Annual Reflections In Depth Perspectives

scanner Art by Richard Lance Williams
This Issue: Health & Well-Being

The Poesis of Dying

Image and Ritual in Hospice Care -Gene Toews

“It seemed to him that he and his pain were being thrust into a narrow, deep black sack, but though they were pushed farther and further in they could not be pushed to the bottom . . . He wept on account of his helplessness, his terrible loneliness, the cruelty of man, the cruelty of God, and the absence of God . . .  Why has Thou done this:  Why hast Thou brought me here? Why, why dost Thou torment me so terribly? ...‘What is it you want?’ was the first clear conception capable of expression in words that he heard. ‘What do I want? To live and not to suffer,’ he answered…. ‘To live? How?’ asked his inner voice. ‘Why to live as I used to –well and pleasantly.’  ‘As you lived before, well and pleasantly?’ the voice repeated…. He suffered ever the same unceasing agonies and in his loneliness pondered always on the same insoluble question: ‘What is this? Can it be that it is Death?’ And the voice answered: ‘Yes, it is Death.’  ‘Why these sufferings?’ And the voice answered, ‘For no reason—they just are so.’1

The poesis of dying. These words, poesis and dying, fit wonderfully well together in myth and literature. But in the embodiment of death?  Death is palpable. One can hear it, see it, smell it. And as death penetrates the mucosa of one’s mouth, taste it. Death. Take a moment and say it out loud. Death. It’s not a warm, comforting sound. Death.  It resonates the chill of chthonic depths. Cold and harsh.  Or perhaps parched and dusty as in Sumerian mythology. Death is the eyes of Erishkegal, fixed upon her sister Inanna, but only after Innana had been stripped of all that had defined her. It is a rape of innocence ala Persephone. To be fair, none of my patients have feared death. Death is, as we shall see, a time of mysteries and miracles. It is death’s journey, the dying process, Innana’s descent, which produces anxiety.  It is as if one was flying to the most wonderful and exotic of lands, and could hardly wait to get there. But were afraid to fly. 

I have been with countless patients during their dying process. I’ve always been struck by the similarity of dying patients’ faces to the image Edvard Munch depicted in his famous painting “The Scream.”  Munch was heavily influenced by the deaths of his mother and sister in this work. What strikes me is how he describes it:

“I was walking down the road with two friends when the sun set; suddenly, the sky turned as red as blood. I stopped and leaned against the fence, feeling unspeakably tired. Tongues of fire and blood stretched over the bluish black fjord. My friends went on walking, while I lagged behind, shivering with fear. Then I heard the enormous, infinite scream of nature.2 ”

This is descriptive of an encounter with what Rudolf Otto describes as the Mysterium Tremendum. He notes that it is “…hidden and esoteric, …beyond conception or understanding, extraordinary and unfamiliar.”3   Otto further describes a “numinous awe,” that “…first begins to stir in the feeling of ‘something uncanny’, ‘eerie’, or
‘weird.’”4 “It implies that the mysterious is already beginning to loom before the mind, to touch the feelings.”5 He emphasizes the palpability of this process.6 This palpable feeling is experienced as something “…’wholly other’, …that which is quite beyond the sphere of the usual, the intelligible, and the familiar, which therefore falls quite outside the limits of the ‘canny’, and is contrasted with it, filling the mind with blank wonder and astonishment.”7 And it leaves one with a sense of being absolutely overpowered by something so totally alien to consciousness as to be unfathomable. So overwhelming is the encounter that “… there is the feeling of one’s own submergence, of being but ‘dust and ashes’ and nothingness.”8 This is death.

It is here, in the liminality between here and there, that death’s tension, what Otto would term the tremenda majestas, or aweful majesty, is experienced.  Actually, the “and” should be italicized: here and there. This between space is the space of soul. Soul is perspective. It is the reflective moment between: between oneself and one’s experiences, between the doer and the deed. It is the space between self and other. Soulful reflection deepens events, changing them into experiences. Between oneself and one’s experience of death is the space of Soul, the moment of Self-reflectivity. This is the moment of Soul mirroring back to us the dimensions of its own objective reality—“What is it you want?” “To live as you lived before?”  In this moment, Soul reflects back one’s alienated otherness, those parts of being from which one has become disconnected. And it is the resultant soulful tension that makes poeses a verb, and helps one navigate the otherworld journey, paradoxically giving peace and comfort.    

Poesis, the language of soul.9 Poesis makes dying peaceful. Poesis is the words of death gently leading one through the tensions of liminality, past the alien otherness of ego’s fears and which lie deep in the memories of human experience and thereby within each of us individually, safely to the Self. Listening with an imaginal ear, one hears Orpheus singing to Eurydice, not for a reassuring glimpse of her living presence, but in my revisioning, to allow his music to envelope her and ease her journey back from whence she came. Mythologies one recalls, do not speak of things that should be. Rather, they are tellings of what is. Once claimed by Death, one can truly never leave—as Persephone reminds us. What if (remembering that “what ifs” lead us to the imaginal realms) Orpheus could do no other than violate the taboo against turning to look for Eurydice, and thereby return her to her where she more properly belonged. Remaining in the tension of death’s poesis, allows for this ease of death’s journey. It is here, in the tensions of this place between, that I as a hospice Social Worker enter the lives and deaths of my patients and families.

Before I continue further, let me tell a little about myself. I am a Licensed Clinical Social Worker, and a Cultural Mythologist with graduate degrees from the University of Denver and Pacifica Graduate Institute. I’ve maintained a private psychotherapy practice for over twenty-five years, and for the past seven, have worked as a Social Worker for a large, metropolitan hospice. But this would be incorrect.  I am a therapeute employed by Death. The word therapy derives from this word, therapeute. It means servant of the Gods. Michael Kearney writes of the function I would have served in ancient Greece: tending patients seeking healing at the Temple of Asklepios in ritual manners.10 It is the function I serve today. And so it is Death I serve, and perhaps the ritual functions I perform are as much for it as for my patients. 

At this point, let us take a brief excursion to the course called Hospice 101. Hospice care originated as places of refuge for weary travelers, safe places where one could sleep, eat, and heal from the rigors of the journey. The word hospice derives from the Latin hospes, meaning to host a guest or stranger. An online history of hospice from the Amitahbha Hospice Service website notes: 

“In Europe with the spread of Christianity, monasteries started to take in the sick and those disabled and unable to support themselves. Then wealthy women and widows in the 6 & 7 century started working in these monasteries as the first ‘nurses’. In Medieval times, at the time of the Crusades, 1095 to the end of the seventeenth century, weary travelers found places of refuge in monasteries and nunneries. Often they were in ill health and many spent their last days cared for, by the monks and nuns and lay women.”11  

It has evolved from these origins.

Hospice care today has only three, simple, eligibility requirements:  (1) a terminal diagnosis, (2) a physician’s prognosis of six months or less, and (3) the acceptance that once one becomes a hospice patient, they will no longer pursue aggressive treatment for their hospice diagnosis. And that’s it. In terms of a diagnosis, this can range from more definitive illness such as cancer, heart disease, lung disease, etc., to those more amorphous such as failure to thrive and global decline. And in terms of a prognosis of six months or less, this is often “crystal ball gazing,” meaning its not rocket science, but rather a good faith opinion of the physician. More importantly, is the patient and family’s response to these requirements, especially to the prognosis of six months or less and the willingness to forego aggressive, curative treatments. For many, this is not an easy decision to come to given the medical zeitgeist of preserving life at all costs. 

I ask you now to take a moment, reflect on your own life, or that of your loved ones. Imagine being presented with this decision—what would it be like? There is no right or wrong. It just is. Some are relieved they “no longer have to fight.” Some feel abandoned by the medical community—consigned to death. Others feel an extreme guilt as if they are condemning loved ones to die. And still others believe loved ones have “given up.” Again remember, death is a hypothetical possibility, until…. Whichever possibility presents, it is pregnant with tension.

Hospice care begins with a suggestion. A doctor, nurse, caregiver, family member, friend, or perhaps the patient him/herself says the words, “perhaps its time for something else, for a different kind of treatment.” Or, “I can’t do it anymore, I’m too tired.” Eligibility for hospice care is very simple, really. All that is required is a terminal diagnosis and a physician’s prognosis of six months or less. 

Before the suggestive words are spoken, death is a hypothetical reality. Yes, we all know we’re going to die. And if one has a serious illness, that reality is hypothetically more real. But. And this but is crucial to life. But not today, probably not tomorrow, next month, or next year. Not now, and probably not ever. Truth be told, this is the way most think (more likely don’t think) about it. Until the words are spoken: “There is nothing more to be done.”  And with this poesis, death speaking, a series of calls are made which initiate hospice care.

Not long after, I receive a clinical picture, images of this particular patient/family’s initial steps along death’s path. What strikes me is the ritual manner in which this picture is given. It’s always the same information, in the same order, with the same words with the same tone of voice. I’ve come to experience it more of an incantation than a clinical report.  I imagine an alchemist from centuries before, talking to him or herself, “The prima materia is …, and to it I add a tincture of this, and a tincture of that, and I heat the mixture to x degrees for y amount of time.” I am given invaluable information, for in this report I’ve learned to expect what symptoms my patient might experience, what lies just on the horizon, and what lies beyond. I can tell what medical interventions will be needed: tinctures of comfort inducing medicines for pain, anxiety, shortness of breath, etc. to alleviate the heat of suffering from not being able to breathe (dyspnea), pain, anxiety/agitation resulting from other medicines and/or disease processes, etc..  And perhaps most importantly, I locate the portal to the otherworld.

It’s always the same with each patient and family. With this information, I encourage my patients and families to take their first, faltering steps into the abyss. Where the alchemist used tinctures, heat, etc., I use words. Rather, I should say, I weave words together ritualistically. Some years ago, I studied Ericksonian hypnosis. I learned how to use words and silence -- how to mirror words used by patients and families in ways that begin to pace emotional and cognitive processes, how to modulate or moderate these processes, and how to lead one to greater senses of calm and stability when feeling distressed. 

Words are powers. Here, one recalls the lessons of Isis:

“From a number of passages in the texts of various periods we learn that Isis possessed great skill in the working of magic, and several examples of the manner in which she employed it are well known. Thus when she wished to make Ra reveal to her his greatest and most secret name, she made a venomous reptile out of dust mixed with the spittle of the god, and by uttering over it certain words of power she made it to bite Ra as he passed. When she had succeeded in obtaining from the god his most hidden name, which he only revealed because he was on the point of death, she uttered words that had the effect of driving the poison out of his limbs, and Ra recovered. Now Isis not only used the words of power, but she also had knowledge of the way in which to pronounce them so that the beings or things to which they were addressed would be compelled to listen to them and, having listened, would be obliged to fulfill her bequests. The Egyptians believed that if the best effect was to be produced by words of power they must be uttered in a certain tone of voice, and at a certain rate, and at a certain time of the day or night, with appropriate gestures or ceremonies. In the Hymn to Osiris it is said that Isis was well skilled in the use of words of power, and it was by means of these that she restored her husband to life, and obtained from him an heir. It is not known what the words were which she uttered on this occasion, but she appears to have obtained them from Thoth, the "lord of divine words," and it was to him that she appealed for help to restore Horus to life after he had been stung to death by a scorpion.”12

Let me reemphasize: the words I speak are carefully chosen, “uttered in a certain tone of voice, and at a certain rate, in a ritualistic manner.” I often have wondered, from whence do these words come:  do they come from me, or from another place in time, from another dimension? Are they my words, or those of the deity I serve? One recalls that Hermes, the messenger of the Gods, used not his words, but those from whom the message was received. 
       
Throughout this process I follow psychic energies. I enter into that imaginal place of and between here and there. Here resides the psyche of Soul, if this isn’t too redundant. It is the psychic space of Soul’s poesis. From a human perspective, these words normalize experiences with the ineffable—that which is beyond words. They organize and order what feels, and is first and foremost, out of control. I often wonder how the myth would have been different had Orpheus received words such as these, words of comfort and support that make it possible to encounter that which is “wholly other.” Or perhaps he did, but as suggested above, he could do no other. Finally, and most importantly, these words touch the humanness of life. 

Daily I walk with Inanna, through the seven gates where at each the gatekeeper asks: “Who are you and what is your business?” At each Inanna is required to discard a representation of her identity before she can pass through. In response to her protestations, she hears:  “Quiet, Inanna, the ways of the underworld are perfect. They may not be questioned.”13 Arriving at her destination her sister Ereshkigal “fastened on Inanna they eye of death.”14

Inanna’s descent gives witness to the losses, small and large, required along death’s journey. It is never easy to not be whom one once was:  to not be able to feed oneself, to toilet oneself, to stand or walk, to sit upright, or even to change one’s position in bed. It is generally an experience of humiliation and degradation. All too quickly one loses the functional ability to do the small things, such as being able to reach the water glass, or the inability to hold it, or to suck through a straw. Add to this the frustration which results from cognitive impairment when one hears words spoken to them, but either is unable to understand their meaning, or more excruciatingly painful, unable to formulate and articulate a response.  

Death, you see, is most often a process rather than an event. One dies over time, in small increments. Passing through death’s gates, one hears the same question: “What is it you want? To live well as you had before?” Initially, this is heard as a mocking—perhaps for many it is thus intended. As one progresses along the way, the words become more comforting: “Do you really want to live as you are now? You know, you don’t have to.” My patients are not their diseases, or their loss of functional abilities. They are humans with rich and storied lives. I’ve come to a greater understanding that what one normally thinks of as consciousness is just the tip of the iceberg of what it means to be human. And here I refer not to the objective psyche in a general, impersonal sense, but to each individual’s connection with it. For example, I’ve had countless patients, with severe dementia, and whom are unresponsive, time their death to correspond to visits from loved ones. It’s as if they were able to watch a clock.

It is this depth of human experience I hope to acknowledge and be present with in each of my patients. In other words, I attempt in a small way, to transcend death’s alien, wholly otherness and return the dying experience from an object to what Martin Buber writes of as I and Thou.  

Maurice Friedman, in his introduction to Buber’s Between Man and Man, writes: “I-Thou is a relationship of openness, directness, mutuality, and presence.”15 He contrasts this with the sense of otherness inherent in an I-It relationship: “I-It, in contrast, is the typical subject-object relationship in which one knows and uses other persons or things without allowing them to exist for oneself in their uniqueness.”16 He continues to elucidate the I-Thou relationship: “It is … the response of one’s whole being to the otherness of the other, that otherness that is comprehended only when I open myself to him in the present and in the concrete situation and respond to his need even when he himself is not aware that he is addressing me.”17 Add to this, Buber’s own words: “The world as experience belongs to the basic word I-It. The basic word I-You establishes the world of relation.”18 And he continues, “Experience is remoteness from You.”19   

My sometimes feeble attempts to be a human connection with my patients and families, are, if I can say without sounding too hubristic, attempts to move the disease progression and dying process from one experienced as an alien otherness, to a soulful poesis of connection with these as Thou. Note the emphasis on “to be a human connection.”  This is a verb—all of it. It is actively doing what I learned as a baby Social Worker, “the conscious use of self.” And it happens in the liminal space of the and -- I and Thou. Friedman notes “… this emphasis on the ontological reality of the ‘between’ and upon the possibility of experiencing the other side ….”20   

This changes the dying process from an experience of something happening to one, to a relationship with it. It takes dying from a remote otherness to a relationship that is an intimate and natural part of living; death becomes a friend and mentor. Here, as Buber suggests, one claims their identity as a human: “I require a You to become; becoming I, I say You.”21 Death, to borrow from Friedman, leads us into relationship with it, to meet it openly and directly and with respect, and to transcend it’s feeling of alien otherness by the process James Hillman terms personification. 

Hillman introduces his chapter on this process in his Revisioning Psychology in just the terms I’ve been discussing: “For to give subjectivity and intentionality to a noun means more than moving into a special kind of language game; it means that we actually enter into another psychological dimension. The noun takes on consciousness, it becomes personified (emphasis added).”22 Reflect on this for a moment. The noun “death” takes on consciousness -- it becomes personified. It becomes Thou, specifically, a form of consciousness that leads one into the depths of an intimate relationship with it. Meeting with families, I often introduce talking about the dying process in this manner: “Its like death is a person; as we approach it, death approaches us, to make friends with us, to help us not to be so frightened.” And this action on the person know as death, turns it from a noun to a verb. More specifically, this intimate I-Thou relationship with death personified leads to death’s poesis—soul making. Hillman asserts, “…personifying is a way of soul-making.”23  

Beginning with my initial contacts with patients and families, I work to create a ritual space. And I do this predominantly with words. Words, as we’ve seen, are powers that lead us to the poesis of death’s intimacy. As Ivan Ilych, in the opening quote, one dialogues with death. Friedman comments on this exchange of words, particularly as Buber would have us understand dialogue as necessary to this process. He notes that Buber terms it an “act of ‘inclusion’”24 and writes: “Dialogue is not merely the interchange of words—genuine dialogue can take place in silence…. It is … the response of one’s whole being to the otherness of the other, that otherness that is comprehended only when I open myself to him in the present and in the concrete situation and respond to his need even when he himself is not aware that he is addressing me.”25         

This dialogue is intended to create a temenos, a sacred and ritual space within which patients and families can be present with death. It is created with words, “uttered in a certain tone of voice, and at a certain rate, in a ritualistic manner,” to create a vessel of psychic containment within which to hold patients and families as they encounter and enter a relationship with death and the dying processes. 
  
I’ve always liked the words, psychic vessel of containment. They evoke images of a womb, a mandala, an urobos, and the alchemical vessel.  It is an imaginal space, woven in the space of that ontological reality of the encounter of the between. This imaginal space is the temenos of death’s epiphany. It is created through the ritual use of words and images, which simultaneously allow one to safely enter it.
       
Mythologically, sacred space is dangerous space. It is, as I’ve demonstrated, where one encounters the awesome dread of the mysterium tremendum. The word “sacred” derives from the Latin sacer, and denotes a space that is set aside from the profane. Another way of looking at this is that sacred space is “ahistorical” space, outside of the dimensions of mortal space and time. This is contrasted with historical space of the relative “here and now” of that which is profane. Mary Douglas argues that sacred space is restricted space necessary to protect that which is divine from the profane, and conversely, “… to protect the profane from the dangerous intrusion of divinity.”26 The danger derives from the nexus of the two. Each defiles the other. Douglas would use the term “polluted” to describe the space of this joining. She writes of pollution, not as one would think of in today’s terms in which it is relatively contained, but rather as a virus that spreads. Douglas uses the term “sacred contagion” to describe her notions of this process.27    

During the dying process, the restrictive barriers separating the sacred and profane thin in preparation for death’s epiphany. One of the notions I share with patients and families is that as part of death’s process, the dying are prepared to enter into and through this space—in a sense, they are no longer mortal, even before they die. They belong to, and are simultaneously in, the realms of both the sacred and the profane. In their work on the nature and function of sacrifice, Hubert and Maus suggest that the sacred and profane intermingle through the person of the dying (in their work the sacrificial victim.)28 But we who are left behind are not equipped to deal with the overwhelmingly powerful energies of this polluted space. I think this partly accounts for the exhaustion experienced by families during the dying process.

Hubert and Maus write at length about the dangers of direct contact with the sacred by the profane, and the necessity of ritual purification rites to safeguard the sacrificer when coming into contact with the sacred. They note: “All these purifications, lustrations, and consecrations prepared the profane participant for the sacred act … introducing him step by step into the sacred world of the gods."29 In my experience the same applies especially to families entering the dying space. 

Death, as we’ve seen, is an overpowering encounter with the mysterium tremendum. And it can have overpowering affects on those it touches. Returning to Douglas’s notion of sacred contagion, it is as if death’s energies are contagious, and pollute those it contacts. This can result in rather extreme emotional and physical experiences. I’ve often sensed myself carrying death’s energy, and found myself looked at in awe as Otto uses the term. I’ve even been called a participant in an execution. In terms of family members, it is a dangerous time as they enter a grief state, dissociating from their minds and bodies. It’s not unusual for them to become ill as immune systems weaken, or to be caught speeding or running a red light. I’ve had family members involved in traffic accidents, or injure themselves walking, or even straining their backs picking up empty sacks from the floor. 

The ritual space I hope to create is intended to safeguard those who come in contact with death and dying. It both prepares one for entry into this sacred space, and guides one through it. As Tom Driver notes, “To ritualize is to make (or utilize a pathway through what would otherwise be uncharted territory.”29 Rituals are pathways that locate one more safely into the experience of what Mircea Eliade writes as “The threshold …, the boundary, the frontier that distinguishes and opposes two worlds – and at the same time the paradoxical place where those worlds communicate, where passage from the profane to the sacred (and back) becomes possible.”30 And finally, rituals provide a sense of ordering and grounding to what is frequently experienced as chaotic, and is always unpredictable.  My hope is it helps patients and families through the dying process.