Friday, March 29, 2013
I received a very large response to my blog on my sister’s death and my experiences related to it. I received many thoughts, prayers and caring words. Several people said they were going through or had recently gone through similar experiences.
One thing I had to bring to the situation was experience with working with pain management, I always refer to it as comfort management because we actually want the person to learn to put his/her focus on the comfortable bits.
I wrote to a few people suggesting some things that seemed helpful for Debi and I thought I would share them with the larger community. It may be that someone will find a way to bring some of my experiences to their own situations in way that is helpful. This would be my hope, so for what it is worth here are a few of the things that I have found generally useful and easy to learn. I have used these with women having babies to make labour and delivery more comfortable and with dental patients and now with a cancer victim. I will try to keep this short and practical. I would be willing to reply to spark mails in more detail and with more specific ideas about specific situations.
These two links are links to sound files of a guided relaxation exercise. They are the same except for the ending. The Sleep one suggests the person go from the guided exercise to natural peaceful sleep. The active version invites the person back to the current time and situation to wake and be prepared to move on to activity.
These to exercises are often helpful for teaching people to learn to relax specific parts of the body by thinking about the numbers 1 to 5, going through these exercise a few times may teach the subject release tension of the associated part of the body, based on thinking about the number.
Another thing I typically do is to use the experience of Christmas Eve and Christmas day time. If the person was from a different cultural background Christmas might not be the correct metaphor, but each culture will likely have some similar event. I might start with something like the following.
I wanted to talk to you about a Childhood experience of mine, it may be that this will map onto some experiences that you also had, and because we share a common culture, you may be able to follow along as I tell you some things about my childhood, some things that may be useful, and helpful to your current experiences.
When I was a child I knew that Christmas was approaching by the arrival of the Sears Roebuck catalog. This was a magic tomb full of wondrous things. From the moment I opened it time began to slow down. Each day time slowed a little more and time passed more and more slowly. This continued until Christmas Eve when time came almost to a complete stand still. It slow to where it almost stopped.
My little brother and I went to bed Christmas Eve and we told each other six stories, ten jokes had several glasses of water and were told that if we did not go to sleep then Santa was not coming. I looked over at the clock and only 5 minute had passed. Christmas Eve was the longest night of the year.
Then Christmas day arrived and we got to open our stocking, then we opened our presents and it seemed that before any time had passed it was time to go to Grampa and Nana’s and open more presents, before we had time to play with them we had Christmas dinner with turkey, all the trimmings and Christmas Crackers and then it was time to go home and go to bed. It seemed so unfair, Waiting for Christmas to come went on and on and on and then when Christmas arrived, was over it was done almost before it started. It was as if time caught up Christmas day for all the delay in the days and weeks leading up to Christmas.
Now as an adult I have watch my own children go through this same experience. I know they had the same time distortion, Christmas Eve went on forever and ever, and yet I know that within about 30 to 60 minutes of going to bed they were sleeping. I know that they were up early on Christmas morning and that by the time we were done with presents and dinner it was a very long day and yet it seemed to be over in the twinkling of an eye.
This is a common every day experience, you might imagine your own experience as a child and understand that time is not fixed, it can pass by fast or it can pass by slowly and you have done this all your life.
This is extremely valuable for a person facing pain. I will use the simple example of a woman having a baby. Labour may be thought of as a series of rests and contractions in preparation for that final big push, bringing a little life into the world. Too often the expectant mom is focused on the contractions, that is, on the uncomfortable bits.
Well meaning family, and staff ask after the woman shows the distress that is often associated with a contraction, “Was that worse than the previous one?”
This gets the woman involved with comparing the last uncomfortable bit with the uncomfortable bit before the last one. While she should be relaxing and resting and feeling comfortable she is being encouraged to compare the painful experiences to try and decide which was worse. What she should be doing is comparing the comfortable experience to each other deciding which was better.
Another thing she could do is have her contractions in “Christmas Day Time” and her comfortable periods in “Christmas Eve Time”. If you remember a very long day passed by in what seemed to be only minutes on Christmas Day; so how long will a contraction lasting only a minute or a few minutes seem to last? Subjectively it becomes almost imperceptible, just a momentary flash. On the other hand, if the rest periods, the comfortable periods are experienced in Christmas Eve time; then they are dragged out and the comfort is experienced as filling almost all of the process of labour.
I have even had a woman who had “Difficult Delivery” and who describe the experience as very good. When asked about “All the awful things that happened”, her response was, “Oh yeah, there was just a very brief moment where things got uncomfortable.”
Her husband who was on the outside in real time just shook his head.
I will often ask the person about a body part that is not related to the pain. I will use the example of a situation where feet and toes are not involved. Unless there has been trauma or disease involving the feet there is a good chance that the feet will not be involved with the associated pain and discomfort.
I will asked the person, “Which of your ‘Greater Toes’ is more comfortable, the Greater Toe on your left foot or the Greater Toe on your right foot.”
I use a term like “Greater Toe” rather than the more common big toe as this requires just a bit more processing for the person to understand what I mean. This is a distraction technique and adding an extra level of distraction can be helpful. Even when the person has to asks, what I mean by “Greater Toe” I make a convoluted but satisfactory explanation.
I will typically ask with phrases like, “Is it the left toe that is more comfortable or is it the right toe, because if the left toe is more comfortable then it is the right toe and the right to is left just a little less comfortable than the left toe; so I might say the left to is right and the right toe left a bit more comfortable, is that right?”
Again I am very genuinely interested in the person’s response to the questions, and I am wanting him/her to have to do a little extra processing to make sense of what I am asking and to make sense of doing what I am asking.
I will repeat this question interspersed with various other things, what I want to build is a connection between trying in vain to answer my questions and the experience of pain. At a psychological and physiological level I am trying to establish an automatic response to the experience of pain. I want the person to automatically begin trying to figure out the condition of one big toe to the other big toe when ever pain creeps into his/her experience. I am not just saying words and phrases, and using voice tones; I am watching and listening and sometimes touch the person to get responses. This is always, always about response set. If the person begins to tense or show some other sign of experiencing pain, I want to be able to creep in before the pain gets control and have him/her shift his/her focus to the annoying questions of which “Greater Toe” is more comfortable, and a vague question below that of which toe is the right one, to pay attention to. It is okay if s/he is mildly annoyed by my stupid question, this is generally preferable than being annoyed due to the experience of pain and fear.
Many of my exercise are also about imagining you can pretend, or sometimes just pretending you can imagine that you can easily float out of your body, just the little tiniest bit, just enough to get a bit comfortable and for some there may be a warm feeling, or a cool feeling or a tingling or some other interesting and comfortable feeling that you were not aware of.
Please notice that imagining you can pretend or pretending you can imagine often makes it easier for the person to do what is coming next. I have moved this task “Floating out of the body and being a bit more comfortable”, in to the helm of imagination, or pretending, of make believe, this eliminates a lot of opportunities for him/her to think, “Oh, I can’t do that.” I am not asking him/her to float out of his/her body I am only asking him/her to “Imagine you can pretend or pretend you can imagine that you can float out of your body just a little and become more comfortable.”
I am paying in the world of sifting focus, of age regression; of going back to a time when play, pretend and make believe were all as real as actual experience. I what him her to be able to make these shifts easily and in response to his/her own experience, not just to follow my lead.
One other technique that I use is stopping in the middle of a sentence. It is very common for a person to show little signs as pain begins to come into his/her experience. The earlier you can detect the external signs of pain the more you can help. You may get this when holding a hand, typically a person will tense his/her grip as pain comes into his/her experience, you may also notice a slight change in breathing, tension around the eyes or at other locations in the face. When I am taking and I perceive this shift from comfort to pain I will stop what I am saying, and I will wait until the pain begins to subside. Again I am looking for the unconscious cues the person provides, it could be his/her hand relaxes, his/her face softens, his/her breathing begins to return to normal (for him/her). I will then pick up on the next word in my sentence.
We have a very strong unconscious understanding that there is almost no time between two words in the same sentence or thought. Therefore s/he will often experience whatever time happened during the pause as if it was very short or sometimes non-existent.
So my conversation might go as follow:
“how are you doing today, Debi, are you comfortable now?”
“No, I have some pain.”
“So you have some pain, and you know that there is something I want to know, and you know I will likely ask you about the way your toes feel? I will likely ask you about the amount of comfort, the fact that your Greater toe on the right foot is either more comfortable or perhaps less comfortable than the greater toe on your left foot. I know that you know that I want an answer, even though you have not yet determined the answer, I…”
At this point perhaps I notice something in Debi’s physiology that indicates pain, perhaps this is a breathing shift, or a tensing of part of her body, a change in the colour of her skin. This requires paying attention. When she begins to return to normal, indicating the pain is subsiding I will pick up where I paused.
“…am waiting for you to discover the answer, and it is very important to me that you do your best to discover the answer, to tell which toe is right for you.”
It is difficult to provide an adequate explanation in words written on the page, but these things helped Debi to be more comfortable. She had a sense of less pain, of more comfort when I was there. I also tried to have some unique touches. A particular squeeze on the shoulder, different form things she was likely to have had done to her by others. It could also be a touch on the writes or arm, again trying to find something a little different than would be typical, something that unconsciously become a trigger to work we had done and to being able to relax and be comfortable. These touches can be show to loved one who can then trigger them. A squeeze on the writs is often easier than a long explanation of distraction, time distortion, etc. They may gain a placebo effect to help person experiencing pain to respond with comfort, dissociation, time distortion, etc.
Another important point here is that I am inviting you to pay very close attention to the person who is in pain, and who is ill. This involves some risk. You may take on too much of the person’s experience; you may put yourself at risk for both pain and illness. It is therefore important to have some ways of connecting and disconnecting. This might be sitting in a particular chair at the person’s side when doing this. This might be mentally stepping into the roll and out of the roll as you enter and exit the room.
When training a counselor I always taught him/her to develop rituals of moving into and out of the state for working with outers.
Some things that may make sense to some of you are things like matching the breathing of the person. This is a very subtle connection, however, a person like Debi who had lung cancer may not breath in a very healthy way, therefore it may be best to match her breathing with you voice tone, or your body movements not with your breathing.
I have presented some techniques that I know work, that I know where helpful, but they also require that you connect with the person and are able to real pay attention and enter into his/her experience. This sharing in the experience of a person who has a disorder like cancer involves risk. I quite often did some of my Qigong exercise before, and accessed them during sessions and they did some more when I was leaving. I do Zhan zhuang (tree standing) as part of my daily routine. I could easily do this going up and down in the elevator. After daily practice for years it takes very little to make the shift and begin to pull up some of the benefits, so it is surprising how much can be done riding in the elevator.
My hope is that some of this is in some way helpful to someone. I know that it was helpful to Debi and help to make her last days more comfortable. I know she would have like me to have more time for her, but this is really an indication that I was not able to help her generalize things enough and get her to be driving the changes herself. In hind sight I would have pushed a little more to get her to start earlier. This is a balancing act, pushing too much, too early might have changed her focus onto the pain and fear before they were really bothering her, however, the earlier we had started the more she would have generalize things and been able to manage these automatically and unconsciously on her own.
If you have thoughts or questions please feel free to address them as comments here or to send me a sparks mail. I will do my best to provide my thought, such as they are and for whatever they are worth.