Towards a Pedagogy of Love
John Glick, MD
August 18, 2010
I am sitting in a house overlooking the beach in Vichayito on the Pacific coast of Peru, having just finished a morning swim. The waves are big, and currents are strong, but the Niño current, from north to south, is running for the first time in days, rather than the south to north Humboldt current which brings cool winds, bigger waves, filling the nights with a roaring, crashing, thundering, earth shaking pandemonium. Dreams are vivid here, and deep. Body surfing in these waters is intensely physical, like being in a washing machine. My body was tossed and twisted, slammed and spun around, reverse somersaults and pretzeling, out of control for the most part, but I was able to dive under the biggest waves (usually), seeking the path of least resistance, avoiding the wall of water in a 9 foot wave. I loved the thrill, the fear, the challenge of making my way through this potentially dangerous place, using my awareness and physicality to find the still, quiet path through all the forces swirling and crashing around me. Boobies and pelicans glide effortlessly overhead just out of arm’s reach, surfing the wind. They soar and dive, and whales and dolphins breach farther out to sea, all seeking food. Life feeding life here as everywhere. A dead sea lion feeds a group of vultures. I feel love for my wife Nanny sleeping upstairs, and for her mother who has awakened just now. I feel love for my family back in the states, my friends around the world. I feel love for the deep nature which is in me and around me, love for the experience of being alive, love for the ocean, the waves and tides, the moon which pulls them, the sun, the stars, all of life and existence.
Love…I feel love…I love…….the word is so deeply woven into our cultural fabric, that it’s meaning obscured by overuse. To consider the education of physicians, nurses, therapists, psychologists, social workers and all care givers in the practice of loving, is to open a Pandora’s Box of challenges and difficulties. This paper attempts to express some ideas and concepts spilling out of this box, and to describe how such a curriculum might be constructed and for what purpose and for whom.
Being loved and Loving
My earliest experiences of loving, as for almost all of us, were in the context of my family of origin. I was part of a large extended family of loving people. I recall being hugged and cared for, and though aware at an early age of life’s strangeness, bigness, and danger, I always felt wanted, loved, and nurtured. This experience of being loved internalized a sense of being lovable, and also loving towards others. I felt secure enough to reach out to others compassionately, without regard to race, age, religion, or class. My father was a family physician, as was his brother. Their father was a Brethren minister and many of my uncles and aunts were educators. Love and non-violence were ingrained in me through their day-to-day examples.
The love and happiness I internalized in my early life became my own social repertoire as I grew. Athletics and competitive play were not where I excelled. It was in the classroom and playground where I developed my abilities in making friends and generating positive atmospheres through silliness, fun, and play. As an ectomorphic geeky teen, I found that my safety was enhanced by befriending everybody, including the big tough guys. This strategy, eliminating enemies by making them your friends, kept me safe, and, by generating positive, playful atmospheres, also made the schoolyard more safe for others.
I met the community of which Patch Adams was a member my first year of medical school. Their modus operandi was similar to mine, only more intentional and developed. Being friends to everyone, through dancing, singing, art, group play and silliness amidst the providing of free healthcare, these were the means create health in individuals and groups, and also a call for grassroots social change. Loving interactions were mutually healing in many unexpected ways. This group of artists, doctors, carpenters, cooks, nurses, lawyers and pranksters, made use of mainstream and complementary approaches in caring for others, bringing the sick and marginalized into the flow of a vital, loving community, thus enabling healing of mind, body and spirit. Behind the fun, the collaborative work and play, was a deep ethic of loving kindness, and a realization of a more full consequence of being human- the vital necessity of belonging, of participating, of loving and being loved.
My Education Continues
Immediately following completion of my family practice residency, my fiancé and I took a one year backpacking and hitchhiking trip around the world, most of that time in remote communities and sites away from electricity, roads and modern conveniences. We were exposed to cultures much different from our own, yet found commonalities as well. I observed, in these remote settings, the critical necessity of a close, cooperative vital community. I learned that, above all, we are social beings. We die without each other.
Acupuncture and Clowning
After ten years of a conventional and successful family practice in rural Virginia I put down the prescription pad, and have for the last 20 years practiced acupuncture. Acupuncture is a deeply humanistic system of care, where treatments are highly individualized, and based on an intimate explorations into the life experience of the patient. The therapeutic goal is to restore a more harmonious balance both within the patient and between the patient and her world. The needles bring about changes which enable health and reduction of suffering. Current research suggests that the autonomic nervous system is significantly involved in the therapeutic effect. Restoring a fluid, balanced autonomic response to life’s challenges enables the patient to be both receptive and assertive, to give and receive, to act and to restore. Many physical and psychological disorders stem from a dysfunctional autonomic nervous system based on sever or prolonged psychological stress. I learned that the therapeutic effect in acupuncture extends to words, gestures, touch, quiet, play, kindness, nature; in essence every moment has health ramifications.
In foregoing the technology of medicine, I gave myself as fully as I could to each patient, most of them with some sort of chronic suffering. I observed that, in an unhurried encounter, I was able to elicit a deeper and more nuanced history, and to form a more intimate and collaborative bond. I witnessed how attentiveness, presence and love can unfold a person in their “stuckness”, in their suffering. Symptoms lessened or even disappeared as people revealed their fears, struggles, despair, wounds, dreams and hopes in a non-judgmental setting. Their physiologies shift into a receptive relaxed mode, more likely to allow tissue repair, and social bonding.
Gesundheit clowning (spontaneous improvisational play) in over 40 countries has demonstrated the individual and group health-giving effects of compassionate engagement with others. At the bedside, the street corner, the barrio, the subway, the prison, the refugee camp, the expression of loving kindness in the guise of play, silliness, tenderness, touch, and fun benefits both giver and receiver. The clown role, in the Gesundheit model of healthcare delivery, allows the clown/doctor to create an intimate bond with the one suffering. Trust, cooperation, collaboration and friendship flow from the deep empathy of shared fun and play. As Patch says, “Clowning is another way of getting love close.”
Good for You, Good for Me
I stopped my malpractice insurance over 10 years ago. I found, as my understanding of my patients grew, that my fear of them diminished. I found that working closely together builds mutual trust, and a shared sense of responsibility in making difficult decisions. I found that every moment is potentially a healing moment, that we are each medicine for each other. I found that compassion and loving kindness builds bridges between patient and doctor, and that care flows bi-directionally. I love my patients. Sometimes I tell them I do. I often embrace them. I don’t force it. I follow the moment, and try to put myself in their reality, such that I can feel what they feel. I ask a lot of questions until I feel that I understand them. They are my friends, and family. They love me.
Whatever are the effects of loving, much can be learned from observing what happens in the absence of loving. Ask yourself this question- Would you be suffering as much from illnesses, from your anxieties, depressions, moods, difficulties had you been loved intelligently, exuberantly, and wisely by your parents and family? Adult psycho-pathology unquestionably can have roots in early childhood trauma through deprivation or abuse. The experience of not being loved as a child or adult causes psychological suffering and is a factor in childhood and adult depression and anxiety.
Psychological suffering has physical consequence as well. The “Adverse Childhood Experience” study demonstrated significantly increased incidence of adult physical illness in subjects having exposure to early childhood trauma. In Dean Ornish’s book, “Love and Survival”, studies from around the globe indicate a 40-500% increase in all cause morbidity and mortality when people have the experience of not having been loved as children.
Carl Jung, in “Psychology and Religion”, says “….psychic disturbances are far more dangerous than epidemics or earthquakes.” Recall the wars, the genocide, the holocaust, the Soviet and Chinese collectivist terror, the threat of nuclear annihilation, environmental degradation over the previous 100 years, all the result of paranoia, greed, hatred.
Is lack of loving part of the problem here? Or is it THE problem? Individual experiences have a cultural resonance. A societal tendency for overemphasis on reason and intellect unbalanced by loving and compassion is the recipe for egotistical power purposes to go unchecked. And when unchecked, what is the result? The spirit of the time- a frenzy of narcissistic compulsive getting and spending; a media driven fixation with the self, with fear, with power, with competition, with titillation. Yet the emptiness inside can be filled only by a deep sense of connection to those around us, a deep sense of meaning and purpose binding us in solidarity, through trust, companionship, loving and being loved.
Love and Healthcare
When we are sick, when we suffer, this puts us in a sick role. Our normal persona disappears and we experience ourselves in a different way. We become less independent, more dependent; less active, more passive; less vertical more horizontal, less assertive, more passive, receptive. Helplessness, weakness and the threat of loss are distressing. The healer role is constellated when someone is sick or injured. When someone is inured or ill, we care. Our gestures, voices, thoughts, feelings are universally recognized as being those of a caring, healing person. Care flows naturally from an attitude of loving kindness. Care is responsive (Rumi-“When the baby cries, the breast milk flows.”) and flows from the giver to the receiver and back again, in an ancient and personal mutuality, part ritual, part improvisation but always in some way responsive, compassionate and intimate. This is the core of care, of the healing interaction. As Francis Peabody MD says, “The secret in the care of the patient is in caring for the patient.”
No Room for Compassion in McMedicine
The corporatization of healthcare has created a system which is not primarily about care (it’s about management) and it’s certainly not about health (it’s about disease). Disease management relies on efficiency, and can be dehumanizing. People become barcodes. McMedicine exploits human suffering by squeezing the possible penny of profit out of our sick and injured brothers, sisters, children, mothers and fathers. Hand in glove with the economic system of healthcare delivery is the medical technologic industry. Its advances and excellence are unquestionable, but technologies are costly. While technologies advance the reach and accuracy of diagnosis and treatment, they also, due to the high costs involved, result in rationing of healthcare, and a disturbing tendency to further reduce the scope of medical inquiry to those findings that the technologies are designed to reveal. The patient’s personhood is obscured or lost altogether.
The medical-industrial complex is geared towards profitability, and it is phenomenally successful at this. Meanwhile, patients are problems, one per visit, and care givers are cogs in the machine. Physicians are referred to as “providers”, “gatekeepers” feeding the maw of McMedicine to generate as much profit as can be afforded and more. The system is paternalistic, manipulative, exploitative, dysfunctional and unhealthy.
Being a patient in this system is often a humiliating experience. Rushed, impersonal interactions with nurses and doctors; lots of procedures and little by way of explanations; medical mistakes; poor outcomes; unanswered questions; unaddressed concerns; devastatingly huge costs. Patients feel victimized by the very system designed to provide care. And burnout among nurses and physicians is rife, with many choosing to leave the field of medicine. At any one time 1/3 physicians report burnout (depersonalization, emotional exhaustion, and lack of meaning). Suicide rates for doctors are much higher than the national average. If our healthcare system has a heart, it’s heart is broken, as what was once a high calling to serve humanity is now just another job, another way to make big bucks, and unhealthy to its givers and receivers. If any system could use some love, this is it.
Calibrating the Physician
Says Jung, “The marvelous development of science and technics is counterbalanced by an appalling lack of wisdom and introspection.” Our machines and systems are better developed than we are. Goethe’s “Sorcerer’s Apprentice” foretold this centuries ago. Lack of development plus access to power in today’s healthcare gives rise to arrogant, overwhelmed, burned out nurses and doctors. Personal development is given little attention in nursing and medical schools, in comparison to intellectual development. There is little time for Introspection when faced with heavy demands on time and attention. We need a curriculum balancing the technologic and intellectual body of knowledge with one directed towards personal development throughout medical or nursing school, and beyond.
A doctor whose character is underdeveloped is at risk in a profession demanding much of its practitioners. A doctor who is cruel, patronizing, rude, unhappy, burned out, cold or exploitative is in need of calibration. A loving healthcare environment would ease the sense of loneliness and alienation many doctors feel in their day to day work. A curriculum in loving could encourage introspection, self accountability, and thoughtful inquiries into the nature of caring and being cared for, loving and being loved.
A Pedagogy of Loving
If love is so central a concern, so crucial for healthy development of a person, and for a society, why is its discussion so infrequent in medical literature and education? Our reluctance to give credence to the anecdote, the subjective experience, or intuition, in favor of hard data, observable phenomena, the experimental model, RCT’s, evidence based guidelines is evidence for a color blindness in reference to the total human experience. Medicine’s strength is its materialistic, empirical focus, and yet this is insufficient in relating to a suffering fully human being. A suffering person needs care and to feel cared for. To care for others we must be fully engaged in service of the other. We must be able to communicate care by more than our knowing or our intellects. We must bring more of our humanity into the therapeutic encounter; our hearts, our imagination, our vulnerabilities, our not-knowing, our warmth, our concern and our love. We must be willing to encounter difficulties in caring- our limits, our biases, our misuse of power, our conflicts, our powerlessness, our failure to love, our egoism.
What are some fundamental tenets in a pedagogy of loving?
1. Care for patients the way the doctor would want to be cared for.
2. The care giver/receiver relationship must involve a mutual exchange of ideas, needs, and agendas. This is the essence of compassion.
3. The care giver must move back and forth between the objective/rational mode and the subjective/ receptive mode to be truly caring.
4. Giving care in an intention of loving kindness means always using therapeutic power in service of the needs of the care receiver.(Motivational displacement)
5. Care itself must be allowed to work bi-directionally.
The three fundamental tracts of a 4 year medical school curriculum in compassion/loving are:
1) Self study
3) Group work
Self Study can consist of:
1) Reading (see attached reading list)
2) Self directed medical literature searches on compassion, empathic communication, mindfulness, love.
3) Self directed exercises (see Patch Adams document)
4) Composing and presenting a research project on compassionate care/loving and health
Mentoring can involve:
1) Electives, lectures, symposia or rotations with clinicians/instructors in medicine, nursing, complementary medicine, hospice care, community health, and other care settings
2) Individual or group therapeutic encounters with psychologists, social workers, psychotherapists, shamans, etc directed towards development of psychological, spiritual awareness and development
3) A faculty body directing individual students and groups in self or group study exercises; overseeing the curriculum; identifying and working with students at risk
Group work can be:
1) Classroom lectures on core principles and research on compassion/ love
2) Grand Rounds, symposia, visiting professorships and journal clubs concerning compassion, love, meaning in medicine, psychosomatic medicine, medicine in literature and art, medical ethics
3) Large group exercises (parties, service projects, dinners, creation of music/art/theater programs,
4) Small groups, with a faculty advisor, meeting regularly to:
a. Provide support
b. Discuss and explore exercises in loving and compassionate care (see patch Adams document)
c. Receive training in yoga, tai chi, and other complementary therapies
d. Have Balint group sessions to enhance emotional intelligence, develop empathic communication skills, self awareness
e. Design and complete research projects on loving
Students must be developed as well as instructed. This requires difficulty and risk. It’s not easy for young people to relinquish ego, and to be vulnerable in difficult situations. This requires that the process be fun, enjoyable, interesting, challenging, and that it connect deeply to the needs and hopes of students and educators. There will need to be modifications and redesigns to best meet the needs of students and the talents of educators. The goal should be that every student completing the curriculum would have enhanced self awareness, skills in empathic, compassionate care, strategies for loving, and strategies for building health-giving families, medical practices, workplaces and communities.
Several questions immediately arise.
How best can loving be taught? How much didactic? Experiential? Reading? Grand rounds?
Will students be graded? What will happen with students who cannot love or give compassionate care?
Should the educational system giving instruction in loving (and its instructors) be loving itself/ themselves?
How do we develop ourselves, calibrating our full human potentials to be loving, healthy and highly skilled physicians and nurses? What is the optimal role for our medical/nursing schools?
Can loving skills be taught? Strengthened?
Is there a choreography of caring? Of loving?
Are there exercises which enable loving and compassion?
Is there a science of loving? An art?
Are there physiologic, measurable parameters for loving and caring?
If so, can they be induced?
Are there sociophysiologic and/or psychological laws for loving? For giving and receiving care?
Is love contagious?
Can love have side effects?
Is there a minimal daily recommended allowance for love?
How do we love who we do not like?
Are there contraindications to loving?
How can we develop an epidemiology of loving? How can we extend loving education into families, communities, society?
Can compassion be a central interest and action in your life? If so, how?
How can we design a healthcare system, a community, a school, a society from which love, justice, balance, harmony, and deep sustainable health is the natural outcome?
The Love You Take is Equal to the Love You Make
It is said that human beings go crazy in herds, and wake up only one at a time. The patient/doctor one-on-one interaction is a potential setting where a person can wake up from the madness, but we as doctors and nurses must first ourselves wake up, for we are caught up in the madness as well. A humanistic comprehensive view requires that we ourselves become aware of our own totality, our conscious and unconscious attitudes, motivations, biases, limitations, strengths, for these we bring to our encounters with others. Unless we are fully aware of them, these unconscious forces intrude into our lives as compulsions, moods, addictions, neuroses, depressions, or obsessions. The awareness which comes through thoughtful self reflection, and the support from a vital, loving community frees us up to live more creatively and compassionately. The more deeply we know ourselves, the more deeply we can know, understand and love others. Loving requires courage, curiosity and the willingness to be vulnerable. Love grows by giving love, loving our difficulties for this is how we grow; loving all people everywhere, for each is a mirror; loving our whole selves, for we each carry the entirety of our cultural inheritance in us; loving our world, for we are each part of the whole fabric of life.
The sun is setting below the Pacific horizon now at Vichayito. Pelicans and boobies are diving for their last feast of the day. A humpback whale breaches a mile from shore. Under the ocean surface, the night time version of the eternal dance of life and death begins. The tide is coming in. Big waves pound the shore, and foam dissolves into the sand. Men came and buried the dead seal, much to the relief of those of us nearby, but to the disappointment of the vultures. A cloudless sky is ready to deepen into night, and the moon will be almost full. I have a sunburned nose. The current has changed from the Nino to the Humboldt bringing cooler air, choppy seas and a wind from the south. Perhaps the current in healthcare can shift from the narrowly focused individualistic, profit-obsessed morass that we have now, to a community centered, compassionate way to care for others. In the meantime, perhaps we can seed our profession with loving care givers, and slowly, one by one, help our patients and colleagues to awaken from this collective madness causing us to fear, exploit and hate one another. As for me, I love being alive. It’s been a wonderfully simple day of walking, eating, resting, writing, being alone, being together, loving our only world.