stories interrupted: weaving creativity, the sacred and meaning at the end-of-life brenda kenyon,...

Stories Interrupted: Weaving Stories Interrupted: Weaving Creativity, the Sacred and Creativity, the Sacred and

Meaning at the End-of-LifeMeaning at the End-of-LifeBrenda Kenyon, LCSWBrenda Kenyon, LCSW

St.Vincent Hospice, Indianapolis, INTony Pinto, MDiv, CTTony Pinto, MDiv, CT

Indianapolis, IN

Learning ObjectivesLearning Objectives

Articulate three loss oriented outcomesArticulate three loss oriented outcomes Identify four components of a holding Identify four components of a holding

environmentenvironment Articulate three constructs defining Articulate three constructs defining

creativitycreativity Define refuge as a function of the sacredDefine refuge as a function of the sacred Identify four methods of interdisciplinary Identify four methods of interdisciplinary

creative collaborationcreative collaboration

Contemplative ExerciseContemplative Exercise

Engage audience in using concentration Engage audience in using concentration through centeringthrough centering

Introduce breath & voice modulation Introduce breath & voice modulation techniques techniques

Blueprint for Today Blueprint for Today

3 Clinical Frameworks to assess, intervene, and provide care to those whose stories have been interrupted.

First provide a panoramic view of two First provide a panoramic view of two stories interrupted.stories interrupted.

Then we set the stage for the Holding Then we set the stage for the Holding Environment.Environment.

Explore the frameworks of meaning, Explore the frameworks of meaning, creativity, and the sacred.creativity, and the sacred.

The Box Experiential ExerciseThe Box Experiential Exercise

Reduced capacity/capabilityReduced capacity/capability Diminished treatment optionsDiminished treatment options Collateral losses associated with terminal Collateral losses associated with terminal

diagnosisdiagnosis Shift from external to internalShift from external to internal Approaching deathApproaching death

Your Blessing BoxYour Blessing Box

Use today to capture ideas, thoughts, andUse today to capture ideas, thoughts, and

Interventions that will bless your work in Interventions that will bless your work in the future.the future.

Two Case StudiesTwo Case Studies

PTSD, adjustment counseling, PTSD, adjustment counseling, interdisciplinary themes, twelve-step interdisciplinary themes, twelve-step model and hospice graduationmodel and hospice graduation

Terminal awareness, family dynamics, Terminal awareness, family dynamics, interdisciplinary ritual, creativity, religious interdisciplinary ritual, creativity, religious imagery and hospice graduationimagery and hospice graduation

Motorcycle MammaMotorcycle Mamma

81 year old Caucasian female81 year old Caucasian female Enrolled in hospice 13 monthsEnrolled in hospice 13 months Diagnosed with Rectal Cancer 5 months priorDiagnosed with Rectal Cancer 5 months prior Radiation treatments caused extreme weaknessRadiation treatments caused extreme weakness Highly independent until her diagnosisHighly independent until her diagnosis Currently bedbound, unable to move legsCurrently bedbound, unable to move legs Prided herself in being able to ride a motorcycle Prided herself in being able to ride a motorcycle

until age 80until age 80

Motorcycle Mamma’s ThreadsMotorcycle Mamma’s Threads Loss of identity (loss of independence and Loss of identity (loss of independence and

increased dependence)increased dependence) Loss of personal narrative (will not live to 92)Loss of personal narrative (will not live to 92) Disenfranchised grief around significant love Disenfranchised grief around significant love

relationship.relationship. Dissolution of social network (square dancing & Dissolution of social network (square dancing &

motorcycle clubs)motorcycle clubs) Matriarch and protector unable to assist her Matriarch and protector unable to assist her

children with their restlessnesschildren with their restlessness Trauma associated with terminal Trauma associated with terminal

diagnosis/hospice placementdiagnosis/hospice placement

Catherine (of Sienna)Catherine (of Sienna)

89 year old Caucasian female89 year old Caucasian female Enrolled in hospice for 9 monthsEnrolled in hospice for 9 months Diagnosed with End-Stage Ovarian CancerDiagnosed with End-Stage Ovarian Cancer Long term care resident since 2006Long term care resident since 2006 In harmony with her own self narrativeIn harmony with her own self narrative Matriarch of her multigenerational familyMatriarch of her multigenerational family Devoted Roman Catholic with a deep sense of Devoted Roman Catholic with a deep sense of

mystic spiritualitymystic spirituality

Catherine of Sienna’s ThreadsCatherine of Sienna’s Threads

Used sense of humor to copeUsed sense of humor to cope ““I ordered homemade chicken noodle I ordered homemade chicken noodle

soup and got canned tomatoes instead.”soup and got canned tomatoes instead.” Relied on her multigenerational familyRelied on her multigenerational family Verbalized her sense of resolutionVerbalized her sense of resolution Support to family to address anticipatory Support to family to address anticipatory

grief issues and recognition of her terminal grief issues and recognition of her terminal awarenessawareness

The Components of The Components of WeavingWeaving

Story Interrupted (Patient)

Holding Environment

Thread-maker (Clinician) Weaving

Other Weavers

Clinical Components of the Clinical Components of the Interrupted Narratives Interrupted Narratives

SufferingSuffering Suffering can be defined as an actual or perceived Suffering can be defined as an actual or perceived

threat to the integrity or continued existence of the threat to the integrity or continued existence of the whole person. (Cassell, 1982)whole person. (Cassell, 1982)

PTSDPTSD Our observation indicates that the persons’ Our observation indicates that the persons’

interrupted stories tend to mimic the signs and interrupted stories tend to mimic the signs and symptoms of PTSD.symptoms of PTSD.

When we implement interventions that address PTSD When we implement interventions that address PTSD patients can experience a significant benefit. patients can experience a significant benefit.

(Boss, 2006)(Boss, 2006)

Clinical Components of Clinical Components of Motorcycle Momma’s Interrupted StoryMotorcycle Momma’s Interrupted Story

Disruption of the Personal NarrativeDisruption of the Personal Narrative Loss of identity Loss of meaning Loss of purpose

Interruption of the Family NarrativeInterruption of the Family Narrative Generational threat (end of tradition, end of the future line) Leaderless clan Emerging responsibilities (concrete and psychodynamic)

Clinical Components of Catherine’s Clinical Components of Catherine’s Family Story InterruptedFamily Story Interrupted

Stability of the multigenerational family unit Validation of her terminal awareness Need to address impending loss with her

grieving daughters To die a happy and peaceful death as

opposed to the traumatic memory of her aunt’s dramatic death

Recognition that she has lived a long and productive life of faith and family

Characteristics of Catherine of Characteristics of Catherine of Sienna’s Story InterruptedSienna’s Story Interrupted

Urgent desire for supportive creativity and spiritual imagination (Fox, 1979)

Strong spiritual path transcendent of religious affiliation

Strong sense of creativity and “play”



Holding Environment


Other Weavers

Holding EnvironmentHolding Environment

Borrowed extrapolation from A. Modell’s (1976) ideas around the therapeutic relationship as he applied D. W. Winnicott’s theoretical constructs of “the Holding Environment”

Gives a basis for understanding boundaries and components to acknowledge, as well as, to leverage for positive patient/family outcomes in the journey

Holding EnvironmentHolding Environment

IntentionIntention Filter and Clear DistractionsFilter and Clear Distractions Single Pointed Focus/PresenceSingle Pointed Focus/Presence

Therapeutic AllianceTherapeutic Alliance Developing trustDeveloping trust Becoming the safe objectBecoming the safe object

StabilizationStabilization Normalize reactions to absurd eventsNormalize reactions to absurd events Name the interruption and its effectsName the interruption and its effects

Interventions To Create A Interventions To Create A Holding EnvironmentHolding Environment

Scanning of the physical environmentScanning of the physical environment Search of obstacles and chaosSearch of obstacles and chaos Identify the sacredIdentify the sacred Engage the immediate family and the patient in the creation of the Engage the immediate family and the patient in the creation of the

holding environmentholding environment Facilitate the transformation of the holding environmentFacilitate the transformation of the holding environment

Cultivation of the psychodynamic “holding”Cultivation of the psychodynamic “holding” Trust (consistent, information sharing, mediate communication Trust (consistent, information sharing, mediate communication

with team and family)with team and family) Honesty (remain objective, establish boundaries/limitations)Honesty (remain objective, establish boundaries/limitations) Reassurance of hopeReassurance of hope Reframing of the experience (redirect to opportunity)Reframing of the experience (redirect to opportunity) Reinforce strenghts and meaningReinforce strenghts and meaning



Holding Environment

Thread-maker (Clinician)Weaving

Other Weavers

Weaving 3 Clinical Frameworks Weaving 3 Clinical Frameworks Meaning Making (R. Neimeyer, T. Attig)Meaning Making (R. Neimeyer, T. Attig)

Search for purpose/namingSearch for purpose/naming Achieving Resolution/Maintaining ResolveAchieving Resolution/Maintaining Resolve Coherence/Making SenseCoherence/Making Sense Reframing Reframing

Creativity (R. May, S. Langer, D.W.Winnicott, A. Modell) Creativity (R. May, S. Langer, D.W.Winnicott, A. Modell) Congruent FormsCongruent Forms Holding Environment/Field of PlayHolding Environment/Field of Play

Sacred/Symbolic Immortality (M. Fox, E. J. Cassel, J. Sacred/Symbolic Immortality (M. Fox, E. J. Cassel, J. Halifax)Halifax)

Refuge practiceRefuge practice Power of IntentionPower of Intention As transcendenceAs transcendence

Meaning-makingMeaning-makingThe Hierarchy of Hope by Helen WongThe Hierarchy of Hope by Helen Wong

MeaningMeaning Making sense of the experience is coping with

emotional, physical, social, spiritual and intellectual consequences…..by transforming the CHAOS into a newly meaningful order.

(Machin, 2009) “Narrative methods can play a role in restoring

or re-storying a sense of autobiographical coherence that has been disrupted by loss (Neimeyer, 2007)

Significant life losses, bring forth spiritual awareness; and yearning for meaning that transcends everyday explanation.

(Martin & Doka, 2000)

Meaning-makingMeaning-making

Meaning can refer to a spiritual sense of purpose in life, which centers around the capacity of an individual to feel the worth of his/her individual life (story).

(Marcia Lattanzi-Licht, “Religion, Spirituality and Dying”, 2007)

Victor Frankl offers three avenues for discovering meaning: Creating a work/doing a deed; Experiencing truth, beauty and love; and the Attitude we assume towards unavoidable suffering. (Frankl, 1959)

Meaning Making Meaning Making Interdisciplinary InterventionsInterdisciplinary Interventions

Grasping and naming emerging themes Use of visualization and creative imagery

to reconstruct meaning Name the fragments, find congruent

forms, reframe language

CreativityCreativity

Is a means of finding cohesion and Is a means of finding cohesion and integration in the midst of chaosintegration in the midst of chaos

A force inextricably linked to the sacredA force inextricably linked to the sacred

Creativity is a way of living, a spirituality Creativity is a way of living, a spirituality just as compassion is (Fox, 1990)just as compassion is (Fox, 1990)

It is the energy of hopeIt is the energy of hope


Creativity is about overcoming fears by entering into them and spiraling out of them. It takes courage to create. (Fox, 1979)

Creativity is a supportive field to begin the necessary work of transformation, re-integration and meaning finding. It is also a significant component of the holding environment. (Kenny, 1989)


Congruent Forms (Langer, 1972) Humans must have “congruent forms of

feeling” to be completely subjectively understood.

When the helper reflects to the patient, images and themes that find resonance, then the patient is able to perceive the congruent form of feeling. As a result of finding the congruent form, the patient experiences the feeling of being profoundly understood.


This yearning for form is a way of trying to find and constitute meaning in life. The creative process is the struggle against disintegration, the struggle to bring into existence new kinds of being that give meaning and integration. (May, 1975)


The helper, meets the patient in this space. The helper enters through intention, active listening (presence) and evidencing the congruent form (naming).

The patient enters through perceiving the congruent form and embracing the emerging force of creativity.


“The point is that when people are experientially moved by feelings evoked through the creative process, they are in a place where change is less frightening and relational revisions become more possible.” (Boss, 2006)

Creative InterventionsCreative Interventions Rituals (Angel Cards, Blessing Box) Honoring /Celebration of Life Ceremonies Art therapy techniques (“I Am A Tree”, These

Hands, family art carts, pillow cases, “Land of Grief”)

Music interventions (CD Compilation, music and art sessions, comfort music)

Legacy projects (“words of wisdom”) Creative writing projects (poetry-writing, memory

pages, favorite scripture pages)

SacredSacred

The Sacred is Present in the Story Interrupted

The Sacred emerges in the Story Renewed

The Sacred is weaved through underscoring symbolic immortality in the emerging post traumatic self

SacredSacred

One is frozen in the moment of traumatization. The disruption of memory in trauma is a corollary to the disruption of self. (Kauffman, 2007)

We use the Sacred as means of reintegrating self as it is weaved into the emerging self narrative.

SacredSacred

Life is threatened when death is not Life is threatened when death is not transcended. (Lifton,1979)transcended. (Lifton,1979)

Humanity needs reassurance about the Humanity needs reassurance about the eternal survival of the self. (Rank, 1958)eternal survival of the self. (Rank, 1958)

The approach to the interrupted narrative The approach to the interrupted narrative must include an element of belief in the must include an element of belief in the sacredness of the story.sacredness of the story.

Symbolic Immortality as SacredSymbolic Immortality as Sacred

Biological Immortality: the sense that one continues to live through one’s descendants

Theological Immortality: a reunion with the Divine in the afterlife

Works Immortality: the feeling of having created an enduring contribution

Natural Immortality: the satisfaction of one’s continuation in the cycle of life

Transcendent Immortality: the psychic depth that sees the cessation of time, space, life and death and only perceives a continuous present (Lifton, 1979)

SacredSacred

One of the congruent forms we lift is reflected by T.S. Elliot when he says: “What we call the beginning is often the end, and to make an end, is to make a beginning; the end is where we start from” (Elliot, 1936)

SacredSacred

Young and Erickson see trauma as disrupting the sense of continuity, leaving one alienated and isolated. The trauma disturbs experience so severely that the pre- and post- traumatic self are discontinuous. (Young & Erickson, 1989)

The introduction of the Sacred into the Holding Environment becomes a congruent form symbolizing continuity.

Refuge & RitualRefuge & Ritual

Sacred is found as we seek and discover refuge. Refuge is also a practice, a mental exercise that requires creative imagery and freedom to feel.

Rituals and ceremonies evoke a cognitive means of making sense of our traumatic losses. (Richards, 2001)

Ritual provides a way to release the chaos of the story interrupted. (Golden, 1996)

Spiritual PracticeSpiritual Practice

A spiritual practice can give us a refuge, a shelter in which to develop insight as to what is happening outside us and within our minds and hearts. (Halifax, 2008)

It can cultivate wholesome mental qualities such as compassion, joy, non-attachments--qualities that give us resilience to face and possibly transform suffering. (Halifax, 2006)

SacredSacred

This meeting in the holding environment “can be looked upon as sacred to the individual, in that it is here that the individual experiences creative living.”

(D.W. Winnicott, 1971)

Sacred InterventionsSacred Interventions

Commendation/Sending Off RitualCommendation/Sending Off Ritual Contemplative PrayerContemplative Prayer Mandala makingMandala making Creation and claiming of symbolic spacesCreation and claiming of symbolic spaces MusicMusic Rosaries and mantrasRosaries and mantras



Holding Environment


Other Weavers

Other WeaversOther Weavers

FamilyFamily Significant OthersSignificant Others Facility StaffFacility Staff Community Community Hospice TeamHospice Team

The Story EndsThe Story Ends

Encourage to widen your creative horizonsEncourage to widen your creative horizons Embrace the risk taker in youEmbrace the risk taker in you Engage in creative paths that thrust you to Engage in creative paths that thrust you to

a new level of experiencea new level of experience Cultivate presence in the holding Cultivate presence in the holding

environmentenvironment Open your eyes to congruent formsOpen your eyes to congruent forms WeaveWeave

stories interrupted: weaving creativity, the sacred and meaning at the end-of-life brenda kenyon,...

Documents