understanding emotion in death and dying understanding emotion in death and dying

Upload: nastya-lyahova

Post on 07-Apr-2018

219 views

Category:

Documents


0 download

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