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The Art of Sitting With and Finding Meaning in Suffering
After a half-dozen people suggested that I read it, I at last picked up and rapidly read Atul Gawande’s, masterful Being Mortal: Medicine and What Matters in the End1 , a book which could equally be titled: The Art of Sitting With and Finding Meaning in Suffering.
Gawande, a surgeon and esteemed author of several books and multiple articles in The New Yorker , brings his signature humility and insightful observations to how we die in America, framing the book through his family’s own journey through the end of his father’s life. He calls for an overhaul of how we traverse the end of life, seeking meaning and connection as diseases prove increasingly resistant to treatment and the specter of death begins to cast its shadow over the scene, rather than increasingly Sisyphean attempts at treatment and cure.
His book is a rallying call for caring for the soul at the end of life, not just the body. But more importantly, his book is a plea for courage. Another alternate title could have been: The Art of the Difficult Conversation.
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Unlike oncologists and cardiologists, we, as mental health professionals, might not treat illnesses with a clear terminal trajectory, but we are no strangers to suffering. Arguably, the depression, anxiety, psychosis, and ennui that we see in our offices, clinics, and hospitals each day inflict far more suffering than they do mortality (and the ascendancy of major depression as soon to be the world’s leading cause of morbidity, supports this2 ).
Not unlike oncologists, who respond to the advancement of a tumor with another, maybe more noxious chemotherapy agent, we respond to the advancement of the maladies that we treat with another drug, another visit to the hospital, another referral to a therapy group, or a doubling of psychotherapy sessions in an attempt to bring relief to those who entrust us with their care. These are all valiant efforts, and I make no disparagement of them. But in a way, these attempts at finding a helpful bromide are a treatment of our own anxiety, as much as they are a treatment for our patient’s malady. By searching for a more complex medication augmentation strategy or a new insight into our patient’s suffering, I help allay my own anxiety at what often feels like helplessness against a formidable foe. Gawande addresses this when he says: “The pressure remains all in one direction, toward doing more, because the only mistake clinicians seem to fear is doing too little. Most have no appreciation that equally terrible mistakes are possible in the other direction – that doing too much could be no less devastating to a person’s life.”
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Repeatedly in the book, Gawande recounts difficult conversations with patients who are approaching the terminal stage of their illnesses: “How do you understand your illness?” “What are your biggest fears and concerns?” “What goals are most important to you?” “What tradeoffs are you willing to make and what are you not willing to do?” These questions are no less important when dealing with an illness, like chronic depression or schizophrenia, which have a far less clear or terminal trajectory. If anything, these questions are even more important, as they help us address the suffering of the patient.
The impotence that we can feel in the face of such illness can render us ashamed at our inability, as clinicians, to cure. Sometimes this shame prevents us from remaining fully present with our patients in a privileged moment of intimacy – that moment where their hopes and dreams are revealed, and where they share the suffering that their illnesses have inflicted. This is where we must learn to be courageous, and to train the generation of clinicians behind us to be courageous as well. Gawande speaks of this when he writes: “ At least two kinds of courage are required…The courage to seek out the truth of what is to be feared and what is to be hoped. But even more daunting is … the courage to act on the truth we find.”
When I am sitting with a patient, I need to use the knowledge of medicine that is in my head to make a good decision (“Which treatment is most likely to help?”) but my patients don’t just want that. They want the medicine that is in my heart, the medicine that I dispense when I can sit with the anxiety of my own helplessness, to listen intently and to wait an extra beat before speaking, and to sit with their fears and hopes. They are hoping that today, I will have the courage to sit with them in all that is uncertain.
References
1. Gawande, A. Being Mortal: Medicine and What Matters in the End. New York, NY: Metropolitan Books; 2014.
