as a person in spite of his inability to communicate. In introducing the problem I
asked him to nod his head or to give us another signal if he did not want to discuss the matter. His
eyes spoke more than words. He obviously struggled to say more and we where looking for means
of allowing him to take his part. The physician, relieved by sharing his burden, became quite
inventive and deflated the respirator tube for a few minutes at a time which allowed the patient to
speak a few words while exhaling. a flood of feelings when expressed in these interviews. He
emphasized that he was not afraid to die, but was afraid to live. He also empathized with the
physician but demanded of him to help me live now that you so vigorously tried to pull me
through. The patient smiled and the physician smiled. There was a great relief of tension in the air
when the two where able to talk to each other. I rephrased the doctors conflicts with which the
patient sympathized. I asked him how we could be of the most help to him now. He described his
increasing panic when he was unable to communicate by speaking, writing , or other means. he was
grateful for those few minutes of joint effort and communication which made the next weeks much
less painful. At a later session I observed with pleasure how the patient even, considered a possible
discharge and planned on a transfer to the West Coast if I can get the respirator and the nursing
care there.
In my personal experience I have seen little growth in the ability of physicians to confront death in
a rational and caring manner. There are many reasons for this. One major one is a little noted factthat most physicians do not have all that much experience with death. For many death is a rare
experience. In the United States there are 828.4 deaths for each 100,000 people each year. That is
something over 2 million deaths a year. Gross division would show that is about 3 deaths per year
per physician. The U.S. mortality rate from heart disease was 382 per 100,000 per year for men and
214 for women or a total of about 1.6 million due to heart disease. In other words out of the 2
million deaths per year 1.6 million are due to various consequences of heart disease or nearly 75 per
cent of deaths and heart disease causes death in many forms, many of them sudden and unexpected.
So many, many physicians will not experience any deaths in a given year and if so many of them
will be sudden or, although in a medical setting, have no bearing on Dr. Rosss book in that they
will involve children, newborns and accidents. Medicine is, obviously, a very applied craft. It is
quite possible for a medical student to never experience a death during medical school and never
experience a resuscitation. What meaning then does a curriculum on death have for them?
For the attending physician each death is peculiar to the patient. The admission comes
unexpectedly. The physician is not prepared. The patient is not prepared. The diagnosis is not
secure. The focus is still on life and not death. The death this six months is a sudden MI in a 40 year
old, the next is lost in an oncology referral, the next is an Alzheimer patient in a nursing home and
only then might we come across a classic case admission, workup, fatal diagnosis and the process.
It is of interest that the first example of a doctor - patient encounter: that of Mr. P. is striking in
that it is not about death at all but about life. The man does not die. One can take away from the
story the horrible idea that the only thing killing the patient was the system. Only when the Dr. and
the Patient understood what they felt and what their true interestshould be did the problemsresolve. It is extremely important here that she uses this example as she says that the doctor called
the consult more for himself than for the patient.
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
3/18
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
4/18
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
5/18
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
6/18
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
7/18
\I/
Leads to a The highly individual state of being based on real time stressors
that elicit negative feelings added to any recalled memory that elicit
negative feelings.
I
\I/
Leads to acceptance.
Why do I make these changes? I make them on the basis of a theory called Affect Theory developed
by Silvan S. Tomkins and added to by Dr. Donald Nathanson. What I wish to now do is give a brief
overview of that theory. I will then reinterpret the five stages showing how my initial
reinterpretation is simply one of many profiles a patient might have.[ You may skip this summary
of the theory if you wish altogether and go to the end of the paper where it says END OFSUMMARY or simply come back to this later. I put it here for those that might feel a need for
some "grounding" for what I have so far said to this point.]
A SUMMARY OF AFFECT THEORY
There are said to be 9 human affects, which may be translated into 9 emotions, which are
biological:
Joy
Interest positive affects
--------------
Surprise neutral affect
---------------
Anger
Fear
Distress
Disgust negative affects
Dismell
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
8/18
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
9/18
theory, that we only have these responses. We have no say in the matter they are a biological
response to environmental stimuli.
In basic biology one studies stimulus - response patterns
Basic High School biology teaches us :
stimulus-------> response ---------> to this point we are at the mercy of the world. Then:
-----------> AWARENESS
Only when we become aware of the affect can we take action on it.
stimulus ---------> response -------------> awareness ------------- ACTION
This action can be any learned behavior.
This is a continuous process as nearly every waking moment we are experiencing some affect.
--------> stimulus ------> physiologic response (affect)------>
cognitive awareness of the feeling of the affect-------> action
Nearly every moment of time we are experiencing some affect: being affected by the environment,
responding physically to it, processing the feeling and , acting on the feeling.
So what is the change? It is instead of simply stimulus-reponse it is stimulus- one or more of
our affects(feelings)-and then and only then a response.
++++++++++++
Our wish is to accentuate the positive and eliminate the negative
Maximize positive affect or feeling
Negative affect is, however, very powerful.
We have no choice but to experience negative affect. So to be accurate we cannot eliminate it. We
want to minimize and mutualize it.
What we are feeling is not me. Me or I become aware of the affect. The self can be thought of
as me minus affect, but I can only experience the world through affect. In any Marshall art or
meditation what we are after is a state of readiness to respond. It seems to me that these systems,
then, intuitively understood the biology of emotion. We can never be at zero (although this is
debated within those that explore the theory) in all emotions but we can become hyper-aware of our
emotions.
We do not all experience emotion in the same way. For example, anger. If we put all the 9 affects on
a scale of 0-10 it seems to me that some people have a higher setting than others. Some people who
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
10/18
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
11/18
I
I
I
I
I
ATTACK OTHERATTACK SELF
I
I
I
I
AVOIDANCE
The shame response can be INTERNAL or EXTERNAL, It is biological... It is before
awareness and action .
A study was done of babies in which a light was put to one side, it was colorful and went on an off.
The babies where taught to turn their heads three times for the lights to go on. Then the light didnot go on and the babies had a biological response of shame-: head down and to the side, eyes
averted. That is the expected response would be for the head to simply go back to a neutral position
or for them to keep looking at the light, but since they where interested in the colored lights and
now knew, or thought they had control over them they experienced shame when that control (and
interest) was interrupted. I experienced this acutely the other day when talking to someone that
means a great deal to me and I had to tell him I could not tell him something due to confidentiality;
My head very forcibly turned down and away and I had to consciously force myself to look at him
again. It is not bad or good it just is.
Shame is neutral it is simply the interruption of your interest. How you handle it, what you think
about it, what feelings follow it depend on what you have learned about the feeling as you havegrown. And, of course many of our experiences with the feeling of shame have not been good and
have resulted in us learning to handle the feeling with actions that can be described in the
COMPASS OF SHAME:
WITHDRAWAL
( FROM TURNING YOUR ATTENTION AWAY FROM A GROUP TO LEAVING TOWN)
I
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
12/18
I
I
I
I
ATTACK OTHER) ATTACK SELF
( MILD DISGUST TO MURDER I ( SELF DEGRADATION I AM DUMB , TO CUTTING, TO
SUICIDE)
I
I
I
AVOIDANCE (DRUGS, ALCOHOL, SEX, WORK)
Shame HURTS, we do not want to suffer it so we will do most anything to avoid it. We do not
recognize it. Shame has never been described as the lynch-pin as it is here. If you accept it as
central to affective life it explains in great detail most human behavior whether it be positive or
negative.
++++++++++++
SHAME is only elicited when there is an impediment to sustained interest or joy.[END OF
SUMMARY]
1) Involved in a good conversation and the phone rings. 2) A toddler with his mother: He sees you,
you say hi he goes behind his mothers leg and peeks at you: sustained interest while receiving a
negative stimuli: your strangeness 3) The guy you are doing business with is not responding. 4)Your partner behaves continually in ways you do not understand: You are giving them bad vibes
or they are carrying bad scripts that dont fit yours.
INTEREST ++++++ +++++POSITIVE STIMULI
III
III
III
III
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
13/18
III
III
\/
SUSTAINED INTEREST============= > SHAME
/\ I
NEGATIVE STIMULI
SHAME LEADS TO:
WITHDRAWAL
I
I
I
I
I
ATTACK OTHER ATTACK SELF
I
I
I
AVOIDANCE
What we want to do is, in a sense, take the hit. We want to realize that this hurt or shame isfirst a physical feeling that is giving us information and that avoiding the hurt by doing one of the
four things the Compass of Shame offers but will only make things worse. We need to look to why it
hurt us and remove the impediment so we can renew our interest or get back to joy. SHAME is
only elicited when there is an impediment to sustained interest or joy.
+++++++++++++++++++++++++++++++++
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
14/18
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
15/18
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
16/18
The third stage is of Guilt it is, again, a highly individual scripted stage. One may or may not have
guilt. If one does it will elicit more negative affect and a sustained feedback loop may be set up.
Guilt engenders more shame, shame more anger, anger more shame or any number of responses.
Each will be married to a scripted response in the world of withdrawal, attack other, attack self or
avoidance.
The fourth stage of Depression then, is simply a continuation of the first three. If it is the same
why is it expressed as a different stage? I think it is because the patient acts definitely. Things
become overwhelming. The internal storm is peaking and the initial actions (scripted behavior) by
the patient to ward off the inevitable are not working. The knowledge of the ineffectiveness of these
actions actually brings on new shame and a new cycle of shame, negative affect, memory and guilt
but now the options on how to act are limited. We have gone around the circle. We have
withdrawn, we have attacked ourselves and others and we have avoided. There is only one thing left
to do and that is to accept. To accept in this situation takes on new meaning. Here we cannot
remove the impediment so that our interests may continue. Surprise, anger, fear, disgust, dissmell
and shame abandon us as useful informative tools. Interest, the ace in the hole, that has always
pulled us out of the rut before abandons us. What then can we do? To me this is still a mystery. We
are left with a self: As Ross says Acceptance should not be mistaken for a happy stage. It is almost
void of feelings. Throughout this exercise reason has been mute. Affect Theory shows us thatemotion is king and will do what it will do unless we take special pains to understand it. It seems to
me that those that die in peace have in some sense triumphed over emotion either by a belief in an
after life that, after whatever negative affect they have suffered has subsided, will produce a
calming of the brain that will produce a sense of joy or we have come to simply a reasoned end
(although to use reason, we must couple it with the emotion of interest) using the uniquely human
ability to dominate emotion at crucial times and ironically well expressed in this poem:
THE LAST DECISION
by Maya Angelou
The print is too small, distressing me.
Wavering black things on the page.
Wriggling polliwogs all about.
I know its my age.
ll have to give up reading.
The food is too rich, revolting me.
I swallow it hot or force it down cold,
and wait all day as it sits in my throat.
Tired as I am, I know Ive grown old.
Ill have to give up eating.
My childrens concerns are tiring me.
They stand at my bed and move their lips,
and I cannot hear one single word.
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
17/18
-
8/4/2019 Understanding Emotion in Death and Dying Understanding Emotion in Death and Dying
18/18