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A Life Larger than Pain

The Pathway from Resignation to Renewal

by Erv Hinds, M.D. (more about this book and author)

Chapter 5: Heartache: The Pain We Neglect
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[Yes,] the world's pain does break our hearts, over and over and over again. but a broken heart is not a paralyzed one … hearts are broken open, not destroyed; and from an open heart's capacity to be with suffering, healing arises.

–ELIZABETH ROBERTS AND ELIAS AMIDON[34]

SEVERAL YEARS INTO my medical career, I had a life-threatening condition that transposed me from doctor to patient. The resulting experience took me well beyond traditionally Western solutions of pills and shots and surgeries, so profoundly affecting me that I changed specialties as a result. This awakening took me deeper into my own beliefs and planted in me the desire to search for and share the meaning of the universality of pain.

In 1986, while practicing in Santa Fe as an anesthesiologist and supporting a wife and three small children, I learned that I had an enlarged heart caused by a mitral valve problem. Without treatment, I could expect an early death from congestive heart failure. The doctors, who were very guarded with their prognosis, were clear that I needed major surgery to replace the valve, with the prospect of repeated heart surgeries following it. I would also be placed on the blood-thinning drug coumadin, which would decrease my chances of an active life while increasing the risks of stroke and a multiplicity of other complications. As an avid runner and skier who enjoyed outdoor recreation with my family, I faced a severely limited lifestyle.
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I was not as certain as my doctors that such high-risk surgery was my only option for treatment, but they were too busy with many other patients to research alternatives for this one problem. I felt anxious and alone, with a time bomb ticking in my chest.

At that time in my life, I had a sense of spiritual reality but had not yet built up my inner life sufficiently to draw on spiritual resources for such a life-threatening crisis. I turned to a close friend who was a pastoral counselor, and I began reading more specifically about spiritual practice. With my friend's counsel, I decided on a prayer-centered approach to building up the psychological and spiritual strength I knew I would need simply to make the decision regarding treatment. I learned to practice petitionary prayer, asking for help in love and openness as I released this overwhelming problem to a Supreme Being. I started a regular practice of prayerful meditation, which has since become a lifelong habit. And I broke the barrier of self-consciousness in asking for intercessory prayer from people in my community, including those in other denominations and religious traditions.

My pastor friend and I began by bathing everything in prayer, including the prognosis. We spent time listening and asking for guidance. His intuition was that we should not be limited by the conventions of Western medicine. Together, we developed a sense of peace that there would be a therapeutic alternative to the surgical answer. He wisely suggested that I study the problem at the university medical school library nearby. I had been an anesthesiologist on an open-heart team and would at least know where to begin.

I began to experience the quiet calm and confidence that so uniquely arises from prayer. As I continually turned over my fears and uncertainties, I found that creative ideas flowed. I discovered information quickly, as if I were being guided to just the right references. Answers that were difficult to obtain on my own came to me clearly. As I received help simply because I had asked for it, I felt increasingly sure that there was a reason for this crisis. Although there were still many uncertainties on the path ahead, I had confidence that the way would eventually become clear. Ultimately, I had hope that a deeper purpose was drawing me along.
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I have observed that regardless of denomination or tradition, authentic spiritual practice–far from shutting down the intellectual dimension, as some suppose–tends to enhance cognitive thinking. The pursuit of rational knowledge combined with listening for intuitive knowledge has a powerfully synergistic effect. Techniques such as meditation, hypnosis, prayer, and relaxation exercises encourage proactive engagement, in contrast to the passivity reinforced by our healthcare system.

Among the journal stacks in the university library I found an article titled "The French Correction,"[35] by a world-famous surgeon who had been performing heart-valve repairs in France. As chief cardiac surgeon of a public hospital in Paris, with few medical and legal restraints, this doctor had developed a highly artistic method of repairing the valve, rendering replacement unnecessary. Although his operation–which had not yet been conducted in the United States–had thus far proven successful, it was not easily replicated and was quite high-risk.

After locating this seminal information, I tracked down an upcoming American Heart Association convention at which this innovative surgeon's work would be presented. When I attended to learn more about the procedure, I was able to meet the surgeon's assistant personally, and with serendipitous ease, we arranged for the operation in France.

Thanks to my immersion in the medical profession, I knew more than I wanted to know about the very dangerous physical situation I was in. My growing spiritual convictions did not spare me emotional turmoil. I often felt as if I were in a black tunnel, with no guarantee that I would ever find my way out into the light of a healthy future with my loved ones.

In the days leading up to my departure for the operation, I prepared mentally and emotionally by meditating each day in the early morning. I followed an active breathing process recommended in a book on spiritual disciplines I was reading at the time.[36] Afterward I would visualize heart and soul leaving my body and slowly rising up into the dark, early-morning sky of Santa Fe, drifting through the changing colors of the clouds into the healing presence of God. Through these interludes, I came to believe that my heart was already in the process of being

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healed. I sensed that the problem with my physical heart was connected to deeper issues within my soul, that my journey of physical healing was also a process of inward purification.

The night before I left for Paris, Native American friends visited me from the nearby San Ildefonso Pueblo. Dora Tse-Pe and her family arrived in their pickup truck to present a gift: one of Dora's beautiful black-on-black pots that she had made from the earth as a symbolic and spiritual gift to the French surgeon halfway across the globe. My surgery was scheduled very close to the San Ildefonso feast day, and I knew that Dora's clan would be offering prayers, dancing, and conducting religious ceremonies for me. This spirit-filled medicine was a powerful support to me–and perhaps to the surgeon as well, for the operation proved successful.

I have been privileged to lead a full and healthy life since that time, but it has been a fuller and richer life than I ever had before the crisis. I now understand from intimate personal experience that healing involves the whole person–physical, psychological, and spiritual. My heartsickness gave me a healthy respect for the literal as well as metaphorical realities of heartache.

the entwining of pain and heartache

Everybody knows what heartache feels like. Why do we avoid talking about it in the context of pain? Heartache is not merely metaphorical: it is an authentic bodily experience, and no less real than an ache in the lower back. Yet the realm of heartache represents the greatest divergence between professional medicine and the non-professional world of self care. Bookstore shelves in the categories of popular psychology and health are filled with variations on the common theme of holistic healing and the integral unity of the human person. Pain practice, one of the newest medical specialties, has yet to catch up with this holistic emphasis. It is still concerned primarily with technique.

Our curious neglect of heartache in professional medicine may well be rooted in our neglect of the human spirit. Physiologically, we experience pain at the mind-body level. On a spiritual level, we experience pain as

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heartache. These realms are profoundly and inextricably connected. When the body suffers injury, the mind and body shift into gear to help repair and heal what is broken. But if mind and body are handicapped by unrelieved pain, the human spirit will be burdened as well, and a sense of meaninglessness and despair will set in. Furthermore, if the human spirit has been injured by loss or betrayal and heartache worsens without any healing, it will have adverse effects on mind and body, intensifying pain. When these inner losses are adequately addressed and healing begins, the consequent renewal of the spirit may strengthen physiological resources, modifying pain.

It is unfortunate that we tend to dance around the issue of heartache rather than confront it, because it has core potential for the greatest change as well as for the greatest distress. But it requires humility in the face of mystery: some realities are accessible through intuition rather than observation and analysis.

I remember a patient of mine who finally found the love of his life at age fifty. They married and settled into a rewarding life together. He was even happier in his work, which he attributed to his newly fulfilling life. To his great sorrow, however, within just a few years his wife was diagnosed with a brain tumor. She died only two months after the diagnosis.

Soon after that, he began experiencing chest pain. He was diagnosed with angina, and he underwent coronary artery bypass surgery. He participated in a cardiac rehabilitation program, but chest pain continued to bother him on a daily basis, despite post-op indications that he was recuperating well. He was afraid he would either die from the pain or need further surgery.

It was his rabbi who finally helped him identify the source of the continuing pressure in his chest. This man was suffering from literal heartache. Once he began to differentiate the heartache of losing his beloved wife, from the angina he no longer had, his fear gradually subsided. But there was still the problem of his heartache, for which no bypass surgery was available.
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The antidote proved to be, in part, a rekindled spiritual awareness. He'd had a spiritual sensitivity in his youth but lost it in the journey through adulthood. Now, the boy had come back to visit the man, and the spiritual nurture was life-giving. Though the process was gradual and painfully slow, his heartache eventually diminished enough to allow him once again to find periods of light and joy.

a hidden pain

Many people come to the pain center stating what they believe to be their problem. The headaches keep recurring. The back pain is causing distress in other parts of the body.

These conditions are real, and they need genuine treatment. But often they are symptoms of an underlying problem. The root cause might be alcoholism, loss of a primary relationship, or a blow to personal identity through job loss. The true problem–that is, the need that must be addressed in order to treat the pain effectively–lies not in the physical manifestations, but in the trauma of some burden they are carrying.

Pain is the result of injury. Treating it would be much easier if we could reduce it to the consequences of direct cause-and-effect events such as touching a hot stove or slamming a finger in the car door. We have made great strides in understanding different types of pain, such as neuropathic (nerve injury), somatic (tissue injury), or bone pain. We have developed sophisticated techniques for understanding and treating these conditions with surgery and medication and specialized procedures. We have discovered the benefits of adjuvant medications, which have a different primary use but serendipitously are also effective in ameliorating pain.

The pain of heartache is just as real as what you feel when you pull a pot off a hot burner without a potholder. Yet it is curiously missing from most professional literature. I have never seen a clinical description, medical or otherwise, of heartache. In our society, we tend to avoid talking about it except in rare conversations with our closest friends, or we cloak it in flippant humor. I believe we need to add it to our list of pain types.
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We are a long way from understanding how to treat heartache. For the most part, it does not respond to treatment by medication. It is a mind-body experience, weighted perhaps more heavily in the mind, but definitely felt in the body. For some it is almost literally a wrenching sensation, as if the heart is being torn from the chest. Whatever its origin–the death of a loved one, the end of an intimate relationship, or the loss of a child–heartache is a very real pain that merits attention and treatment just as much as an ache in any other part of the body.

Some might prescribe the antidote to heartache as a visit to a therapist, perhaps in conjunction with medication prescribed by a psychiatrist. For a lucky few, that may be the beginning of the end to that particular heartache. But heartache is not necessarily synonymous, or even associated, with depression. For many, it must simply be endured as a daily experience until in time and by grace, the ache gradually diminishes.

Much of the time, heartache remains a hidden pain. I wonder if we tend to neglect it because our mad dash through schedules and commitments keeps us so disconnected from our inner life. The movement toward simplicity in recent years reflects our rebellion against such fragmented, outer-directed living. In years past, our forebears may have lacked the conveniences of technology, but at least they had built-in opportunities for slowing the mind and easing the spirit while riding a horse across the fields or walking to their next destination. We transport ourselves in self-enclosed bubbles equipped with tools and toys to keep us productive and preoccupied. At home, the incessant drone of television conveniently fills in the empty spaces between activities, further distancing us from the potentially healing power of solitary reflection and inner renewal.

If it doesn't catch up with us in our daily routines, heartache will inevitably visit us in the lonely night hours. If we suppress it there as well, it will likely come back to revisit us in physical and mental distress. It can be a very insistent and demanding form of pain.
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a very real pain

Heartache is a hidden pain also because it is rooted in some of the most personal and private experiences of life. It is bound up in the inner life, and so it cannot be objectified or defined in the recognizable function of a particular body part.

Fundamentally, heartache is pain felt on the level of the spirit. It is a hurt that manifests itself in body and mind but extends well beyond. We speak of feeling heavy-hearted or light-hearted because these terms accurately describe the physical sensations. Yet these sensations are the results of intangible realities, perceived at an intuitive level. They are no less real–and are often more devastating to overall well-being–than is pain entering the body via receptor sites.

Body-mind healing exercises such as appropriate touch and meditation will certainly help alleviate heartache, because the human person is an integral unity. The growing trend in healthcare today is to treat "the whole person." This is a good and necessary development. We are more sensitive than ever before to the ways in which mind and body interrelate in coping with illness or injury. We know that we have an innate drive toward wholeness, and that the mind has great power to facilitate the body's natural desire for healing.

The increasing popularity of so-called complementary medicine, which combines traditionally Western medicine with alternative healing approaches, reflects our deepening understanding of the inextricable unity of mind and body. Yet we still tend to separate heartache from medical treatments, consigning heartache to a support level and perhaps bringing in a chaplain. To treat the whole person requires physicians to pay attention to heartache as a foundational, not a peripheral, aspect of the pain experience.

For those suffering pain from a life-threatening condition, treating the whole person includes relating proactively to loved ones and family members, if the patient is fortunate to have such support nearby.
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While I was recovering from my heart operation in Paris in a hospital primarily for patients from former French colonies, I avoided special privileges such as seeking pain medication frequently. Since I was a curiosity among the patients, I was trying not to be the ugly American. I sought ways to deal with the discomfort common to all of us, so that the other patients could accept me and I could participate with them in the healing process.

After surgery, I was on a ward of nine people, most of whom were from Africa–Mauritania, Ivory Coast, Algeria, and Tunisia. Others were from Italy and Greece. None spoke the same language. Patients were cared for by their relatives, most of whom stayed with them at the hospital–nursing them, feeding them, sleeping under their beds. At first the sight of all these people startled me, but it quickly became clear that they were not intruders, and in fact quite the opposite. They came not only to help their loved ones, but others as well.

My companions included a nine-year-old with congenital heart disease who sat on my bed and drew pictures for me. I remember trying to focus attention away from pain into his eyes and onto his pictures. An "earth-motherly" Italian woman would scurry out of the hospital to get biftec for the American physician who looked so blanco-blanco. She fed me as if she were a mother bird, shoving little pieces of food into my mouth. I received massages from the family of the man from the Ivory Coast. The first time I ventured to the one bathroom on the ward, I was assisted by an Algerian patient on one side and a Tunisian patient on the other, helping me with my chest tubes and IVs. A week later, I was doing the same for the next patient coming to the ward.

In our mental, spiritual, and physical touch with one another, our ward formed a little United Nations of pain. Language and customs defined our differences, but we were united in our common trauma of heart surgery and in the compassionate caring we gave to one another.

This community of wounded individuals had more power to facilitate genuine healing than did all the pain medication dispensable through an IV within the four walls of a sterile, isolated recovery room in a state-of-the-art hospital. Each time an injured patient came out of surgery, he was immediately enveloped in an atmosphere of personal warmth.
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Words were few, but communication was profound as we joined in the common task of helping everyone get better. These loving acts drew me past mental preoccupation with the pain into active participation in a community healing process. How much I would have missed had I taken a purely pharmacological approach to recovery!

My Paris experience represents yet another paradox in our society–we think it is advanced care to have a private room with the most monitors and technology, while screening out visitors and relatives. In fact, healing may be more rapid and effective when patients are surrounded by many people. Intensive care is often the most isolating. So-called advanced treatment sometimes obstructs a hands-on healing process. Ironically, what is considered the best treatment compared with the most primitive treatment actually may reverse the expected outcome.

Perhaps heartache is rarely addressed in the context of illness and pain because we tend to fragment the human person into component parts–body here in the biological sciences, mind over there in the psychological disciplines, and spirit consigned to religious traditions. The heart we leave to writers and composers. In the discipline of pain treatment, we do not have the luxury of narrowing our focus to one component part. In fact, the failure of such specialized scrutiny is often why patients are referred to us at the pain center.

The most effective starting point in treating heartache in the context of pain management may simply be to recognize it as an inevitable aspect of the pain experience. Sympathetic recognition of what others are struggling with can be a powerful facilitator in their healing.

In our medical system, the patient's passive isolation is broken only by visits from the nursing staff for impersonalized routine tasks. The only action expected of the patient, other than cooperating with these tasks or exercises to regain movement is pushing buttons for the television or for assistance. Our culture's premium on entertainment extends to the way we design our hospitals. Rather than giving people tasks for helping themselves and others, we separate them from each other and give them a television set for a companion. We rely on medication and entertainment to treat their pain. Visitors file in and out for brief exchanges–a gift of flowers, a quick squeeze of the hand, a whispered "we're

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praying for you." These gestures may be genuine expressions of caring, but they lack the power of sustained human presence.

The hectic pace of our routines, the demand to cluster tasks so that we are always doing two or three things simultaneously, the urgency to get where we're going faster, the drive to beat the clock and get more done in the limited time we have–all of this propels us right over the heads and hearts of suffering individuals. Rarely do we simply sit in silence, giving others the unhurried attention of compassion–the genuine desire to understand what they are going through, the attempt to feel something of what they are feeling, the assurance that their suffering is not ignored or overlooked. Genuine compassion moves beyond brief rituals of pity in seeking to ease the burden of pain in any way possible. Sometimes, entering into another's heartache is best communicated silently, through the mysterious and wordless language of the human spirit.

heart-felt grief over loss

Most of us associate heartache with the loss of primary relationships, but it is a frequent companion to illness, especially terminal illness. When seventeenth-century British poet and cathedral dean John Donne wrote Devotions upon Emergent Occasions, he described with remarkable clarity of detail both the physical and spiritual implications of his life-threatening illness. In the fifth of twenty-one brief meditations chronicling the progress of his disease from onset to recovery, he described the experience of isolation:

As sickness is the greatest misery, so the greatest misery of sickness is solitude, when the infectiousness of the disease deters them who should assist from coming; even the physician dares scarce come. … [The] height of an infectious disease of the body is solitude, to be left alone. For this makes an infectious bed equal, nay, worse than a grave, that though in both I be equally alone, in my bed I know it and feel it, and shall not in my grave; and this too, that in my bed my soul is still in an infectious body, and shall not in my grave be so.[37]
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This passage resonates with a deep awareness of loss of relationship and of bodily health. Here, Donne mourns the toll his disease has exacted on his physical well being, but also in his separation from relationships. The awareness is so painful that death would be a relief–not simply an end to suffering, but an end to his consciousness of its effects.

Pain sufferers are continually made aware of their loss of health and the multitude of other, daily losses in the simple routines and pleasures of life that are no longer accessible to them. The medical profession has made great strides in treating the physical and psychological effects of pain, but it has yet to address the effects of chronic pain upon the human spirit. Heartache reveals that to understand the complexities of the pain experience, we must move beyond the body-mind loop into the body-mind-spirit loop.

Heartache is a recognition of loss, and therefore an experience of mourning. When a marriage ends, there is mourning for the life together that was lost. When illness strikes, there is mourning for the healthy life that has vanished. Veterans of open-heart surgery will sometimes describe a curious awareness of a profound before-and-after difference: something is lost when the heart is stopped in order for the surgery to be performed; one is never again the same.

Heartache over a disruption in the body's health is a genuine inner knowing, an intuitive apprehension that is no less real simply because we cannot pinpoint its location in the body. The mind may or may not be consciously aware of the body's loss, because this kind of loss is not always perceived on a cognitive level. Nor is it simply an emotional response to a bodily event, such as an operation, which will fade with time. The knowledge of loss to the body remains.

The late writer Andre Dubus was a former Marine Corps captain, an athletic man who loved baseball and running. At age forty-nine, he stopped along a highway to help people who had just been in a car accident. He escorted a wounded woman and her brother to the side of the road and turned to flag down help from another motorist. But instead of stopping, the oncoming car swerved suddenly and plowed

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into them. Dubus pushed the woman out of the way. She survived; her brother died; and Dubus recovered from his injuries sufficiently to spend the rest of his life a paraplegic in a wheelchair. "After the dead are buried, and the maimed have left the hospitals and started their new lives," he wrote, the healing process starts with the "transcendent and common bond of human suffering," which eventually gives rise to forgiveness and love. In the recovery from injury, he described how "the physical pain of grief has become, with time, a permanent wound in the soul, a sorrow that will last as long as the body does."[38]

The physical organ of the heart is often used metaphorically to represent the seat of the soul, or spirit. Perhaps we should pay more attention to this. Heartache is evidence of a wound to the spirit, a disruption of our fundamental sense of self. Perhaps that is why the ache is so deep and profound. We sustain minor losses regularly–worsening eyesight, decreased muscle strength with lessened activity, fluctuations in social status and self-esteem–but they do not necessarily cause heartache. When the perception of loss is severe or deeply rooted, we grieve over the sense of having lost a part of ourselves irretrievably.

Acute or sustained pain of the body can reverberate in pain of the spirit. Conversely, when we suffer injury or illness that is not a physiological event, such as emotional wounds in the loss of a primary relationship, the associated pain can reverberate in pain of the body–headaches, depression, anxiety, stomach pain, and other physical symptoms. Because mind, body, and spirit are interconnected, no matter where pain originates it will inevitably affect the whole person if left unattended. Figure 5.1 illustrates the cyclical nature of the pain experience.

Technically speaking, we cannot experience wholeness of the body without physical health. Spiritual wholeness, however, does not require physical wholeness. The well-being of the spirit is affected but not determined by the health of the body.

Wholeness is an integration of all aspects of the human person–physical, mental, emotional, and spiritual. A high percentage of pain patients are in crisis because their relationship with their soul is weak.
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When illness or injury occurs, we want a remedy that will make the problem go away completely. But that is not healing. That is a cure.

Writer Nancy Mairs (a self-described Catholic feminist) discovered this distinction one afternoon while attending Mass. In "the interior jumble that forms my post-communion meditations," she was reflecting on her rapidly worsening multiple sclerosis. She realized that her "resolve to cope bravely, in a manner befitting my stern Yankee heritage, was weakening even faster than my muscles were. I just wanted to get rid of the damned disease. 'God, God, God,' I prayed, 'please, heal me!' And then, for the first and only time in my life, I got a response … Three monosyllables simply materialized in my consciousness: 'But I am.'"

She realized that she had asked for the wrong thing. She had wanted to be cured of the disease entirely, to resume the life she used to have, to live even more fully with a healthy body. But instead she had asked for healing: "not to be freed from my limp or my nasty habits, which might be effected instantaneously, but to be made whole, which might entail collecting scattered fragments and painstakingly fitting and gluing them into place."[39]

heartache and healing

While paying close attention to the recovery of the whole person, I work very hard at mending the body. Continuing professional education improves the likelihood that I will find successful ways to treat patients. For example, I attended a conference of the International Spinal Injection Society on new techniques for treating neck pain. Learning the procedure for treating cervical facet (side joints in the neck) arthritis is difficult, but it can markedly decrease certain types of headache, neck pain, and shoulder pain. After returning from the conference and practicing skills I learned there, I found I was able to help many patients who had suffered from post-whiplash injuries for years.

Of course, not everyone experiences concrete improvements. With some patients, we travel together the slow and very arduous road toward healing without immediate and dramatic improvements. For these

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sufferers, there is no way of taking away the scar tissue around their nerves. But I can help take away the scar tissue around their hearts.

 

Christian tradition refers to Christ as the "great physician." The Gospel narratives record many instances of physical healing, but Christ made it clear that miraculous cures were not the object of his ministry. They were signs of the kingdom of God, which he was ushering in. He restored wounded bodies, but he also healed broken spirits. Blessed are the heartbroken, for they shall be comforted.[40]

 

Many years and life experiences later, I am still experiencing the spiritual healing that has come from the crisis with my health. I am grateful that the surgery was completely successful, and I am able to live an active, normal life without medication. But truly, the heart of the matter was operated on in more than just one way. During that experience I learned

The Cycle of Physiological and Emotional/Spiritual Pain
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a profound truth that is one of the hidden blessings of pain: even in the loneliest or most painful times there is a grace in the wilderness. "The people who survived the sword found grace in the wilderness," declared the Old Testament prophet Jeremiah to the Hebrew nation.[41] Israel had been defeated by the Babylonians and taken captive in prolonged exile. From this period of defeat and destruction, the people were being offered new hope and new promise. Pain can herald a new promise of profound change, if we have eyes to see the opportunity and heart to walk through the wilderness of confusion and loss.


It is not possible to suffer the pain of a life-threatening illness, whether you are the victim or a victim's loved one, without experiencing the heartache of impending loss. Our neglect of this spiritual wound makes it much harder for us to deal with major losses. It is hard enough simply to cope with the mechanics of treating illness and its accompanying injury to the body. It is even harder, in our society, to draw upon resources for coping with the effects of illness and pain upon the human spirit.

Embracing Mystery

American society still clings to the notion that if you live right, you can avoid pain; and if you have pain, there must be something wrong with you. We are obsessed with making sense of life, with controlling pain and eradicating suffering. We demand solutions. But we seldom mention mystery–not a temporary ignorance that will disappear with more scientific information, but a reality essentially beyond human understanding. Appreciating the role of prayer and meditation in healing, understanding the relationship between spirituality and health, requires us to cultivate an acquaintance with mystery.

Our culture jettisoned long ago the idea that medicine and religion are the twin traditions of healing. The Medicine Man of the North American Indians embodies this concept. I saw it dramatized in the life of one of my patients, a woman whose journey took her through two very different cultures.
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I met Virginia Begay when she was admitted to the University of Colorado for treatment of choriocarcinoma (retained placental parts) after the birth of her third child. If diagnosed late, this cancer has a very poor prognosis. While I was making preoperative rounds, I found Virginia receiving a unit of blood on the oncology ward. She appeared to be Native American, and I presumed that she was far away from home in a big city hospital and therefore bewildered by her surroundings. I began explaining to her in an exaggeratedly simple manner why she was receiving blood. The twinkle in her eyes as she gave me an intelligent and articulate reply exposed my error immediately, as I realized she was a well-educated woman. Instead of treating me scornfully, she gently made me aware that she understood her medical problems and the Western treatment she was receiving for them.

Virginia was fundamentally and culturally Navajo, although she was a college graduate and seemed to walk in two worlds simultaneously. She had initially gone to the Navajo "sing" man when she first got sick, but as her illness progressed she sought Western medicine as well, and began chemotherapy treatments. She firmly believed that she needed to keep one foot in the camp of her traditional Medicine Man. She wore a pouch around her neck, and she participated with her family in healing procedures. For her, Native American tradition and Western medicine were not mutually exclusive.

The Pueblo Indians of the Southwest, neighbors of the Navajos, have often thrived in two worlds simultaneously, practicing the Catholicism that was introduced to them centuries ago intermingled with their own nature beliefs. Native Americans have a very pragmatic attitude toward healing. They have no qualms about mixing various healing ceremonies. They are humble in their openness to the potential for success in other people's ways of healing. In contrast to Western culture, which presumes that theirs is the only way, Navajos easily accept the mystery that two entirely different treatments can work together to heal.

Anemic and in constant pain when I first met her, Virginia was struggling with shortness of breath and nausea induced by her medication. I remember being in her room one day when her father, a traditional Navajo wearing a great big cowboy hat, walked into the room and

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started speaking to her in their native tongue. Virginia relaxed into what appeared to be a hypnotic trance. As her father began chanting, peacefulness settled over the entire room. Indeed, each time family members arrived and invoked the traditional life by chanting, singing, or using power objects, there was a palpable serenity in the room.

Subsequently, Virginia's cancer metastasized to her lungs, and she was sent to a hospital in Houston to try yet another method of healing. She and her husband and their three sons became friends with my family. When I moved to Albuquerque to begin practice as an anesthesiologist, we maintained close contact.

I did not get to see Virginia again after she was transferred to Houston. As the futility of further treatments became evident, she discontinued her chemotherapy, disconnected her IVs, and with the help of her sister made the journey back home to Haystack, New Mexico. She had chosen to die in the traditional Navajo way, surrounded by friends and family. We were invited to participate in her ritual of dying, but unfortunately we received the message too late. In the high desert landscape of her youth, Virginia finally found relief from pain.

Virginia's family told us that she became calm, comfortable, and serene at the end. It often happens that people who are in excruciating pain will inexplicably have a day or two of lucidity and comfort immediately before their death. I wonder if this manifestation from deep within is a renewal of the fundamental, spiritual self.

Ultimately, what had given Virginia the ability to face her circumstances with acceptance instead of fear was not the Western science of treating disease and managing pain, but the spiritual grounding in her ethnic and tribal heritage. For Virginia, the primacy of spiritual reality was the only meaningful context for dealing with her pain and facing the consequences of her illness.

Other cultures and religious traditions have much to offer us as we cope. Their differing perspectives on illness and suffering can help us change our responses to pain in profoundly helpful ways. Recognizing heartache

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as injury to the spirit, and responding to it with spiritual resources, may be the first step on the path to healing and wholeness.

Somewhere in your town or city there is a child with a terminal illness. The child's relatives and friends have a deep injury to the spirit–heartache. They are praying for a miracle. The child may die right on schedule, and there still may be a miracle. It may be a renewed prayer life for the relatives. It may be the coming together of estranged family members. Or the miracle may simply be the gradual and graceful repair of the human spirit in the lessons learned from the waning heartache.
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STEPS FOR THE PATH:

recognizing injury to the spirit

1.

Today, I would rate my general pain level as:

0

1

2

3

4

5

6

7

8

9

10

pain free

excruciating pain

2.

The word "heart" is often used metaphorically–heartbreaking news, heartfelt joy, heartwarming experiences–to point to intangible realities rather than in literal reference to the physical organ. In this chapter, heartbreak has been defined as injury to the spirit. Do you believe that injury to the spirit can intensify your physical pain?

3.

Physicians often neglect heartache in treating pain because it is not reducible to direct observation. What hidden heartaches are you carrying that might be intensifying your physical pain?

4.

Reflect on how nurturing your spirit has helped you recover from injury to the heart.


[34] Elizabeth Roberts and Elias Amidon. Prayers for a Thousand Years. San Francisco: Harper San Francisco, 1999, pp. 50-51.

[35] The French Correction. Keynote speech by Dr. Carpentier at American Heart Association convention 1985.

[36] Richard Foster. Celebration of Discipline. San Francisco: Harper & Row, 1978.

[37] John Donne. V. Meditation from Devotions Upon Emergent Occasions in Seventeenth-Century Prose and Poetry, 2nd ed. Alexander M. Witherspoon and Frank J. Warnke (eds.), New York: Harcourt Brace Jovanovich, 1963.

[38] Andres Dubus. Broken Vessels. Boston: David R. Godine, 1992, p. 138.

[39] Nancy Mairs. Ordinary Time: Cycles in Marriage, Faith, and Renewal. Boston: Beacon Press, 1993, p. 178.

[40] Luke 6:21, NRSV.

[41] Jeremiah 2:2, NRSV

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