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Chaplaincy for the caregiver: Compassion training for hospice volunteers

in a rural setting

Thesis Completed As Part Of

The Upaya Buddhist Chaplaincy Training Program

Jean Ashland March 2013 – March 2015

Ashland – Thesis 2

Table of Contents

Abstract ……………………………………………………………………………..4

Introduction…………………………………………………………………………5

Relationship of Suffering and Compassion ………………………………….…...5

Personal Context………………………………………………………………….6 Role of Buddhist Chaplain………………………………………………………..7 Training Compassion in Hospice………………………………………………....9 Overview of Thesis……………………………………………...……………….11

Background and Literature Review ……….…………………………………......11

Views of Compassion…………………………………………………………...11

How Compassion Benefits Others……………………………………………....14 Training in Compassion and Contemplative Care……………………………....16

Role of Buddhist Chaplain in Hospice……………………………………….....20

Guidelines of a Buddhist Chaplain………………………………………...20 Role of Chaplain in Hospice……………………………………………….22 Methods…………………………………………………………………………...23

Participants………………………………………………………………….…..23 Procedure Overview…………………………………………………………….24

Trainings………………………………………………………………………...25 Session One………………………………………………………………...25 Session Two……………………………………………………………......28

Session Three…………………………………………………………...….32

Session Four………………………………………………………………..35

Measurements…………………………………………………………………...37

Results……………………………………………………………………………..38

Data Analyses…………………………………………………………….……..38 Fears of Compassion Scales……………………………………………….38 Attendance…………………………………………………………...…….41 Home Practice Logs………………………………………………………..41

Narrative Findings……………………………………………………………....45 Session One…………………………………………………………..…….45 Session Two……………………………………………………….……….47 Session Three……………………………………………………………....49

Session Four………………………………………………………………..53 Participant Review of Training Program………………………………….…….56

Buddhist Teachings Integral to this Project…………………………………….58 The Five Buddha Families……………………………………………………....58

The Four Noble Truths…………………………………………………………..66


Table of Contents (continued)

Discussion and Conclusions………………………………………………………..74 Buddhist Perspective……………………………………………………………...76 Future Considerations…………………………………………….…..…....……...76

Limitations…………………………………………………………………………78 Conclusions………………………………………………………………………...79

Appendix A…………………………………………………………………………...81 Appendix B…………………………………………………………………………...84 Appendix C…………………………………………………………………………...86

Appendix D…………………………………………………………………………....87 Appendix E……………………………………………………………………...…….89

Appendix F…………………………………………………………………………….91

References……………………………………………………………………………...92

Bibliography…………………………………………………………………………...97

Acknowledgements…………………………………………………………………….98


Abstract

This study explored the chaplain’s role in caring for the caregiver with hospice volunteers

through training volunteers in compassion. Specifically, four 90-minute compassion training

sessions were offered over a four week period to 12 hospice volunteers in a rural setting. The

hospice volunteer participants in this project did not have regular volunteer support meetings

and had low patient census for volunteer opportunities. During this training, approaches and

activities for self-care and compassion were provided for being with difficult situations and

emotions in hospice volunteer situations using a combination of didactic and experiential

opportunities. Sample activities included: attuning to the self and other, setting intentions,

grounding, using a resource, deep listening, ethical behavior, and exploring shadows of

caregiving. A scale in compassion was administered at the beginning and end of the training

and weekly diaries were encouraged along with home practices between meeting times.

Findings suggest that the hospice volunteer participants had a low fear of offering compassion

to others and to themselves at baseline and continued to have a low fear of compassion

following the training. Narrative reflections from the participants commented on gratitude for

increased connection with one another and for depth of shared feelings, as well as felt support

on caring for the self while offering care to hospice patients. In addition, the participants

reported using the practices from the workshop, such as offering presence, being with

difficulty, and deep listening with family, hospice patients, and in their community. Evidence

of increased awareness, ease in being with difficulty, and cultivating compassion were

observed during the training activities and in self report by participants.


Introduction

Relationship of Suffering and Compassion

Being human, we naturally gravitate toward things that make us happy and we avoid things

that are difficult or unpleasant. When we are not satisfied with how things are we suffer.

Cultivating compassion for ourselves and the other provides resources for being with

difficulty, doubt, or distress. If we are not aware of our own distress or our view is ‘clouded’

by our distress, than our capacity to offer compassion to another will be limited. Health care

providers are faced with human distress on a daily basis and thus resources for being with

difficulty are paramount. Cultivating empathy and compassion for the other and oneself are

tools that can serve the care provider to ease the ability to be with difficulty (Halifax, 2014).

Compassion is about being with the suffering or distress of another, including the self.

Components of compassion include: affective feelings, insight or awareness of the feeling

states of another, and knowledge of how the other’s state of being relates to oneself (Asher et

al., in press; Halifax, 2012; Klimecki et al., 2013). Reported empirical benefits of cultivating

compassion include increased positive emotions (Dunn, Aknin, & Norton, 2008), improved

physical health (Carson et al., 2005; Kok et al., 2013), and a reduced immunological stress

response (Pace et al., 2010). Weng and colleagues (2013) reported positive increased altruistic

behavior after a two-week training of cognitive activities in offering compassion to the self,

loved ones and strangers. Weng and colleagues further reported FmRI findings from their

study with 56 young adults showed increased activation in the inferior parietal and

dorsolateral prefrontal cortex which are areas associated with compassion and emotional


regulation. In contrast, compassion can transpire in a negative manner. For example,

compassion can be offered in unskillful ways that Trungpa Rinpoche called ‘idiot

compassion’ (Chodron, 2007). Chodron (2007) described unskillful compassion as enabling,

or helping someone else for your own purpose when you cannot bear to see them suffer. She

countered that sometimes the compassionate response is "no,” speaking the truth, or setting

clear boundaries. Therefore, skillful means and discernment are imperative for compassion to

be beneficial.

Personal Context My journey to this project of training compassion for hospice volunteers started in my

professional career as a speech language pathologist caring for medically fragile children,

often in ICU settings. This exposed me to death and serious illness on a frequent basis. As

my meditation and spiritual practice evolved over the last 15 years, I had the increasing

insight and desire to bring more of my spiritual life into my work life. In 2010, I was

encouraged to enroll in CPE (clinical pastoral education) for healthcare workers at my place

of work after I spoke of my waning enthusiasm/satisfaction in my professional life. I was

opened up to a new blending of worlds that allowed talk of spirit and professional care in the

same conversation with my patients and their families. My professional practice was renewed

after completing a unit of CPE. I also began to offer compassionate care rounds to my

department co-workers. So in 2012, when I came across an advertisement for the Upaya

Buddhist Chaplaincy program on the hospital CPE website, I felt a calling from a deep place

to apply immediately. Once enrolled, it felt natural to seek my volunteer hours for the

chaplaincy program through hospice since my work life had been with serious illness and

death for the past 30 years. I took review of my trainings at Upaya Zen Center, including the


G.R.A.C.E. program in compassion introductions to SRM (Social Resiliency Model) by Drs.

Leitch and Sutton of Threshold Global Works, and the chaplaincy fundamentals. Examples of

the fundamentals included the Three Tenets of the Zen Peacemaker Order (i.e., Not-knowing,

bearing witness, and loving action), the Buddhist precepts, such as doing no harm and not

putting self above others, The Four Noble Truths about the existence of suffering, and the

Eightfold Path that highlights the eight-part path to liberation as the fourth noble truth. From

this review I had an insight that I could once again combine my spiritual and work life by

offering compassion training in the healthcare profession to graduate students in speech

language pathology. I pursued this and had arranged to offer the training to a group of

graduate students where I was teaching as adjunct faculty in Boston. However, I made a life

transition in this process and moved to Maine so was not able to complete the training.

Subsequently, resources available in Maine led me to the local hospice where I enrolled as a

volunteer. This hospice organization was seeking to revitalize their volunteer training and

reconnect the currently trained volunteers who felt under used in the setting of a low patient

census. The hospice volunteer coordinator was quite receptive to my proposal of offering

compassion training to their current group of trained volunteers. I then began adapting the

training approaches I had planned for the graduate students for the hospice volunteers. This

approach of caring for the caregiver was a natural flow for me since I have been doing so

throughout my career in supporting parents of children with serious illness and disabilities.

Role of the Buddhist Chaplain The Buddhist chaplain was described as following in the Buddha's footsteps to offer relief of

suffering from dying, illness and old age (Block, 2013). Specifically, acting as a Buddhist

Chaplain offers the opportunity to share our recognition and awareness of our true nature to


allow others to awaken and gain freedom from their suffering. Rev. Jennifer Block describes

this journey that the chaplain takes with others to alleviate their suffering as a profound

opportunity to develop skillful means to allow others to see where they are clinging and ways

to “loosen the grip.” Likewise, the chaplain’s role includes deepening in their awareness of

their own suffering to know the suffering of others, to know when they are seeing through the

lens of hope, fears and dreams versus seeing things as they are. As a chaplain, it is key to be

aware of the trap of dualistic thinking (good/bad; right/wrong) and to keep impermanence

(including death) as a guiding principle, knowing that change can be beautiful and safe as a

means of easing suffering. Rev. Block offered that the Buddhist chaplain provides spiritual

support by being willing to bear witness to the suffering of others, willing to listen to stories

of other’s lives, creating opportunity for awakening, and helping others face their lives in a

truthful way. This requires cultivation of inner stillness, clarity, and love in order to help

others hold all that is present from grief to joy.

The chaplain’s role in the end-of-life care includes caring for those distressed, seriously ill and

dying as well as their families. In addition, the chaplain’s care also extends to the community

and those that care for the sick and dying. Roshi Joan Halifax (2013) wrote: “meeting the

community in death may create community in life.” Halifax goes on to describe the Pew

Health Professions Commission model of caregiving with the sick or dying as a relationship-

centered care model. This model includes the importance of the relationship between

healthcare practitioners, including volunteer care providers. Health care practitioners often

connect around values, knowledge and skills. When offering care to another, the Pew

Commission highlighted the importance of respect and appreciation/gratitude for the patient’s

personal and community life. The practitioner will benefit from honing their listening skills to


know what will serve. Halifax (2013) contends that caregiver relationships in community

building benefit from including: self-awareness, appreciation of diversity, sense of mission,

openness, humility, trust, empathy, and support. These caregiver relationships are

strengthened by having self-knowledge, knowing diverse healing approaches, knowing about

team building, team dynamics and power inequities. Halifax offers that leading care providers

in self exploration and supporting them in deepening their communication and listening skills

helps to support their care of others. When the caregiver has greater peace, stability, openness,

and acceptance, they benefit themselves, the dying and the community (Halifax, 2013). Thus,

the care provider, including hospice volunteers, may receive support and benefit from a

chaplain. Specific benefits from a Buddhist chaplain include training in meditation,

compassion, awareness, and inner stillness for being with suffering.

Training Compassion in Hospice

One approach to supporting volunteers in communication and listening skills includes

meditation and compassion training. For example, Coberly and Shapiro (1998) conducted a

study offering approaches in meditation, mindfulness, and compassion training for hospice

volunteers and reported positive outcomes for patients feeling heard and cared for at the end

of life. Further, Coberly and Shapiro examined the concept of transpersonal experience in

hospice volunteer training. The authors advocated for increased training approaches for

hospice volunteers that examine transpersonal experiences around each person’s own feelings

and awareness of death. Transpersonal approaches in the hospice setting reportedly also

included training in empathy and compassion so that love, acceptance and openness could be

offered to the dying person. The authors also spoke of the value of meditation to strengthen


the container for deep listening and connection between the caregiver and patient. The authors

described early programs in the 1970s that supported such concepts including the Shanti

Project developed by Charles Garfield and the Hanuman Foundation Dying Project developed

by Ram Dass and Steven Levine, and more currently, the Zen Hospice Project founded by

Frank Ostaseski. Coberly and Shapiro posited that the caregiver who has the courage and

compassion to actually “stop for a moment, take a deep breath, and be with the dying person

can offer a deep and loving presence.”

Contemplative care approaches for training hospice volunteers were further explored by Larry

Schwerwirtz and colleagues (2006) who developed a 12-month training for hospice volunteers

at the Zen Hospice Project in San Francisco. A group of 46 volunteers participated in a one-

year prospective study receiving an initial 40 hours of training in compassion, equanimity,

mindfulness, meditation, and practical bedside care over a two-week period. The focus of the

training included approaches and activities to foster openheartedness and readiness to serve

the resident. Specific exercises included: empathic listening; a loss exercise involving

imagining loss of abilities, valuables, and loved ones; learning skillful touch with a patient;

and a group review of volunteer family members who died over the past year followed with a

Buddhist ritual goodbye and sharing of reactions. Additional activities included basic massage

techniques for muscle inactivity and a photo exercise in which a series of photographs of

residents, not known to the volunteers, who died at the hospice are shown to the volunteers

and a circle is formed to share reactions. This training was supported by monthly lectures on

topics related to Buddhism or dying. The reported findings showed there was reduced fear

about dying and the volunteers rated themselves with increased ability to feel and express

compassion. In addition, the volunteer coordinator observations revealed that the volunteers


demonstrated increased skills in being a calm presence, listening empathetically, and bearing

witness to suffering.

Overview of Thesis

Overall, there is a trend to expand hospice volunteer training to include more in-depth training

in empathy and compassion, as well as self-care. Such approaches are generally occurring in

larger hospice programs in metropolitan areas (e.g., Zen Hospice Project). The purpose of

this pilot survey study is to replicate compassion training with trained hospice volunteers in a

rural setting who currently have a low patient census, are offering primarily home and nursing

home based care, and have no regular group volunteer support meetings. I explored the role

of a Buddhist-trained chaplain providing care for the caregiver. My hypothesis was that such

training would provide support for volunteers during caregiving with hospice patients as well

as caring for themselves, and renew connection among themselves as a support to one

another. Further, that embodiment and attention practices would improve the volunteers’

capacity to respond to difficulty and to care for others. The components of this training were

drawn primarily from trainings I received during the Upaya Chaplaincy program the past two

years (e.g. attuning, setting intentions, shadows of caregiving), as well as from meditation

trainings with my current teacher, Lama Willa Miller and from inquiry approaches learned

through Diamond Approach retreats.

Background and Literature Review

Views of Compassion

Getz, Keltner, Simon-Thomas (2010) define compassion as “the feeling that arises in

witnessing another's suffering and that motivates a subsequent desire to help. Chogyam


Trungpa Rinpoche taught that compassion involves loving kindness and generosity, including

friendliness toward ourselves. This can result in extending this loving warmth to other

sentient beings (as cited in Shambala Sun Magazine, 2015, p. 47). Condon and Barrett (2013)

further discern about compassion in their study of conceptual and direct experience of

compassion that compassion can be both pleasant and unpleasant as one takes in the suffering

of another. The topic: ‘Is compassion good?’ was recently debated at the International

Symposium for Contemplative Studies with Davis and colleagues (2014) that reportedly had

mixed views on the subject. When examining where compassion arises in the human, Getz

and colleagues (2010) provide a mapping of the emotion in the brain. They discuss the

findings from FMRI studies showing how the various components of compassion are

registered in the brain. They reported that as a person has awareness of someone’s distress by

their facial expression there is activity in the tempero-parietal junction. Then, the receiver

mirrors back the emotional experience noted by activation in the frontal and temporal lobe,

followed by decision-making if the sufferer deserves a response in the prefrontal cortex. The

prefrontal and frontal cortex help cope with empathic distress in knowing the suffering of the

other. Then the expression of warmth and tenderness stem from the basal ganglia region and

dopamine neurons, supported by motivation to act in the left hemisphere.

Examining compassion from a Buddhist perspective, Halifax (2012) discusses her new

heuristic model of enactive compassion (ABIDE) that is especially applicable to training

compassion in clinicians. Halifax contends that the traditional view of compassion with two

components of noting the suffering of another and then acting to relieve that suffering may be

limited. This enactive model views compassion as an organic process that unfolds from the

interaction between a living being and the environment based on how humans are sense-


making beings. Thus, compassion is a dynamic process involving the body, mind and

environment. There are internal components of interaction with attention, cognition and the

somatosensory systems. These internal realms are influenced by an individual's external

political, social, and ethical values. In addition, non-compassion components are discussed

that ‘prime’ and optimize compassion: balance of attention and affect, cultivating intention

and insight to prime discernment, and embodiment and engagement that prime enactive,

ethical, and engaged responses to the presence of suffering. These latter components are

subjective in relation to each person’s internal responses. Halifax divides these non-

compassion components into three axes that support or prime the three parts of compassion:

emotion, cognition, and somatosensory. Emotion axis: Attentional balance requires focus,

sustainability, and selectivity to attend to what suffering is present and one’s response to

suffering. Affective balance includes both kindness and equanimity. Kindness allows one to

offer warmth or concern to the other or the self, while equanimity is the stable base of wisdom

and openness. Cognitive axis: Intentions to alleviate suffering (for another or oneself) can

call on one’s ethical commitment or vow (from a Buddhist view) of doing no harm or helping

others. Insight is aided by self-awareness, moral grounding and understanding of

impermanence and interconnectedness when responding to suffering. Also, not being

attached to outcomes is crucial. When certain outcomes are expected, then the caregiver may

strive toward a particular direction and not allow what is called for or be disappointed when

suffering may not be alleviated. Somatosensory: Embodiment (or grounding) is an enactive

resonance that involves one sensing the other’s suffering in the body, creating an interactive

resonance. While engaging refers to the body’s readiness to act, Halifax contends that to train

cultivation of compassion, including in those providing care at the end of life, compassion


needs to be defined in all its interactive components and what will sustain and optimize

compassion.

Another important concept in cultivating compassion is to know how it is different from

empathy. Empathy is about feeling with the other person, having affective resonance whereas

compassion is feeling for another person, having insight about that person, resulting in mental

or physical action. Over-arousal can occur with empathy and create fatigue or burnout from

neurobiological responses that are related to interoceptivity (i.e., resonating with the sufferer’s

affective state). So to go beyond empathy to compassion requires attentional and affective

balance, especially in the setting of the sympathetic nervous system being up-regulated in

intense emotions. When one can be embodied and grounded with clear intentions and insights

about self and other, than equanimity can be present in the relationship versus enmeshment

and loss of boundaries. This is a space where true compassion can flourish to allow well-being

for the other (Halifax, Back, & Hylton Rushton, 2013).

How Does Compassion Benefit Others?

The in-depth study of defining compassion and how it is cultivated has also yielded a

multitude of benefits of practicing compassion from health to social connection (Condon et

al., 2013; Hutcherson et al,, 2008; Seppola et al., 2014). Seppola and colleagues examined

social connection and compassion and reported how training in compassion and loving

kindness facilitated increased immediate emotional connection and acts of kindness toward

others. Social connection has become increasingly fragmented as we move faster and faster

with electronic media and move away from our social supports and families. The General

Social Survey (GSS) by McPherson and colleagues (2006) indicated that from 1985 to 2004


the number of Americans who feel isolated has tripled to 25% that means one in every four

people feel that they don’t have someone to share important matters. James Doty (2012),

director of the Center of Compassion and Altruism, and Research at Stanford University,

reported that loneliness is associated with health complications. Doty references work by

Steve Cole that shows immune disruption at the gene level related to loneliness. The

psychologists, Diener and Seligman (2004), add that social connectedness is a predictor of

living longer, greater happiness and sense of purpose.

Other examples of positive benefits of compassion include increased prosocial behavior.

Leiberg, Klimecki, and Singer (2011) reported that after offering short term compassion

training they found evidence of increased prosocial behavior with participants more likely to

help a virtual partner in a computer game. The compassion-trained group of 68 females

received a one-day training of six hours in loving-kindness meditation directed at themselves,

a neutral person, and someone about whom they cared. The matched control group received

memory training. Other positive outcomes from cultivating compassion were reported by

Jazaieri and colleagues (2013). Jazaieri and colleagues examined 100 participants:

randomizing 50 to the compassion training group, and 50 to the non-trained group. The

Compassion cultivation training (CCT) was a structured, comprehensive compassion

meditation training program developed by a team at Stanford University. CCT consists of 18

hours of training over seven weeks and daily compassion-focused meditation practices.

Sample practices included loving-kindness meditation (LKM), meditation with attention to

one’s experience, tonglen with focus on the suffering of self and others and offering freedom

and wellness, and focuses on quieting the body and mind. Jazaieri and colleagues reported

increased mindfulness and happiness on self-report tools, as well as reduced reports of worry


and pushing away of emotions. As mentioned previously, Seppola and colleagues (submitted

for publication) reported positive outcomes using a 10-minute loving-kindness meditation

with a randomized study of 168 college students. Assessment outcomes showed improved

well-being and feelings of connection as well as decreased self-focus compared to the other

two control groups. Seppola and colleagues conjectured that such an efficient approach may

serve as a resiliency measure to be used with healthcare providers whose time is limited in

their daily work, as well as have a positive effect on patient care.

Compassion training for those in health care has included aspects of mindfulness, meditation,

self-care and building resiliency while caring for others (Halifax, 2014). Fernando and

Consedine (2014) discuss a Transactional Model of Compassion for physicians that goes a

step further to note the influence of families and patients as well as the work system. These

authors supported mindfulness and meditation approaches as offering support for healthcare

providers to self-regulate emotions, being present in the moment of care, as well as

compassion training to enhance awareness of others’ suffering, and to act to relieve that

suffering. However, for healthcare providers to sustain the compassion, Fernando and

Consedine proposed that the other components of the interactive system also need to be

sources of support. Patients and families could benefit from communication and education

training on how to effectively state their needs and to have increased understanding of the

medical perspective. Also, a supportive work environment with cooperative interdisciplinary

interactions for best patient outcomes would allow compassionate care to be provided with

greater ease.

Training Compassion and Contemplative Care


Based on these prior studies of benefits of compassion, researchers have been exploring

effective approaches to training compassion and to establish a more universal understanding

of compassion with all its complexities and controversies. These approaches have originated

from a variety of professional and theoretical backgrounds, such as science, psychology,

social work, and non-secular Buddhism. Compassion training has been implemented with a

variety of approaches, including meditation, mindfulness, metta practices (loving kindness),

deep listening, and developing kind language toward the self (Jinpa, 2015; Klimecki et al.,

2013; Leiberg, 2011; Neff & Germer, 2013). Neff and Germer reported positive changes in

compassion for the self after an eight week-training using such approaches. Compassion

training practices have been implemented with physicians and nurses with reported positive

outcomes for being with difficulty in their profession (Halifax, 2014; Klimecki et al., 2013;

Neff & Germer, 2013).

Dewer (2012) used creative approaches such as poetry, photo elicitation, and role play with

healthcare providers in a medical setting to foster increased insights to what compassion

meant to them. Healthcare providers enacted role play situations with their own patient care

scenarios, created team summaries using poetry phrasing to tell stories of patient care versus

more stark clinical summaries, and viewed photos depicting compassionate care and tender

interaction over a period of several months. Outcomes revealed changes in healthcare

provider patterns with patients, such as offering more caring compliments to patients and their

families, spending more time with an episode of care, and more positive views of themselves

as care providers.

Halifax (2014) describes a training she developed based on Buddhist principles to cultivate


compassion in the healthcare setting called G.R.A.C.E that was used with nurses in a hospital

setting. The G.R.A.C.E training is supported by the principles of her earlier ABIDE model of

compassion (Halifax 2012). The pneumonic GRACE represents Gathering attention,

Recalling intention, Attuning to self and other, Considering what will serve, and Engaging in

skillful action followed by ending the interaction. Attention practices involve internal

processes of noticing and being present for one’s experience. For example, pausing to gather

attention, grounding in the body by feeling the feet on the floor, attending to the in and out

breath, or recalling a resource such as a positive patient interaction. Recalling intention

involves bringing to mind a person’s motivation and purpose of what is intended to be offered

in a moment of care for another. Setting intentions taps altruistic motives for why one is

engaged in their work. Recalling intentions is followed by attuning to self and other.

Attuning involves noticing one’s direct bodily experience that can aid attention to what

emotions and thoughts may be present prior to interacting with a patient as well as what

emotions and thoughts are being activated by the situation of care. Attuning helps to highlight

attitudes and biases that can affect patient care delivery. Once you attune to the self, then a

base for empathy has been created for the provider to attune to the emotional and physical

state of their patient. Once attention has been gathered, intentions have been set, and

attunement is present for self and other, than the care professional can consider what is needed

in the situation. Professional training, intuition, institutional guidelines, and knowledge of the

patient needs all interact to guide the provider to know an appropriate response in a care

situation. Once all these elements of attention, attunement, and discernment are present,

ethical and compassionate-based action can unfold. This process of G.R.A.C.E. allows for

slowing down responses in a moment of caretaking that offers space to cultivate compassion.


Social Resilience Model (SRM), developed by Laurie Leitch, PhD and Loree Sutton, MD, is

another source of supporting those who are suffering (Leitch & Sutton, n.d.) This model

focuses on building individual or system (e.g., an organization) resilience to distress through

biological self-regulation. For example, if a nursing department was experiencing distress

over random downsizing of staff, SRM could be used to assist with emotional distress

behaviors of staff. Neurophysiological aspects of safety, attention, attachment, and integrative

function are incorporated within practical skill-building approaches to support human

resilience to distress. Approaches include building attention, how to shift physiological

responses when dysregulation occurs, and promote resilience or capacity to establish and

sustain stability. These SRM approaches (e.g., grounding in the body, recalling a resource)

can be offered in a training setting for dyads and groups, or used alone to sustain and regulate

the nervous system balance in the setting of under and over arousal when a disruption occurs.

Sensory system language is highlighted in this model to include sight, touch, smell, taste, and

sound as a means to access the nervous system regulation. Overall goals of SRM are to

encourage curiosity about internal sensations in response to disruption, to foster resilience for

the nervous system capacity to shift attention between states of comfort and discomfort,

release unknown/undigested stress, restore balance, to deepen the resilient zone with practice

so reactivity is less and recovery process to distress is shorter, build self-regulation skills, and

increase prosocial behaviors. SRM was developed from a trauma resiliency model used in

situations such as natural disasters and physical/emotional trauma (Leitch, Vanslyke, & Allen,

2009).

Halifax (2008) offers some easily accessible contemplative care practices for care providers at


the end of life that involve following the lead of the dying person. Offerings may include

sharing a prayer or other contemplative practice, or simply slowing down and watching the

breath to offer oneself stability. Other suggestions include a short verse or meditation, such as

“breathing in, I calm my body and mind, breathing out, I let go” (Thicht Nhat Hahn). The

caregiver can also stay connected to the dying person through their senses, noticing sights,

smells, objects in the room. Finally, Halifax offers a Tibetan practice of envisioning the dying

one as your mother or dear loved one as a way of connecting more deeply. These are all wise

suggestions that a chaplain may have at their disposal while caring for someone who is dying.

Role of Buddhist Chaplain

Guidelines of a Buddhist Chaplain. Halifax and Senauke (2014) offered guidance for

Buddhist chaplains in training. They discussed how the precepts are moral guidelines for

being upright in the world. Approaches were offered to cultivate a steady mind and open heart

to be ‘worthy’ of witnessing the suffering of others, and to live an ethical and moral life.

When the mind is stable, response with skillful means is possible in the presence of difficulty.

Important qualities to uphold as a chaplain include trust, truth, and open presence/awareness.

Starting with knowing our own suffering and being deeply present and kind to ourselves is

vital for serving others. As stability of the mind grows we have better access to our basic

goodness and inner wisdom that will inform how to be with suffering.

There are three views or lenses to examine the precepts that include: literal (to abide by rules

in a system), practical (to live out in our lives), and wisdom (to be able to keep a bigger view).

It is important to customize the precepts to illumine our own biases, such as the need to

control, lack of trust, or complaining/speaking ill of others. Likewise, from the view of classic


Buddhist teachings, we also need to strictly monitor the ego as it may override our

consciousness and allow elements of the three poisons (greed, hate, delusion) to cloud the

mind. In this way, transparency to self and others can be cultivated. Chaplains often face

moral distress, uncertainty and conflict in the setting of conflicting moral values or system

dysfunction. Thus, cultivating moral sensitivity and having moral values to guide our actions

can keep balance and harmony in our responses.

In addition, the Zen Peacemaker tenet of Not Knowing keeps the field of respect and humility

alive so that we are fully aware of the consequences of our actions or non-action. Roshi

Bernie Glassman describes Not Knowing as “entering a situation without being attached to

any opinion, idea or concept. This means total openness to the situation, deep listening to the

situation.” (Glassman, nd) Employing inquiry into our behaviors and views can help to sustain

meaningful connection as well as keep us on a moral and ethical track. What is my intention?

What do I need to atone for today? We may need to cultivate bravery to be with our fears and

to allow intimacy and vulnerability to be present. Speaking the truth can be difficult and yet

being accountable is vital as a chaplain. It is important to leave our suffering at the door so

we do not transmit it to the one we are serving. Knowing impermanence and holding non-self

helps one to be with change, loss of control and to know we are not separate from the other.

Then, ultimately, you can see what is needed in the situation, show up with full presence, and

act with skillful means. This allows the other to more fully explore their own suffering.

Along the path of service, the six paramitas, i.e. “practices of perfection” (dana or generosity,

sila or virtue, kushanti or patience, virya or whole heartedness, dhyana or concentration, and

prajnaparamita or wisdom) support us in caring for others as we cultivate aspects of each


paramita. Looking through the lens of how things are versus lens of deficiency helps one to

act from a place of love rather than violence. Create community; take time to know a system

before entering so right relationship may unfold. These are the tenets of a chaplain (Halifax &

Senauke, 2014).

The Role of a Chaplain in Hospice. Hospice chaplains provide a spiritual presence

generally without a particular religious orientation though they do have a religious rooting.

Chaplains operate in an interfaith/multi-faith capacity that allows them to be supportive of the

religious beliefs of those they serve. A hospice chaplain may offer patients and families

companionship, prayer, and listening from the heart without judgment. The chaplain also

provides support to hospice staff and care providers, and bereavement support to family

members (“Role of Chaplain,” 2014; Williams et al., 2004). The role of the chaplain with

hospice team members has been reported to include supporting individual self-care

(Wittenberg-Lyles et al. 2008). The hospice chaplain also provides support and training to

team members in spiritual care and are often included as a part of the volunteer training

curriculum. (“Chaplain Guidelines from the NHPCO”, n.d.). In the programs where I received

volunteer training, the chaplain offered a one-hour seminar on the spirituality needs of

families and children. At Hospice Volunteers in Waldo County, the chaplain provides a two-

hour curriculum on self-care and listening skills.

In summary, contemplative care and Buddhist-based practices in meditation, mindfulness and

compassion have been offered on a limited basis to hospice volunteers. The most extensive

training of this kind is being offered to hospice volunteers through the Zen Hospice Project in

San Francisco. Evaluations of hospice volunteer training programs cite the need to improve


more in-depth trainings in empathic listening, compassion, and communication. Studies have

shown the benefits of training health care providers and hospice team members, including

volunteers, with meditation, compassion, and empathic listening. The purpose of this pilot

survey study was to offer training compassion to hospice volunteers in a rural setting who had

not previously received this type of training.

Objectives of this study:

1. To heighten awareness of what is present in the body, mind and feelings through

reflective circles and dyadic inquiry.

2. To increase knowledge of personal pitfalls/shadows that can create limitations to

caregiving in the hospice setting.

3. Provide education for understanding the similarities and differences of compassion

and empathy.

4. To explore how to engage with patients and the community on the topic of death and

dying.

5. To provide training in practices of embodiment, attention and mindfulness to assist

being with difficult emotions and situations.

Hypotheses:

● Hospice volunteers will benefit from self-care practices in compassion and empathy to

support their care for patients and families in a hospice setting.

● Embodiment and attention practices improve one’s capacity to respond to difficulty

and to care for others.

Methods


Participants

Twelve hospice volunteers participated including ten from Waldo County Hospice Volunteers

in Belfast, Maine and two from Coastal Family Hospice Volunteers in Rockport, Maine in this

survey study using a longitudinal design. There were 11 females and one male participant.

The age range spanned from 35 to 83 years of age. Years of hospice volunteer experience

ranged from zero to 30 years with a mean of nine years. Four of the 12 volunteers had two

years or less experience. Approximately 72 volunteers from Waldo County Hospice and 40

volunteers from Coastal Family Hospice were eligible to participate. Enrollment was offered

to hospice volunteers with Waldo County Hospice first and then later offered to a neighboring

hospice program: Coastal Families Hospice Program to increase enrollment. Volunteers of

any age or gender were invited to enroll. Participants were required to have completed

volunteer training and actively available to receive patient assignments. Commitment to

attending all four training sessions was required for participation.

Procedure Overview

The hospice volunteers were offered four 90-minute training sessions. The sessions met once

a week over a four-week period. The location of the sessions was at the Waldo County

Hospice Volunteer conference room. The meeting time was 6-8 pm, including a light meal

from 6 to 6:30 pm. The group was arranged around a rectangular table. A center piece was

arranged on the table including a khata with seasonal gourds, a candle, and fresh flowers.

The focus of the training was compassion using practices in reflection, inquiry, and

contemplation. Tools such as reflections circles, embodiment, deep listening, inquiry,

recalling a resource, role-play, attention and mindfulness were offered. These tools were


applied to caring for the self, caring for hospice patients, and caring for the community. An

initial introduction to the trainings was offered at the first session explaining the importance to

be aware of how we are feeling and the value of being present and compassionate to our self

before we can be fully present for another, that we are caring for, as a hospice volunteer. The

Fear of Compassion Scales (Gilbert et al., 2011) were administered at the first and final

session (see Appendix A). Participants were encouraged to engage in the practices that were

introduced in each weekly session during the following week between training sessions. A

home practice log was provided to each participant to record the type and frequency of

practice completed (see Appendix B). These practice logs were collected the next session each

week. Each session began and ended with a council format referred to as a reflection circle

for the participants. At the final session, the participants were each provided with a laminated

pocket card summarizing the compassion practices demonstrated during the course of the

training (see Appendix C). A request for feedback was emailed to the group three days after

the last session and again one month later. Participants were invited to comment on what

worked for them in the trainings and what changes or suggestions they had to offer, as well as

what practices they were continuing to use in hospice or outside of hospice.

Trainings

Session one. Caring for the caregiver.

Meditation and reflection circle. An altar space was created for each person to place

an object of meaning that they were asked to bring to this first session. The session began

with two minutes of guided meditation where I invited participants to notice the contact of

their feet with the floor and then the contact of the body with the chair. This was followed by


three deep breaths into the lower belly. I continued to guide the participants, inviting them to

notice physical sensations in the body, awareness of what thoughts were present and arising of

emotions.

A short reflection circle (10-15 minutes) followed the meditation. I provided guidelines that

mirrored a council format (Zimmerman & Coyle, 2009), including one person speaking at a

time, no cross talk, speaking from the heart, listening from the heart, speaking to essence,

maintaining confidentiality, an option to offer silence, and speaking spontaneously. I

provided further details regarding listening from the heart, including listening from the heart

space, hearing the tone versus the words spoken, letting go of advice or judgments, being a

vast container, and noticing what arises in you as you listen. The talking piece was a gourd

from the center piece that each participant passed counterclockwise around the circle as as

they shared. For this first circle, each person gave their name, residence, length of

volunteering and answered ‘what draws you to hospice work?’

Deep listening. Following the opening activity I gave an introduction to deep

listening with an inquiry question completed in pairs. Each person in the pair spoke for five

minutes in a monologue format to answer the question: ‘what are your concerns about being

with a dying person?’ The listener provided deep listening, with no verbal responses, limiting

their facial expressions, and noticing their own physical or emotional responses to the speaker.

Pausing occurred before starting, after each speaker and when the group returned to the table.

Popcorn style of sharing experiences occurred after the activity.


Preparation for patient visit: setting intentions, grounding, and recalling a

resource. The next series of activities followed the timeline of a patient visit, including

preparations before entering the patient’s home, during the patient visit, and following the

patient visit. Preparing to see a patient started with having each person generate a written list

of intentions they might say to themselves before entering a moment of care to indicate why

they are there and what is their motivation. Examples given to the group included, “may I be

a loving presence”, and “may I arrive with an open mind and heart.” After each person

generated a list, I guided the group to close their eyes and say one of their intentions silently

while sensing into the body what they noticed when indicating why they are really here to do

this work. Brief group sharing occurred after the activity.

After the intention activity, I guided the group in grounding and recalling a resource. I invited

each person to write a list of personal resources that offers a sense of peace, calm or freedom.

Then the group gathered in pairs to share one resource from their list and asked to notice what

arose in the body as they described their resource. Following this, I led the group in a

grounding activity. I suggested to visualize yourself in your car or outside your patient’s

place of care. I then guided the group through grounding in the body, followed by three slow

deep breaths in the lower belly, and then bringing a resource to mind while noticing

sensations in the body. While you visualize entering the patient’s residence, I guided, repeat

your intention to yourself. The remainder of the patient care activities were extended to the

next training session to comply with the meeting time of the group.

The session ended with a reflection circle where each person gathered their object from the

group altar and shared what meaning the object had for them. I then provided home practice


logs for the coming week. I encouraged the participants to practice and record during the

following week what we had learned today: deep listening, use of three deep breaths, and

recalling a resource.

Session Two. Session two focused on caring for the patient and for ourselves.

Meditation and Reflection. I extended the gathering meditation to three minutes this

session. In addition to the awareness of body, breath, and mind, I added some aspects of

Maull’s (2013) meditation: you are safe, fully resourced and connected. The short reflection

circle following the meditation started with reviewing the principles of council: speaking and

listening from the heart, speaking to essence, not rehearsing, and offering silence as an option.

I asked each person to share “a way you offered care for yourself today.” Following the

reflections, I invited each participant to close their eyes, recalling this episode of self-care and

to bring to mind where they were at the time (inside/outside), any sensations of temperature,

visual or auditory input, and what the body was sensing in this moment as a means of

intensifying this moment of resourcing.

Caring for the patient. The patient care activities continued from session one, now

focusing on direct interaction with a patient. I shared information on the stages of dying:

separation, transitioning, and active. The activities for this session focused on the separation

phase including finding meaning and expressing feelings that had been outlined at the retreat

at Upaya Zen Center titled: “Contemplative Practices and Rituals in Service to the Dying”

(Ostaseski & Halifax, 2014). I outlined various approaches for the volunteers to consider

during a patient visit such as drawing a mandala, creating a scrapbook of photos or recording


life stories, a finger labyrinth, open-ended questions, Go Wish cards, a sand tray/altar, or

inviting the family to share stories about their loved one.

In addition, I provided suggestions for the volunteers if they found themselves overwhelmed

or distressed such as connecting to the moment: sensing into the body, taking three deep

breaths, looking out the window or around the room, or having a drink of water (Halifax,

2008). I then invited the group to share recalled moments of patient care that involved

making meaning or expressing feelings. Following this sharing, the participants took part in a

role-play activity using either a finger labyrinth or Go Wish cards. I reviewed the instructions

for using the finger labyrinth and Go Wish cards with the group. I then asked the group to

generate two or three patient scenarios before gathering in pairs. The group selected a 49-

year-old woman with Stage Four cancer, and a 73-year-old male with new onset of dementia.

After the group generated the scenarios, they moved into pairs with either a finger labyrinth

and labyrinth instruction sheet, or Go Wish cards. Each person in the pair took turns as the

volunteer and then the patient. Before starting, I asked the group to pause, ground in the

body, attune to what sensations or emotions were present, perhaps they were nervous, unsure,

or irritated and to just to simply notice. I then invited them to notice their experience

throughout the activity, and pause and slow their pace as needed. Each person was allowed 10

minutes to be in each role for a total of 20 minutes. Afterwards, I invited a brief pause to

reflect on what was spoken and heard. Then the group offered reflections on what worked

and what was difficult about the activity.

Compassion and empathy. As a prelude to discussing empathy versus compassion, I

led a brief group activity to highlight our common experiences with illness, old age and death.

I first explained that knowledge of our shared experiences with suffering can connect us with


our patients and can provide a basis of having compassion and empathy. I then asked people

to stand briefly at the table after the following statements were read: “if you have lost a family

member, if you or someone you know suffers from addiction, if you know someone who has

died from suicide, if you or someone you know suffers from depression, if you or someone

you know suffers from cancer.” I then invited a moment of pause and reflection to notice our

common experiences and what understanding we bring to our patients.

I then introduced compassion and empathy concepts, including definitions that were provided

in the G.R.A.C.E: Training in Compassion-based Interactions in the Clinician/Patient

Encounter at Upaya Zen Center (Halifax, 2013). Compassion was defined as “the capacity to

attend to the experience of another; to feel concern; sense what will really serve another; and

potentially be able to help another (can't always do something)” and empathy was

distinguished as “feeling with the other person, having affective resonance (an understanding

or resonating with the other’s feelings)” coming from a knowing of the other person’s

experience based one’s own experiences (G.R.A.C.E. training, 2013). I offered a further

comparison, indicating that “compassion is feeling for another person, having insight about

them that may result in a mental or physical action.” I emphasized that keeping one’s

attention and affect in balance was key when offering care to a seriously ill or dying person so

that we do not become enmeshed in the other. Also, I suggested that grounding in our body

and keeping clear intentions about the care and presence being offered will help in

maintaining a clear boundary between the volunteer and hospice patient. I explained that our

nervous system can become activated in confusion and fear, so using the body and breath to

be aware of our feelings and body sensations can help regulate our responses and allow us to

be a beneficial or skillful presence to our patients. If we over-engage in our patient’s


suffering, fatigue and burnout can occur as well as unskillful responses or reactions. Consider

what is really needed, such as silence, listening, or perhaps leaving. Monitoring our language

is also important, so that we do not attempt to ‘fix’ things, offer advice, or assume how the

other feels.

Compassion-empathy practice activity. The group then participated in a final dyad

practice in deep listening focusing on empathy and compassion as well as use of grounding

with balance of attention and affect. Each person in the pair shared a mild to moderate

difficult situation from a patient care, personal life, or work situation. The person listening

practiced grounding, deep listening, noticing their own physical and emotional responses to

what was being spoken. The speaker also grounded in the body and noticed their experience

while speaking. Pausing occurred before and between each verbal sharing. I then invited

everyone to close their eyes and visualize that they had just finished a patient visit. I asked

the participants to imagine sitting in their car and taking a moment to notice what feelings or

sensations were present, perhaps anger, sadness, tears, jaw clenching, burning in the chest. I

encouraged them to allow whatever arises to be present. I suggested that there was no need to

“get calm.” I then guided them to offer a cleansing breath to themselves, placing a hand to

their heart and offering themselves kindness, saying a prayer, or simply an offering of letting

go. The group then shared their own practices of care at the closing of a volunteer visit.

Closing reflection circle: I asked each person to share about an object that they

brought. Specifically, how the object reflected something from their heart or to share

something that came up during this training session.


I provided a home practice log to each person with an invitation to practice caring while

attuning to oneself and to the other, noticing episodes of compassion and empathy, and

continue with deep listening and resourcing. Later in the week, I emailed a summary handout

to the group outlining patient activities for making meaning and expressing feelings (See

Appendix D).

Session Three. Caring for ourselves.

Meditation and reflection circle. The session started with a 3 minute meditation. The

reflection circle after the meditation opened with the question: “share a moment of listening

you offered this week and describe your inner experience while listening, such as tense,

anxious, distracted, or judgment” or your assessment of how the interaction transpired.

Attunement activity. The group engaged in a silent activity to practice attunement to

self and other. The group gathered in pairs and I instructed to face each other with eyes

closed. I directed them to first ground in the body, feeling the support of the floor under the

feet and the sensing into the body contact with the chair, taking 3 breaths into the lower belly.

I then asked the group to simply notice or be curious what was present for themselves, noting

body sensations, any discomfort, or feelings arising for 1-2 minutes. I then guided each person

to open their eyes to attune to the person across from them using a soft gaze to take in the

whole person across from them, not needing to stare. I suggested to sense into how the other

was feeling by noting their body posture, skin coloring, or facial expression for a period of 1-2

minutes. Next I guided the participants to consider that one day this person in front of them

would die, to allow themselves to take this in though could be far in the future or any day. I

then suggested to take a breath, relax and notice what was coming up for each person, such as


fear or sadness. Then I invited each person to close their eyes, take a breath, relax and notice

what was arising in the body and the emotions. Each person then placed their hand on their

heart and I invited them to note that they, too, will one day die. I guided the participants to

notice their own experience as this thought was considered and to note that they are the same

as the being across from them, and then to offer themselves some kindness in this moment.

The participants then opened their eyes and took two minutes each to share their experience

with their partner in monologue fashion. I encouraged pausing between each sharing at the

close to acknowledge what was spoken and heard.

Brief Resource Recalling Activity. I guided each person o close their eyes, take 3

slow deep breaths into the lower belly, systematically relaxing the body, sensing the feet

being supported by the floor or the body in the chair. I then invited each person to recall a

resource from the list they had each previously generated for themselves. As they had the

resource in mind, they I suggested to notice any visual, tactile or auditory details and notice

what sensations arose in the body.

Shadows or Pitfalls of Caregiving. I described shadows of caregiving, including

habits or behaviors from our family of origin or difficult experiences that may influence our

caregiving with others. I provided examples such as wanting to be liked, avoiding

confrontation, wanting acceptance, love of drama or needing to be helpful. I noted that

having negative feelings arise during caretaking episodes (e.g., anxiety, fear, irritation) were

expected and not to be pushed away. However, the key is to notice our response or reaction to

these feelings such as causing one to freeze, to be over-helpful, or perhaps to talk too much to

fill the silence. Attention and awareness of feelings and emotions can connect us to our


patients, recognizing what it is like to have fear or anger. I then asked the entire group to

brainstorm about shadows of caregiving and then divide into groups of three to share

individual behavior patterns that may influence their caregiving approaches as a hospice

volunteer.

Listening and bearing witness activity. I instructed groups of 3 to each bring to mind

an episode of caregiving with a patient, family member, or friend that they felt they were not

skillful. Each person played the role of speaker, listener and witness. The speaker shared

their story in 3 minutes in monologue fashion with the listener. The listener offered presence

and deep listening without verbally responding and provided limited facial expressions. The

witness observed the resonance, tone of interaction, and connection between the listener and

speaker. After the speaker completed their story, the listener briefly reflected back what they

heard and the speaker affirmed or modified how the listener relayed their story. The witness

then provided feedback to the speaker and listener what they observed in relation to the

rapport and resonance noted between the two of them. Then each shifted to a new role until

each party had completed all three roles. At the end of the rounds the triads briefly shared

their experiences among themselves.

Closing Reflection Circle. The group shared any take away points or surprises from

today’s session.

Home practice log. Each person took a home practice logs to document during the

following week any of their shadow behaviors during moments of caregiving, and attuning


practices to themselves and others. Later in the week I emailed a handout of caregiving

pitfalls to the group along with encouragement in the practice activities (See Appendix E).

Session four. Caring for the Community.

Meditation and Reflection Circle. The session started with three minutes of guided

meditation. The group then completed the reflection circle in silence with each person offering

connection to each person in the circle through eye contact using a soft gaze.

Caring for the Community. I guided a brainstorm activity to explore ways hospice

volunteers offer care to the community outside of hospice. I gave examples to start the

activity, such as a listening presence or offering knowledge of community support services.

Once a list was captured on a flip chart, I asked the group to share stories when they had been

engaged in conversations with family or community members regarding death and dying, or

about misconceptions about hospice care.

Role Play Activity. The group then divided into pairs to engage in role play around

community conversations on illness, death and dying with one person being a hospice

volunteer and the other being a person in their community. I provided three scenarios:

community or family member who genuinely wanted to know what hospice was about,

someone who was skeptical about hospice, and then someone who had just had a recent

serious illness diagnosis. The group requested to generate their own questions instead that

could be picked out of box so it would be a surprise to both people in the dyad. Each person

then wrote a question they had been asked in the past or imagined they might be asked as a

hospice volunteer. Each member of a dyad then picked a question from a basket. Then each


pair took turns being a community member and the volunteer using the question they had

picked, allowing 5 minutes per question. I provided a review of deep listening and a reminder

to use pausing, grounding in the body, or waiting to respond as they took part in the activity.

Each person attuned to themselves and to the other to discern what was really being asked in

the question. The facilitator and the hospice volunteer coordinator provided availability to

each pair to offer suggestions or guidance. After the role play was completed, the group

shared their experiences and what answers they gave for their questions.

Brainstorm of tangible offerings to the community. The group then engaged in a brief

brainstorm of possible tangible offerings they might provide to the hospice or greater

community as another way to be engaged as volunteers outside of direct patient services. I

offered examples including: a comfort shawl, fabric finger labyrinths, or small decorated

notebooks for writing stories. The group generated a list with some additional ideas.

Brainstorm for volunteer support meetings or activities on a monthly basis. The

group then generated a list of ideas and suggestions how they might like to stay connected on

a monthly basis. I provided examples such as meeting one time per month to share patient

stories in a reflection circle, a film night with potluck and discussion, or inviting a speaker.

The group generated a list of ideas that was captured on a flip chart. The hospice volunteer

coordinator indicated she would be following up with the group regarding a monthly

volunteer meeting.

Meditation Round activity. The final activity for the session was a spoken round

using the Five Remembrances (See Appendix F). This practice had been demonstrated for

me during the Contemplative Practices and Rituals in Service to the Dying workshop at


Upaya Zen Center (Ostaseski & Halifax, 2014). Before starting, I prefaced to the group that

everything is impermanent and we are not separate from the patients we serve. I instructed the

group to stand in a line and face each other in pairs. Each person in the pair was directed to

read the printed Five Remembrances provided to them. Line A started and read to Line B,

and then Line B read to Line A. When the entire group had finished the person at the head of

line A moved to the end of the line and everyone in Line A shifted to the next person in Line

B. The group then repeated the reading of the lines until everyone in Line A had been paired

with everyone in Line B.

Closing reflection circle. The group returned to their seats at the table. During the final

reflection circle, each person shared one word to reflect how they were in the moment.

Measurements

The Fears of Compassion Scales (Gilbert et al, 2011) one and three were administered prior at

the first session and at the close of the fourth session. Scale 1: Expressing compassion for

others (“the compassion we feel for others, related to our sensitivity to others’ thoughts and

feelings” Gilbert et al, 2011, p. 244) had 10 items. For example: “People will try to take

advantage of me if they see me as too compassionate” or “I worry that if I am compassionate,

vulnerable people can be drawn to me and drain my emotional resources.” Scale 3:

Expressing Kindness and Compassion Towards Yourself (“compassion we have for ourselves

when we make mistakes or things go wrong in our lives” Gilbert et al, 2011, p. 244) had 15

items. For example: “I feel that I don’t deserve to be kind and forgiving to myself”, “I find it

easier to be critical towards myself rather than compassionate.” The instructions were to read

each statement on the scales and circle the number on the Likert scale of zero to four that best


describes how the statement fits you. Zero being ‘don’t agree at all’, one-three indicating

‘somewhat agree’ and a score of 4 that you ‘completely agree.’ Scoring instructions

including adding the raw scores for each scale and calculating a mean.

Another measure included a home practice log. A log was provided to each participant at the

end of training sessions one, two and three to record use of compassion and care practices

during the following week that had been demonstrated in the session. After sessions one-

three, an electronic copy was emailed to all participants so that each person had a copy for

those who did not attend a session, misplaced their copy, or preferred an electronic form. The

practice log for week one focused on: grounding in the body, taking three deep breaths, and

resourcing. The practice log for week two included: grounding in the body, deep listening,

and attuning to self or another person. The practice log for week three included: attuning to

self or another person, noticing our shadow or habit behaviors, and pausing or three minute

meditation/reflection. The participants were instructed to record the number of times and the

length of time that they practiced each activity. An additional space was provided to add an

activity as appropriate or needed. An emotional stress scale was included on the log for each

day to rate the level of stress from zero-10 with 10 being extremely stressed and zero being

not stressed at all. A section for written comments was provided at the end of the form.

Results

Data Analyses

Fears of Compassion Scales. All twelve participants completed the scales (Fear of

Compassion for Others - FCO, Fear of Compassion for the Self - FCS) prior to the training,

11 of 12 participants completed the scales after the training sessions. The scores were

analyzed by the mean rating scores of individual questions and also by the total scale score


per participant. Baseline rating scores (zero-four) for individual questions on both scales

revealed predominantly low scores across the majority of the participants in the zero-two

range indicating low fear of compassion for other and self. FCO mean rating score was 0.52

(SD = 0.39) and the FCS mean rating score was 0.58 (SD = 0.74). In comparison, the

individual rating score means after the training revealed similar rating scores. The mean post-

rating score for FCO was 0.595 (SD= 0.46) and FCS mean rating score was 0.46 (SD = 0.50).

A 2-tailed paired T-test was used to examine the pre-post mean rating scores for both scales.

Outcomes for the FCO scale revealed a T score of -1.18 and a p-value of 0.265, thus there was

not a significant change in fear of compassion for others before and after the training with a p

< .05. The T-test outcomes for the FCS scale revealed a T-score of 1.049 and a p-value of

0.132 indicating no significant change before and after the training in fear of compassion for

the self with a p < .05. See Table 1 for a summary of the pre-post means, standard deviations

and T score values for both scales.

Table 1. Mean rating scores of individual questions for FCS* and FCO* scales.

Baseline

Mean (SD) Post Training

Mean (SD) T score P Value

*Fear of

Compassion for

Self (FCS)

0.58 (0.74) O.46 (0.50) 1.049 0.132**

*Fear of

Compassion for

Others (FCO)

0.52 (0.39) 0.595 (0.46) -1.18 0.265**

* Range of Likert rating scale for FCS and FCO scales: 0-4

** Significant at the p<0.05 level

Additional analysis of the scale score revealed that the overall scale mean score (based on


total raw scores) for the 12 participants for the FCO Scale pre-training was 4.83 (SD 3.13)

and post training mean for 11 of the 12 participants was 6.09 (SD 4.99). The overall pre-

training mean score for the FCS scale was 8.5 (SD 10.5) and mean score for post-training was

6.82 (SD 7.56). The low baseline fear of compassion scores may be reflective of the

population of active hospice volunteers that participated in the training. When Gilbert et al

(2011) completed the validity testing for the Fears of Compassion Scales the participants

included 222 graduate school students in psychology and criminology and a comparison

group of 53 therapists. The mean student score for the Fears of Compassion for Others was

21.18 (SD = 6.71) and the mean for Fears of Compassion for Self was 16.12 (SD = 10.38).

Whereas, the mean score for the therapists for FCO was 10.51 (SD = 5.36) and the mean for

FCS was 8.15 (SD = 6.51). The hospice volunteer baseline mean scores for both scales (FCO:

4.83; FCS: 8.5) were notably lower compared to the student group. Whereas the baseline

hospice volunteer scores on the FCS were similar to the therapist group (8.50 and 8.15). The

HV had lower baseline scores on FCO compared to the therapist group (4.83, 10.15). See

Table 2 for comparison of mean scores.

Table 2. Comparison of Total FCO and FCS Scales with Scale Validity Scores.

Baseline

Total Scale

Score (n=12) Mean (SD)

Post Training

Total Scale

Score (n=11) Mean (SD)

*Comparison Graduate

students (n = 222)

Mean (SD)

*Comparison Therapist

Scores (n = 53) Mean (SD)

Fear of

Compassion

for Others

(FCO)

4.83 (3.13) 6.09 (4.99) 21.18 (6.71) 10.51 (5.36)

Fear of

Compassion 8.5 (10.5) 6.82 (7.56) 16.12 (10.38) 8.15 (6.51)


for Self

(FCS)

*Scores obtained from validity study of the Fears of Compassion Scales (Gilbert, McEwan,

Matos, & Rivis, 2011)

Attendance. Weekly attendance ranged from 75-100% of the total 12 participants.

Specifically, week one there were 12 (100%), week two there were 10 (83%), week three

there were nine (75%), and week four there were 11 (92%).

Home practice logs. A low return rate of less than 50% of completed practice logs

occurred each week. There were 5 forms returned for week one home practice, five forms for

practice week two, and three forms for practice week three. Generally only frequency of

practice use was reported across the participants, with occasional recordings of the length of

time spent for each practice. Therefore, only the frequency of practice was examined.

Home practices after session one from a sampling of five people, revealed three deep breaths

was used with the highest frequency for a total of 52 episodes by five of five people with a

mean use of 10.4x/day. This was followed by “other” practices used a total of 24 times by

three of five people with a mean of 4.8x/day. Examples of “other” reported practices included

singing, listening to sounds, tensing/relaxing muscles, and sending cards to family members.

Grounding and recalling a resource were used with the least frequency from 11-14x/day by

two of five people with means of 2.8 and 2.2 respectively. See Figure 1 for summary of

practice uses) for findings.

Figure 1. Home Practice Log One: summary of five participants.


*Other: singing, listening to sounds, tensing/relaxing muscles, and sending cards to family

members

A summary of the home practice log after session two from a sampling of five people showed

that all three of the primary practices: grounding, deep listening, and attuning to self and

other were used all seven days by each of the five participants. While the “other” practices

were used by three of five people. The total frequency of use and the mean scores for the three

primary practices were a similar rate ranging from 35-40 with means from 7.0-8.0 for the

week of practice. In comparison, the “other” practices were used with less than half this

frequency with 15 occurrences and a mean of 3.0 per person. Example “other” practices

included: pausing, singing, talking with family doctor, positive thoughts, reflecting on family

pet (See Figure 2 for summary of results).

Figure 2. Home Practice Log Two: summary of 5 participants.


*Other: pausing, singing, talking with family doctor, positive thoughts, reflecting on family

pet

Findings from the home practice log after session three from a sampling of three people

revealed again that all of the primary practices for the week: attuning to self and other,

noticing shadows of caregiving, and pausing/three minute meditation were used all seven days

be each of the three participants. The "other" practices were used by two of three people for

all seven days. The highest frequency of use was reported with attuning and pausing/short

meditation ranging from 33 to 41 occurrences, respectively over the week, with means of 11.0

to 13.7. Noticing the shadow followed in frequency with a total use of 27x and mean of

9.0x/per person. “Other” practices were used with the least total frequency of nine times and

a mean of 3.0 per person. Examples of "other" practices included: reflecting on personal

health, visiting primary doctor, visualizing nature, and caring for the family pet after surgery.

See Figure 3 for summary of log three findings.


Figure 3: Home practice log three: summary of three participants.

* Other: reflecting on personal health, visiting primary doctor, visualizing nature, and caring

for the family pet after surgery.

Also included on the home practice logs was daily emotional stress ratings (scale of 0-10: 0

being not stressed at all and 10 being extremely emotionally stressed). An analysis of the

stress ratings that were recorded on the five home practice logs received for week one showed

a range of mean ratings from 1.8 to 6.6 with a mean of 3.5 (SD = 2.0). Stress ratings for the

five home practice logs received for week two had a range of 1.0 to 3.7 with a mean of 2.24

(SD = 1.18). The final set of two practice logs received for week three showed mean rating

scores ranging from 1.0 to 3.7 with a mean of 2.8 (SD = 0.28). Overall mean stress levels

were in the low range (two-three) across the three practice logs received in a three week

period.

The number of daily practice episodes were calculated for each participant and compared with

the daily recorded stress rating to determine if there was a correlation between the level of


stress and the number of practices used on a daily basis. A Pearson Correlation was

calculated between the daily stress ratings and the number of recorded daily practices per

participant. The R value for week one across all five participants who returned forms was

0.16 with a p-value of 0.25 indicating there was not a significant correlation at p < 0.05.

Similarly, the R value for week two across all five participants who returned forms was 0.14

with a p-value of 0.45 indicating there was not a significant correlation at p < .05. A

correlation was not completed for week three as only two participants completed the stress

rating. Thus, for week one and two the number of practices recorded each day and the stress

scores did not show a correlation with using more or less practices pending the level of daily

stress.

Narrative Findings

Session One. Participant responses to the various activities and teachings.

Opening council. The group responded well to the council format to begin and end

each session with a reflection circle. The first reflection circle the sharings were brief

regarding what brought each person to hospice. At the close of council session one, a

participant commented on the guided three minute meditation/grounding as follows:

“Beginning with the guided meditation was so helpful to bring everyone into the heart space

before starting the session, otherwise it would have been much more difficult to connect.”

Recalling a resource. Resources shared with the larger group included places in

nature, music, family members and pets. The group was responsive to the grounding and

pausing episodes used with silently repeating their intention while invited to notice the

sensation and feelings arising in the body, followed with grounding in the body prior to


recalling their resource while sitting with their eyes closed. The group was still and eyes

remained closed until they were verbally prompted to open them. A comment after session

one on the home practice log included: “I slept better than I have in weeks after the first

session as I was able to relax my body.”

Closing council. During the closing reflection circle people shared touching stories

about an object of meaning that they had brought. One woman read a small laminated piece of

paper with an inspirational saying that her father had carried in his wallet and now she carries

it in her purse. Another shared about a photo of an island that is her refuge in situations of

difficulty, even just by calling it to mind, and the final sharing was a poem read on a worn

piece of paper that the person kept in their wallet to use on occasions when they were asked to

offer something at gatherings. The person eyes welled up with tears as they read it. Time was

running out and this final reading was a little long. People were initially moving about in

their seats, but by the close, their faces had softened and their attention was fully on the

speaker.

Inner chaplaincy. I found myself nervous as the session began with sensations of

tightness in my chest and increased heart rate. As I started the first council sharing, I realized

I had given an incomplete description of council. Also, I noticed I was experiencing clenching

and fear with seeing one participant who had a furrowed brow and flat facial expression

during most of the session. Someone also commented for me to speak up as my voice kept

dropping which cued me on my chaplaincy goal to “not hold back and speak my truth.” The

need to be liked, competent and accepted were also arising for me. As the session progressed

into dyad experiences, I found myself making multiple promptings to have the pairs return to

the group. A feeling of lack of control came up and some self-judgment arose about


incompetency. Also, I was monitoring my desire for control as a means of safety and tried to

use deep breaths and relaxing into my body for a sense of spaciousness. I was aware of

pacing and, mid-way into the session, I could see that the amount of material I had planned

could not be completed. I was able to find a stopping point and then offered a short preview

of the next session. After the session, as I was self-critiquing my performance, I could see my

grasping at wanting acceptance and gratitude from the group. During an email exchange with

a chaplaincy cohort member, I was offered two wonderful pith instructions: “don’t be attached

to outcome,” and “you are only making an offering and it is not your responsibility if others

want to take it.” These one-pointed instructions gave me insight and ease in letting go of ego.

Session two. There was greater spontaneous sharing after small group activities

compared to session one and people indicated how they were using the practices in their

everyday lives. In the opening circle one person commented that they found the 3 deep breath

practice helpful for centering and presence, and that they had offered it to a family member.

In addition, there were more frequent episodes of participants sharing their personal wisdom

with the group compared to session one. When reflecting on some of the direct patient care

activities for making meaning and expressing feelings that we had reviewed and practiced,

one participant commented “that it was important not to overwhelm the patient with offering

too much when people are so sick.” The group all nodded in agreement as this experienced

hospice volunteer in her 80’s shared her wisdom with the group. I concurred with her words to

those in the circle. When sharing how people prepare to enter a patient’s home, one person

commented that “Before I used caring for ‘getting high’ and I don’t do that anymore when I

had the insight it was about the patient and not about me.” Another person added that they


visualize letting everything go before entering patient’s residence, repeating this intention to

themselves while moving their hands down and away from the body so they can be fully

present.

I noted that during the listening dyads in session two there were fewer episodes of

conversational exchange and more frequent listening with open facial expressions. There

were also shared moments of caring for one another. For example, two participants

commented that they were taking care to listen to another participant who was experiencing

difficulty with a friend who was dying. As we moved into role play activities for patient care

with finger labyrinths and Go Wish cards, the participants were helpful in generating patient

scenarios for the activity. Each dyad was observed to be actively engaged with this role play

event as I observed their exchanges. After this role play, the group offered feedback

regarding their experiences. Some commented that the Go Wish cards were too complicated

for the role play with a patient with dementia where mental faculties compromised following

the directions. They did think, however, that the process of selecting Go Wish cards reflected

what was most important to a dying person and was a useful and interesting activity from the

perspectives of both the patient and the hospice volunteer. We discussed how discernment

would be needed for deciding which individuals would benefit from particular meaning

making activities.

Later in the session, when we were discussing how to define compassion and empathy, one

person gave their view as “compassion being from the heart and empathy being more mental.

For example, thinking how I had a similar experience.” Following my explanation of empathy

and compassion, we completed a practice activity with deep listening in dyads. Each person


was invited to share a mildly distressing event currently in their lives. This sequence flowed

well between the discussion of empathy and compassion and the paired practice activity of

sharing a difficulty. I noted that in the dyad activity, the pairs were listening and speaking

intently. There was less social exchange compared to the prior dyad activity in session one.

After the training session, people individually commented to me how they appreciated the

session. People stayed after the session and were talking with one another.

Inner Chaplaincy. Prior to the session, I noted that tension and worry were present as

I had planned a number of activities and concepts to be covered in the session and I was

doubting how well it would unfold. As I was getting out of my car in the parking lot, I took a

moment to look at the sky. There were amazing cloud formations as dusk was approaching. I

recalled my practices of sky gazing from my teacher Lama Willa and allowed my body to be

breathed by the sky. Spaciousness filled my body and a sense of lightness and gratitude

carried me into the building to begin the session. I reflected how effective using a resource

for the self can be in difficult moments. I used this sky description in the opening council as

an example of self-care. Others shared other poignant moments in nature during the opening

council that were then commented on during the closing circle by participants as touching

moments for them. Interconnectedness and Indra’s web seemed present with us as we shared

from the heart. As the session unfolded, the activities seemed to flow and build on one

another. I noticed myself more relaxed during this session compared to the first session.

Letting go of ego, attachment to outcome, and changing my view of teaching as coming

through me versus from me may have influenced the reception of the teachings.

Session three.


Opening and closing council. The participants were observed to be deepening into

the listening practice with insights and increased awareness of how they were listening to

others. During opening council, the prompt was to share an episode of listening and each

person’s own inner experience that occurred while listening. One person commented that

“this training has been a transformative experience” and they found themselves listening in a

deeper way. The person continued that they noticed a different level of listening with patients

with more openness. However, when they were in a familiar setting with a friend, they “fell

into offering advice/judging.” The person questioned why would they do that, especially

when the friend was speaking about the treatment of her husband with a recent cancer

diagnosis? One person commented how easy habits of speaking can unfold in a familiar

setting such as with friends and family.

Levels of sharing and vulnerability continued to increase compared to the prior sessions. For

example, the one male participant, a long-term volunteer in his 80’s, shared his concern with

an elder female hospice patient who seems to becoming attached to his visits because she likes

the male attention. He added how much he admired this patient as she was so giving to others

in her housing development. He indicated it was a quandary for him of how to handle the

situation. The hospice volunteer coordinator offered to add a second volunteer for this patient

and that she would talk with the participant about the situation at a later time. The hospice

volunteer indicated that that would be helpful. After the session, it was shared that this level

of sharing by this particular volunteer was not typical.

Attuning activity. The opening activity was attuning to self and other in pairs with

eyes closed and then open in guided silence. After a period of silence and each person in the


pair attuning to the other, I guided them to consider that the person across from them would

one day die. One participant began to giggle and continued to laugh off and on throughout the

activity. I listened during the sharing between pairs of their experience. I heard one 80+ year

old participant comment, “I am prepared to die anytime. I feel ready” with no visible sense of

fear. Another person commented to their elder partner that they had known a long time: "I will

miss you when you are gone.” Though I heard these sharings in pairs, no one was willing to

share in the larger group.

Shadows of caregiving. After pausing and bringing to mind a resource, we moved to

shadows of caregiving. The group was asked to generate examples after I provided some

initial examples such as, wanting to be liked, avoiding confrontation, wanting acceptance, fear

of risk taking, love of drama, need to be helpful; unresolved anger. Responses indicated

inconsistent understanding of the concept. For example, one person remarked: "don't wear all

black.” She reported that she wore all black to a visit and her patient exclaimed: “who are

you, what do you want!” The patient thought that the Grim Reaper had arrived. In contrast,

another person remarked having feelings of shame and doubt that “I am not the best choice for

working with this family.” She named other more experienced volunteers that she felt would

have been a much better choice. She remarked how the feeling of “I am not good enough, or I

can't do this” was a story she was telling herself.

Bearing witness activity. This triad listening activity required several repetitions of

the directions for the group to understand the process and the roles of the speaker, listener and

witness. I offered to simplify the activity into dyads without the witness, however, the group

wanted to try it with a triad, and so I moved group to group, offering the instructions again.


After the initial sharing by the speaker, the activity began to flow. I heard one witness

provide feedback to the listener: “you were a good listener, you reflected accurately what the

other was saying.” The small groups readily engaged for the remainder of the activity.

Closing council. The closing council people were asked to share their take-away from

any part of the session. Most spoke of their gratitude for the other participants and for the

opportunities to listen and to be heard. One person mentioned how they were enjoying

getting to know one another. Another commented liking having time to share stories with

each other and to listen to one another. The final comment was: "this would be a good format

to continue in some way, so we can share our experiences and support one another.” The

essence of community with caregivers supporting one another in the process of caring for

others.

Inner Chaplaincy. When giggling occurred during the attuning activity I felt my

body tense and disappointment as this was not what I had expected. I paused and recalled the

one pointed teachings: “don’t be attached to outcome” and to be with Not-Knowing.

Breathing, I continued the activity. The next phase was having each person return to closed

eyes and placing their hands on their hearts to know that they too would one day die. When

the giggles came again, once again I breathed. I then opened my awareness to the room to

soften my attention. As I relaxed, I was able to take in the other interactions and also hear

tender moments of sharing. This relaxing of the body made space for compassion to arise for

the one giggling who likely was experiencing many layers of responses that may not have

been bearable.


Session four.

Opening council. Opening council was done in silence with each person gazing

around the circle and acknowledging each person. The process was not prolonged and each

person participated. I sensed some awkwardness among the participants with the silence.

Brainstorming and role playing activities. The first activity was a group brainstorm

about ways we connect in the community. I offered a couple of examples such as a listening

presence and being knowledgeable about resources for those with illness or in hospice. The

group added suggestions that seemed not exactly related to being a hospice volunteer, such as

thanking Vets for their service, smiling at people, offering patience, shopping locally, paying

it forward, reaching out to teens, complimenting others, and helping others by engaging in

community home improvement projects such as weather stripping. This was followed by a

role play activity in small groups of two-three with hospice volunteers answering questions

from a person in their community. I offered that “the community person could be one of three

scenarios: someone curious about hospice, a challenging inquiry about hospice, or sharing

about a recent serious diagnosis or loss.” The group chose to modify the activity and

generate their own questions that they had experienced in the past as hospice volunteers.

Then, when in pairs, one person from the pair selected a question from the basket so that the

question would be unknown to both parties. The questions generated by the group included:

“What are you here for and why are you here?”; “What exactly happens when someone

dies?”, “Is hospice for dying patients?”, “What does hospice do with the money?”, “We are

not ready for hospice to come, does that means he’s dying soon?”, “I was just diagnosed with

cancer, am I dying?”; “why do you volunteer for hospice?”, “I just got a 6-12 month terminal

diagnosis, when should I call hospice?” Generally the group completed the activity without


difficulty along with observed episodes of laughter. Some groups were not sure how to

answer the questions, such as “Am I dying?” The group pondered about the role of the

hospice volunteer with such questions. When the group reconvened, this question was

brought up for input. The group offered various suggestions, such as “respond with a

question: the goal is not to answer but to open dialogue”; “say: I don’t know; what do you

think?”; “if you were dying, how would that be for you?” The hospice volunteer coordinator

suggested this response: “that is a good question for your hospice nurse.”

After an invited period of pause, I then moved on to the next activity of brainstorming

potential tangible activities the hospice volunteer group might offer to the community outside

of direct patient care. There was limited response from the group despite me offering a couple

of suggestions, such as comfort shawls or making fabric finger labyrinths. One person offered

that the group could make quilt cover small pillows as their wife had enjoyed this from

hospice, offering music or massage. The hospice volunteer coordinator responded that some

members of the larger volunteer group that were not attending this workshop had made

comfort shawls in the past and massage was being offered by volunteer members trained in

massage. In the realm of bearing witness, I felt I had been incomplete in my observation and

knowledge of this hospice volunteer system before inviting them to take part in this activity.

A second brainstorm activity followed to generate ways the volunteer group could keep

connected, such as meeting once a month. The group liked the idea of continuing to meet and

suggestions were offered for the monthly gatherings, such as having a specific topic,

reviewing an article on death and dying, or a book discussion. I suggested the possibility of a

film night and discussion, sharing patient stories, or having a speaker. The volunteer


coordinator said she would arrange a monthly gathering to include a light meal. The group

could then finalize the format when they got together. The entire pool of volunteers would be

invited.

Round activity and closing council. The session was concluded with a round format

with people in pairs reading a print out of the Five Remembrances. I had done this activity at

Upaya two months prior and had a very moving experience and wanted to share this with the

group. Space in the room was limited, so people stood in pairs in a line format. Each person

in the pair read the Five Remembrances to each other, then the head person in line A moved to

the end of the line and every one in line A moved up one person. I instructed that we are all

impermanent, and that we are not different from our patients. Time was running out in the

session. I could see that as the activity started that the space was awkward, people were close

together making it noisy and difficult for some to hear. Some people seemed uncomfortable.

Instead of being flexible and modifying the activity, I continued to maintain control and safety

for myself. At the conclusion, the session was 10 minutes past the ending time so I had a one

word check out for the closing reflection circle. Most responses were about gratitude for this

time together and for the people in the group and all they do for the patients and their families

in hospice. The second to last person replied that they were annoyed. I breathed and smiled

as I heard that and acknowledged to myself that a negative feeling was equally welcome with

positive feelings; however, my attachment to the positive was notable. There was little

exchange between myself and the group as people left.

Inner chaplaincy. I felt disappointment and lack of competency with this final

session. I had tears upon arriving home. My attachment to ego and outcome were strong as I


replayed the session to my husband. I had an idea in my mind how much they would be

touched by the Five Remembrances just as I had experienced it. I could see my shadow

padma responses of wanting to be liked, appreciated, and complimented. Following some

meditation, passing of time and creating space, I was able to let go of my discomfort, invite in

some light heartedness, and see that I was not responsible for other’s reactions. Also, as I

created space and ease, I began to see how my first attempts at teaching this information

provided rich offerings and there were many changes I could make in the next offering. I also

acknowledged that I was human and a beginner, in the dharma one need only begin again, and

not to take myself so seriously.

Participant review of trainings

An email request for feedback was sent three days and then one month after the training.

There were four responses the first email at day three and the two responses two the email

query at one month.

Responses three days after the training. The following are abbreviated pieces of comments

made by four participants.

● “Thank you for the tremendous supportive goodness in your four week workshop. I

was so grateful to have been a part of it. I especially enjoyed the emphasis on skill

building with self-care when going on visits: i.e. Three breaths, a strengthening

personal resource, awareness of the shadow voice and attuning to self and other.

Beginning with meditation was so skillful because it got the group into the heart space

right away, and made the sharing richer. Hearing the reflections of others as they


presented a favorite item or a quote was the most powerful for me as a new volunteer.

To hear other's strengths, and uncertainties, and laughter was strengthening and

encouraging and memorable. A highlight. I was surprised and puzzled by our final

exercise [Five Remembrances]. An interesting choice. I would love to have heard the

rationale for it. To me, it seemed so suddenly clinical, catechistic, devoid of mystery

and wonder in a group that is all about love. I don't doubt for a second we're leaving,

but I find it can be a climactic event, not something to be approached with grim

acceptance. Am I missing something, love to hear your thoughts?”

● “I feel so rich to have been included in your workshop! Everyone has to do something

for the first time, and I’ve done it a lot because that has been my career! The total feel

of our being together is far beyond what you ever might have imagined! Getting a

group of busy people together for four evening sessions, treating them so beautifully,

and enabling them to speak deeply with each other is not merely wonderful. It’s the

gift that is most needed in this entire world! Truly, in every setting, this is the most

that any one person can do with a group. Your teaching about the core importance of

self-care is the tender subject MOST needed, and, as you know, often made to be

considered last for people who volunteer to care with and for others.”

● “Thank YOU, Jean!! I'm afraid the timing of your class was not good for me as my

friend's surgery, subsequent death and my mourning made my participation difficult

and I feel I was only fully present for the first class only....I wish you all the best on

your journey...and thank you.”

● “I want to thank Jean for her hard work, dedication, and deep compassionate ways. I

enjoyed spending time with everyone. I don't normally get the giggles, but it was nice


to be with others who could share in the lightheartedness, as well as the serious nature

of the whole agenda. I felt blessed to be a part of such a loving and community based

group of people. It is a warming feeling to be with those who have the same desire to

serve our fellow community members in the ways that we do. I thank each and every

one of you. I enjoyed ALL the feedback and all the words that each and every one of

you spoke. It helps to continue "out in the field" spreading our desire to assist others.”

○ I know we discussed getting together again, and I am willing to do that. It does

help us to reinforce and support all of us in this hospice community of

volunteers.

Responses one month after the training. Two people responded, one saying they would

provide answers in a couple of days with no following reply.

● The timing of your workshop was perfect for me, as I have said before. I have been

putting myself into volunteer positions in hospice and in spirituality support with a

chaplaincy team. So I have used: three deep breaths, attuning to the person,

resourcing, and deep listening routinely; which has surprised me, actually. I wonder if

that is because I learned this in the medium of the heart space, and not cerebrally at a

workshop. Just a thought.

Buddhist Teachings Integral to the Project

The Five Buddha families

The five buddha families called - vajra, buddha, ratna, karma, and padma- have been

described as the mandala that surrounds the charnel grounds with the buddha family in the


center. The charnel grounds from a spiritual viewpoint can represent the death of ego and

letting go of aversions to impermanence and death (“Charnel Ground”, 2011). According to

Maull (2013), as we burn through our own charnel ground, a spaciousness is created that

allows one to hold the suffering of others with skillful means versus nervous 'fixing' or doing

behavior. Then we can sit in not knowing, bear witness, and allow compassionate action to

emerge for what is being called. Roshi Bernie Glassman has an expanded view of the Five

Buddha Families from the lens of social action. Glassman’s iteration of the Five Buddha

Families is described as the Five Course Meal: study and learning, spirituality, livelihood,

social action; relationship & community. Glassman (2013) suggests that chaplains keep in

mind the Five Buddha families as there may be a need for cutting through or destroying to

achieve right or compassionate action. Also, forgiveness may need to occur in serving those

who suffer in the role of a chaplain. Letting go of who is right or wrong and being present to

everyone’s views involved is helpful in this process. He comments to keep in mind that all

beings want to be loved and to be recognized. Serving people with love and not waiting until

you have all the ingredients to get started was offered as advice to the chaplains, “make the

best meal you can with what you have” (Glassman, 2013). Glassman offers that operating on

“not enough” leads to non-action. He comments to keep in mind that every action shakes the

web of energy.

Rockwell (2002) speaks of the five wisdom energies of vajra, buddha, ratna, karma, and

padma. She reflects on how energy is an experience that happens through the five senses and

that our emotions are a reflection of our energy. Rockwell contends that energy can be

negatively expressed or become stuck or imbalanced. She furthers that when our wisdom is

aligned with the five wisdom energies one can be opened to their basic goodness. These


energy centers were described as a critical lens for training chaplains in the realm of serving

others and alleviating suffering (Maull, 2013). Maull suggest that our difficulties and

inadequacies are part of the richness of life that are held with care by our basic goodness.

Each of the five families has a side that is aligned and energizing and also a negative

expression. Every individual tends to have one buddha family that is predominant, referred to

as “home base.” Seeing our neurotic tendencies in each of the families is the step towards

transformation and cultivating wisdom aspects of each of the families can guide one further

along the path of awakening. It is important to know our “home” family, the place that is

comfortable and likely reinforces our habitual behaviors and reifies our perception of ourselves.

Padma would be home base for me as I am inclined to create connections and relationships in my

personal and work life. Examining the negative side of padma, demanding attention, seeking

affirmation, I see where suffering arises for me from trying to please others or avoid my limitations by

seeking confirmation such as telling others acts of kindness I have done or accomplishments I have

completed. Receiving compliments and being accepted reifies my sense of okayness.

The buddha family at the center represents vision, wisdom, and the holding space of not

knowing. The negative side of the buddha family was described as ignorance or wrong view.

vajra in the east is about clear view, speaking truth, cutting through using training and study.

The negative side of vajra is arrogance, critical, subsiding fear by knowing answers, feeling

insufficient, anger and righteousness. Padma family in the west symbolizes connection or

relationship, making the guest welcome. The negative of padma may be demanding attention,

seeking affirmation. ratna family in the south exhibits the wisdom of equanimity and

abundance (having/being enough), as well as having patience and the ability to let go, a place

of human and financial resources. The negative side of the ratna family can present as a sense

of lack or poverty as well as pride and arrogance. A person that needs to fill the silence with


chatter or clutter space with possessions. Finally, the karma family of the north represents

action and/or social action such as socially engaged Buddhism. Wisdom of the karma family

is efficiency (Maull, 2013; Rockwell, 2002). Maull (2013) reflected that when we engage in

overdoing, others may feel resentment if they cannot keep up or do not feel included or

valued. He encouraged us to act from a true place that would create a welcoming and

engaging space with others.

In addition, the 5 buddha families have been described as including the four karmas or

energies of transformation: pacifying, enriching, magnetizing and emptying or destroying as a

means of responding to suffering (Maull, 2013; Rockwell, 2002). Each of the karmas are

associated with one of the four surrounding Buddha families in the mandala: vajra with

pacifying, ratna with enriching, padma with magnetizing, and destroying with karma.

Pacifying means causing psychological imbalance or physical sickness to subside. Enriching

means imbuing experience with a sense of richness; also giving physical wealth and long life.

Magnetizing means attracting power and powerful relationships, which give control over

situations. Destroying means annihilating confusion and obstacles (Formica, 2008).

The compassion training for this study was about creating a mandala of connection and

support for hospice volunteers in Waldo County Belfast Maine. The intent was to create

conditions for compassion and caring to arise or be known for the caregiver and those being

cared for in a hospice setting. The five buddha families or wisdom energies was the mandala

created to hold the space and served as a container for the participants to explore their own

wisdom as care providers.


Buddha family. The center of the mandala was represented by the buddha family of

wisdom, space and not knowing. The participants were invited into a space of not knowing to

explore compassion and self-care in a training format that had not been offered in their

original hospice training in the Waldo County Hospice Volunteer program. Spaciousness was

weaved into every training session with the initial three minute meditation to settle into the

body and space, as well as frequent use of pausing at the conclusion of reflection and listening

activities. Also, during the listening activities the listener was instructed to listen silently

from the heart without offering feedback so that a container was present for the speaker to

explore their own wisdom. One person commented that this practice of listening and speaking

was transformational for them. One negative expression of the buddha family was ignorance.

It was apparent that this was not a familiar listening practice for some of the participants with

frequent dialogues instead of monologues occurring in the listening pairs. As the trainings

progressed, there was gradually increased silent listening from the heart by the majority of the

participants. As for myself, when I held tightly to the schedule I had planned for each session,

I sometimes lost sight of what would be skillful and beneficial for the group. I had some

missed opportunities to expand on an activity or I limited the space for others to share their

wisdom in my own fear of being with not knowing.

Vajra family. The clarity of vajra family was weaved into the teachings by having

participants still their mind and body in the present moment via guided meditation and periods

of pausing interspersed throughout the sessions. In addition, conceptual knowledge was

offered to include the exploration of empathy and compassion and how to manifest and know

these behaviors. The group offered their own insights on empathy and compassion. This was

followed by a listening practice episode of offering compassion and empathy to a partner


while the other shared a difficulty in their life. Another vajra quality that was lifted up was

speaking truth during the shadows of caregiving activity. Small group work included each

person sharing some aspects of their shadow behaviors before engaging in a triad practice

activity. The participants shared some personal insights to their shadow behaviors that

included: doubt, shame, and wanting to be the hero. I also noticed confused/negative aspects

of vajra for me that included wanting control of the group that showed up in irritation when I

had difficulty calling people back from their small group activities. In addition, I experienced

episodes of being clouded by fear when an activity did not seem to be flowing or engaging.

Subsequently, I would move on to the next item on the session schedule instead of possibly

inviting feedback or allowing space for anything new to unfold. Also, I noticed periods of

aggression toward myself with critical thinking about how things did not go well before I

came to my senses of offering compassion. The pacifying karma of Vajra was expressed by

the participants offering compassion to one another with deep listening and awareness of the

suffering of others in the group. After one session, two people commented how they had

made a special effort to listen to one colleague whose friend was dying.

Ratna family. Ratna wisdom was manifested in the homemade meal of soup and

salad that was offered before each session. The hospitable nature of one member who brought

the soup each week was noted in her joy of providing nourishment to others. The group

responded with appreciation and openness while sharing their lives with one another during

the meal. The ratna energy of equanimity was also noted with how each person expressed

their gratitude for the others in the group during council sharings. This gratitude was equally

offered to the senior volunteers across levels of experience to the novice volunteers. When

someone expressed doubt in their volunteer skills, others offered empathy in how they, too,


had felt that way at times. In concert to this, I made efforts not to single out the more

experienced volunteers when asking for contributions from the group. When I shared my

experiences with hospice patients with the group, I monitored my elaboration and offered my

experience to embellish a point in the teaching (i.e., enriching karma). For example, when we

were talking about shadow behaviors, I talked about wanting to be liked and so sometimes I

over accommodated family member requests. In contrast, I also manifested negative ratna

energy with hints of boasting how I had been able to read poetry for my dying patient in the

hospital that she had requested from me the previous week when still working and living at

home. I felt some puffing up as people offered some adoring sighs following the story. I also

had to monitor tendencies to place myself on a spiritual pedestal. Ego wanted to say how I,

the teacher and Buddhist practitioner, knew the importance of grounding in the body to be

with difficulty. I had some humbling moments when others would share their wisdom of

being with those who are dying.

Karma family: The karma family of action was present in people’s expressions of

individual caring for the community, such as helping with weather proofing homes of the

underprivileged, thanking vets for their service in the military, and reaching out to teen

groups. Also, the group generated actionable ideas for making tangible offerings to the

hospice community such as decorative pillow covers and massage for patients. As for myself,

I invited the group to practice between sessions and supported this with a home practice log

for reference and recording, thus hopefully creating a welcoming space to explore the

practices at home. I tried not to be demanding that people complete the practice logs so that I

was not overwhelming people, keeping in mind they had volunteered to take the workshop.

Another form of engaged action was how the individual participants reported offering some of


the workshop home practices with friends, family and hospice patients. For example, one

person described how she offered her upset niece guidance in grounding in the body and use

of three deep breaths that her niece found helpful. In the negative aspect of the karma family, I

found myself ‘overdoing’ in the preparation, frequently having twice as much material as

needed each session. From a practical view, I was able to let go and not push through the

agenda I had planned for a particular session. As I inquired into this style of over-preparation,

I saw the need for safety and control with the potential of being vulnerable and imperfect as

the visible “teacher.” Also, in some of my ‘overdoing’, I can see I did not make room for

spontaneous or organic processes to take the group in different or expanded directions. In

terms of the extinguishing karma energy, I was able to arrange this training by extinguishing

my fears of incompetency and intimacy by asserting my voice and standing for how I

envisioned the training in relation to views of the hospice volunteer coordinator. We had

many iterations of the training sessions and I stood firm with the content and frequency of

sessions when difference of opinions arose between myself and the hospice coordinator.

Padma Family. The passionate and connecting aspects of Padma wisdom energy

unfolded initially through the opening and closing council groups each session. As trust and

connection began to build in the group, people shared more deeply from the heart, including

worries about their own health and families. Further connection and shared vulnerability

occurred through the dyad practices such as, sharing concerns about being with a dying

person, contemplating the other will someday die, offering one another deep listening while

sharing a personal difficulty or a care episode of being unskillful, and role playing offering a

meaning-making activity to a hospice patient. Thus, connecting occurred through sharing

suffering and experiencing increased awareness of each participant’s own suffering. The


magnetizing quality of padma was evident as people expressed how they were touched by one

another’s level of sharing and vulnerability. This opening of vulnerability was then extended

to participants’ family members and patients. For example, one person commented how the

training in listening had been transformative how she was listening to others in her life,

including her hospice patients. In contrast, a negative aspect of padma family occurred

intermittently with members of the group that commanded attention through laughter during

contemplative activities or prolonged speaking during council circle. As for myself, I was

able to connect with the group by speaking from a compassionate heart. One person offering

written feedback after the workshop thanked me for my “deep compassionate ways”. I also

noted a twist of negative padma with desiring affirmation from the group and feeling a lack of

competency when one person reported in council that they were ‘annoyed’ after we had

completed the Five Remembrances practice as a group round.

Four Noble Truths

The Four Noble Truths are pointing out instructions from the Buddha about how

things really are, allowing one the opportunity to burn through obstacles and mistakes and

thus ending the causes of suffering (Thrangu, K., n.d.). The truths point out that suffering is

present, the causes of suffering stem from wanting things to be different than they are, it is

possible to be free from suffering, and the way to be free is following the Eightfold path: right

view, right resolve, right mindfulness, right intention, right speech, right effort, right

livelihood, and right concentration. Sensei Hozan Alan Senauke (2014) offers a social

interpretation of the four noble truths when he writes about right anger and the caste system in

India. His commentary writes from the view of the four truths as: 1. What is the problem?, 2.


What is its source or cause?, 3. What is its purpose? or, What would its end look like?, and 4.

How do we get there?

The first noble truth is awareness that suffering is present. This is often experienced in

concrete ways with pleasant and unpleasant experiences. Suffering can be obvious, like

physical pain or loss. However, the more subtle experience of suffering is when things

change, or in Buddhist terms, when impermanence is experienced. For example, when

happiness cannot be sustained as naturally things change.

The second noble truth evolves from wanting things to be different than they are at any

given moment. When the cause of our suffering is attributed to causes and conditions outside

of ourselves and out of our control, then we will continue to suffer. When the source of

suffering can be viewed as our internal view of wanting things to be different than they are,

then freedom of suffering becomes a possibility.

Thrangu Rinpoche expands on the third noble truth saying, what we experience is our

complete responsibility and not anything external to us (Thrangu, K, n.d.). Further, Thubten

(2012) describes pure awareness/consciousness as a neutral place of neither bad or good,

pleasant or unpleasant and it can be accessed when we are fully present in the moment while

not being lost in thought. He continues to describe the possibility of accessing this inner

stillness in ordinary moments once we know how to pay attention to it.

The fourth noble truth offers a way to free ourselves from suffering by following the

Eightfold path. Another view to freedom from suffering that Thrangu Rinpoche talks about

are the five paths that include the stage of accumulation, the stage of junction, the stage of


insight, the stage of cultivation, and the final stage of non-study or enlightenment. He

explains that first one starts by accumulating good qualities (e.g., merit, kindness, generosity,

and compassion) followed by examining ways to remove obstacles or habits such as shadow

work or meditation. Once habits are known, then you must be convinced habits are

worthwhile to change. Changing our habits will require letting go of “self” and seeing our

interconnectedness (right view) with all other beings (I am just like the other: my listening

partner, my patient, my family). Then you will gain insight and see your delusions of who

you thought you were and see how things really are, resulting in freedom from suffering.

Cultivating good qualities are demonstrated in the eightfold path with right speech, right

concentration, right mindfulness, right resolve and so forth (Bodhi, n.d., Halifax & Senauke,

2014; Rahula, n.d.).

First noble truth. When examining the first noble truth in relation to this group of

hospice volunteers, suffering could be seen of course in the hospice patients being served. In

addition, since life is inherently suffering and there is nothing in the conceptual world that

will make us happy or satisfied, suffering was also apparent for each of the participants in the

workshop. Suffering was evident when the participants reported how they could not ease the

sadness of a family member whose loved one was dying, wanted patients to get better or not

to suffer, saw a child struggle with a terminal illness, or all the complicating factors of poverty

and family dysfunction that sometimes compromised the comfort of a patient and their family.

One view of the problem could be insufficient resources for treating social or medical

complications. From a system view, some of newer hospice volunteers spoke of not feeling

adequate in their role, and a seasoned volunteer brought up a gender issue when he spoke of

his female patient being too attached to him. Also, overall, this group of volunteers do not


interact on a regular basis nor do they serve as a support system to one another as there are not

regular volunteer support meetings. So the problem of isolation and not seeing the

interconnectedness in the volunteer group further contributes to their experience of suffering.

Overall, Waldo county Maine has a low hospice patient census and high number of trained

volunteers (72). Subsequently, many volunteers do not have active patient assignments and

feel under engaged in the program. For myself, suffering from disappointment occurred with

all the many changes in establishing and initiating my project. I felt pressed by time to initiate

this project as I had moved and left my job over the summer, so I had to shift my project

population from Boston to Maine. Then, arriving in Maine, my project focus with graduate

students at the University of Maine fell through, so there was a time lag in finding a new

subject group with the local hospice volunteer program. I also suffered with confusion and

struggle while trying to obtain clarity in developing the training sessions in self-care and

compassion. In our human form we continually want things to be different than they are, and

so we suffer.

Second noble truth. During the workshop, the causes of suffering were evident in

wanting things to be different than they are, such as wanting more hospice assignments when

the patient census is low. Or pushing away unpleasant experiences, such as during some of the

dyad activities that involved intimacy and vulnerability. For example, when the pairs of

volunteers were guided through a silent attuning activity and then asked to imagine how one

day the other would die, one volunteer could not stop giggling. Or when one person reported

being “annoyed” after a five-part round the Five Remembrances, perhaps requiring too much

intimacy. In contrast, grasping toward things that are pleasant was also evident with


protracted social exchanges during the beginning meal and people slow to transition to the

opening workshop circle, or when engaged in the dyad pair activities and requiring multiple

prompts to complete their social exchanges and return to the circle. For myself, I was often

critical of my teaching and reflecting on how things could have gone better. I lamented that

there was not more time in a session or more sessions. I was disappointed that the participants

did not always have the experience I hoped for or that I had experienced with some of the

activities in which I had similarly participated as part of the Upaya Chaplaincy Program. In

particular, the Five Remembrances round activity had been very moving for me with Frank

Ostaseski at the Upaya Chaplaincy training (Ostaseski & Halifax, 2014), and I observed

awkwardness and tension as this group completed the activity. I wanted to hear from people

who were offering compliments and gratitude and avoid those who looked unhappy or not

engaged.

Third Noble Truth. The possibility of ending or being free from suffering was

offered in this workshop by inviting moments of awareness of suffering and then inviting each

person to stay with that awareness. Opportunities to access awareness during this training

were offered in activities such as attuning to one another in pairs and contemplating the death

of the other and then themselves. The participants were encouraged to stay with whatever

emotions or physical responses that arose in the body. Awareness practices of emotions in the

body were applied to having compassion for our own difficulties, and subsequently

compassion for the other. When we can know our own difficulties, such as anger, irritation,

confusion, or worry with a kind heart, then when we are caring for someone who expresses a

similar difficulty we can pause when we sense our own activation and offer compassion to the

other “oh, I know how it feels to worry.”


Also, suggestions were offered to the participants that if they were sitting with a hospice

patient and found themselves not connecting because of irritation, fear, or being overwhelmed

that they could reconnect in the moment by attending to the weight and sensations of the

body: sitting, looking out the window, standing and moving about in the space, or viewing the

other as a dear loved one. I noticed for myself that I would be anxious while setting up the

sessions. There was one particular person who would approach me before each session with

comments and questions while I was trying to prepare and my chest would tighten. When I

paused, I found the breath and commented to myself, ‘I know how it feels to want to connect’.

Then, I would turn my attention to this person to listen with full attention and then excuse

myself to continue prepping for the session.

Fourth noble truth. Accumulation of good qualities was focused on in this training

by examining ways each participant cared for themselves, offered generosity to others through

listening, and were present for their own difficulties and the difficulties of others. The path of

knowing and removing obstacles or habits was approached with consistent meditation periods

each session, guiding people to examine their present experience (pleasant or unpleasant).

Then later in the training we engaged in looking at each person’s shadows or obstacles.

Opportunities were then provided to look beyond ego to the inter-connectedness of how we

are all one with other beings. For example, in the pair listening activities each participant was

invited to recognize how their difficulties and discomforts were the same as their listening

partner or the patients they were serving in hospice. It was highlighted that death occurs in

every moment with the loss of connection, loss of hopes, or one less breath we will ever

breathe. The participants were invited to reflect that “I too suffer just like my patients and

their families, I know fear, worry, joy, irritation”, “I am not different from you.”


As a continued discussion of the path to freedom, here are general guidelines of the Eight-fold

path for the hospice volunteers in this project:

Sila:

● Right speech: pausing before speaking with patients, bearing witness to see what will

serve the patients and their families, speaking one’s truth, not gossiping about co-

workers or hospice patients and their families; not interrupting when listening.

● Right livelihood: Even as a hospice volunteer, one can cause harm. We discussed

examining our intentions on an ongoing basis. Why am I here? Who am I serving?

One person spoke that she used to crave a “power buzz from helping in the drama of

death,” and keeps close tabs on her intentions when caring for others. Also, the idea of

wanting be a hero or rescuer was discussed. For example, being in a ‘selfing’ mode

with patients: “Am I a good hospice volunteer?”

● Right mindfulness or attentiveness: When we are attentive or mindful to our body,

mind, feelings, and thoughts, then this awareness allows one to be present for the self

and for the other. Grounding and meditation were then engaged while listening to a

colleague share a moment of difficulty and noticing what thoughts and sensations

occurred. As a hospice volunteer with those who are seriously ill or dying, awareness

of one’s own internal responses is critical for offering care from the heart space.

Samati:

● Right concentration: how we attend to what is needed with deep presence, focusing on

the other; offering our time with generosity and presence (e.g., listening with our full


attention). Awareness practices such as meditation, grounding in the body, and

attuning to self and other provide training of the mind for offering sustained presence.

● Right effort: The idea of not overdoing was discussed, such as allowing other

members of team and family to be equal part of patient’s care, and knowing when our

presence is wanted or not wanted. Also, we examined balanced effort, not too relaxed

and not too hard. One participant spoke about being ‘exhausted after listening to her

patient’. The group encourage her to relax and not try so hard!

● Right Action: Moral and peaceful conduct that includes not stealing or lying, or

destroying life. When providing care as a hospice volunteer, it is important to know

what is true for you and not over-extending what you are capable of offering. Also, to

bear witness when entering a new system (a family or place of care) and see what is

needed (right action). If one is seeking affirmation, this could ‘steal’ attention away

from the patient or family members.

Prajna:

● Right thought/intention: Our thoughts influence our action, so having loving or kind

thoughts will have a different outcome than malicious or critical thoughts. Thus,

setting an open and loving intention with our thoughts before beginning a moment of

caretaking can influence how we care for another. There was practice in setting

intentions of care for patients during this training, such as to be a loving presence. The

participants were encouraged to enact this practice in their personal life and as a

volunteer with patients.

● Right view: Be mindful of transference and countertransference issues, so we do not

personalize anger from a patient or family member. Practice equanimity. Also, it is


important in hospice to know when we are seeing through our projections. For

example, a patient may remind us of a family member and elicit particular reactions or

judgments about a patient we are offering care. Personal examination of our habits,

triggers, and psychological wounds can help to see with clarity and wisdom. Pause

before speaking and see the other with clarity, versus thinking we know their

experience. For example: “Oh that must have been so sad,” and the person was really

feeling relief.

Discussion and Conclusions

The purpose of this study was to determine if hospice volunteers in a rural setting would

benefit from self-care and compassion practices to support their patient care. Formal

measures of compassion with the Fears of Compassion Scales: for others and for the self

(Gilbert et al., 2011) showed no significant changes during pre- and post-testing after the four

week training. This was not surprising in the short amount of training that was offered. Also,

this group of hospice volunteers showed lower baseline scores in fear of compassion

compared to the population of college students that was used for the validation study of the

scale. This may be a reflection of what type of individuals who are drawn to volunteer for

hospice. However, narrative reports from the participants and observations during the training

sessions indicated positive benefits from the various self-care and compassion practices

including, meditation, deep listening, attuning, calling on a resource, setting intentions, being

with difficulty, and exploring shadow behaviors. Narrative responses captured to support this

included: “quieting into the heart-space was so helpful before starting”, “these listening

practices have been transformative”, “I offered the meditation and breathing practices to my

niece who found them helpful when she was having a difficulty”. Though there was moderate


to low return of the weekly home practice logs, the sampling of logs handed in indicated that

there was increasingly consistent use of the practices stipulated for each week as the program

progressed. Also, the participants added many of their own self care practices to the home

practice logs, such as singing, caring for the family pet, and writing cards to friends and

family.

In addition to reported use and benefit of the practices outside of the training setting, there

was evidence of increased connection and sharing among the participants over the course of

the four week training. For example, I observed increased depth of sharing at the opening and

closing councils that others in the circle also noted. One member commented “can we take a

pause and acknowledge how wonderful this is to share and listen to one another in such a deep

way.” Participants also commented how much they enjoyed getting to know one another

better. At the conclusion of the training, the group wanted to initiate regular volunteer support

gatherings to continue similar conversations and sharing with one another. The participants

were observed supporting one another in shared moments of difficulty. This outcome of

prosociality and increased social connection aligned with the findings of these prior studies

that provided training in compassion (Hutcherson et al., 2008; Leiberg, Klimecki, & Singer,

2011; Seppola et al. submitted for publication). It also supports the hypothesis of this study

that compassion and self-care training would provide support for volunteers during caregiving

with hospice patients as well as caring for themselves, and renew connection among

themselves as a support to one another.

In addition, this training provided more in depth opportunities for learning empathic listening

and compassionate care for others and the self compared to the hospice volunteer training


curriculum of Hospice Volunteers of Waldo County that offered one session on self-care and

listening. This type of training is in alignment with the reported trends in the literature to

modify hospice volunteer trainings with increased focus on empathic listening and

communication (Wittenberg-Lyles et al., 2012)

Buddhist Perspective

From a Buddhist perspective, these trainings could be viewed as an offering of the dharma

and contemplative practice to care for the dying. As the hospice chaplain (in training), I was

in the role of healer and holding the space for compassion to arise. I attempted to show up

wholeheartedly and speak my truth. My intention was to make such offerings without

attachment to outcomes. However, I frequently found myself attached to outcomes, wanting

appreciation and a sense of competency, and wanting the participants to have positive

experiences from the trainings. This was a continual teaching and examining of my own

shadows. The precepts of “do no harm”, be generous, kind, do not put yourself above others,

and do not gossip or speak ill of others were weaved into the trainings. Examples of the

precepts in the training practices included: offer yourself some kindness; consider that one day

this other will die, listen deeply as a vast container, be mindful of your speech and actions

when caring for others, and empty yourself and enter each home as a gift. Pause before

proceeding so you can know what is needed. Also, meditation and the use of a sacred pause

was offered to show the power of space and slowing down to allow compassion to arise

(Ostaseski & Halifax, 2014). I view this as training as planting a seed, and time will see what

grows. Continued encouraged practice for the hospice volunteers will be needed.

Future Considerations


Overall, I would have fewer concepts and activities for each session to allow for more

participant involvement and for organic changes to be possible in planned activities. I would

also engage the participants more in leadership roles for activities and seek participant input

during the training to help modify the sessions per group needs and interests.

Regarding particular aspects of the training activities, the council sessions were well received

and provided an opportunity for depth of sharing and exposing vulnerabilities. I would not

attempt a silent opening council again in a four week training as the opportunities to share

verbally in such a manner were limited in the brief meeting time. In addition, the intimacy of

gazing at each member in the group for check-in may have been premature at this point in

forming a group. The dyad activities offered shared intimacy and opportunities to know one

another on a different level. I would provide additional time and structure to encourage more

sharing about the dyad experiences with the larger group as, in my observation, that offers

benefit to the group and opens opportunities for discussion. The brainstorming activities in

session four were not fruitful or energizing to the group. In review of the activity, perhaps the

group was not yet at a place of connection to create community offerings and needed more

focus on their own group connection as volunteers. Another consideration, depending on

group dynamics, would be to offer more time for the role-play questions from the community

activity in session four as the group was enthused and sharing with this activity and I cut it

short to move to the brainstorming activity. The final round activity in session four with the

Five Remembrances did not go well for a variety of reasons, including time budget, space,

lack of clarity in my instructions and rationale, and depth of intimacy required. I would

carefully consider using the Five Remembrances for a future training, and be prepared to

either exclude or modify this activity.


Limitations

It became apparent that this particular group of hospice volunteers had additional unique

features, such as being a large group of 72 trained volunteers with a low patient census,

resulting in many volunteers not being assigned patients. In addition, the group functioned

quite independently over a wide geographic area without a central place of hospice care (i.e.,

mostly home based care and some institutions) and did not have regular volunteer support

meetings. Per the volunteer coordinator, the current group of volunteers tend be independent

and “do their own thing”, resulting in difficulty with follow through on documentation

requirements and seeking help with challenging patients. This independent nature may have

limited the group response to filling out the weekly home practice forms. Or, not turning in

the practice logs may have reflected that people were busy, or that the logs would require

being ‘seen or revealed’.

In addition, with respect to no significant changes on the formal measure of compassion: four

weeks is a short time to expect changes in compassion ratings. Prior studies of compassion

training frequently reported a period of 8 weeks of training. Also, the particular tool: Fears of

Compassion may not have been the optimal choice for assessing changes in being with

difficulty that were offered in this training. Also, the hospice volunteers demonstrated such

low baseline scores, that there was not much room to demonstrate changes in fear of

compassion. This tool may be better suited for a group with less experience serving others

who are suffering, as was demonstrated in the validation study with college students (Gilbert,

et al., 2011). Perhaps a tool such as the Self-report Functional Assessment of Chronic Illness -

Breast (FACIT-B) spiritual well-being subscale of 12 items, and, Self-Transcendence scale of


15 items used by Scherwitz and colleagues (2006) may have offered more insights on the

training outcomes. The spiritual well-being subscale includes a likert scale rating of items

such as, “I feel peaceful”, “I have a reason for living”, “I have trouble feeling peace of mind”,

“I feel a sense of purpose in my life”, “I am able to reach down deep into myself for comfort”,

and “I feel a sense of harmony within myself” that have the potential to examine participants

changing insights of self-care and how they offer compassion (Bredle, et al., 2012). The Self-

Transcendence scale was initially developed for the elderly but has been used for young and

middle ages as well. It targets topics such as aging, terminal illness and events that heighten

awareness of the end of life that are relevant for hospice volunteers. Sample scale items

include: “Being involved with other people,” “Sharing my wisdom or experience with

others,” “Helping others in some way,” “Accepting myself as growing older,” “Adjusting well

to my present life situation,” “Accepting death as a part of life,” “Letting others help me when

I may need it,” and “Enjoying my pace of life” (Haugan & Innstrand, 2012). An additional

idea would be to conduct individual interviews or to provide a self-report questionnaire at the

conclusion of the trainings to discern changes or insights that occurred for each participant.

Conclusions

One of the most positive outcomes of the training was that the group chose to establish a

monthly volunteer support group. The hospice volunteer coordinator organized a monthly

meeting schedule that started the next month and will continue to meet. They have now met

on two occasions. The December meeting had 10 attendees on an evening of bad weather.

Also, the group was offered more in depth training in empathic listening and provided with

approaches to be with difficulty (e.g., grounding in the body, use of the breath for calming and

being present, pausing/contemplation, offering ourselves kindness) than is currently offered in


the base training for this volunteer organization. There were also observed changes in

relationships among the group members with renewed connections, sharing more openly and

the opportunity to know one another beyond the level of ‘colleagues’. Finally, there was

sustained group attendance with no attrition that spoke to commitment of the group to

complete the trainings.


APPENDIX A

FEARS OF COMPASSION SCALES


APPENDIX B

HOME PRACTICE LOG SAMPLE

ID: __________________ Starting date for this week: ___________

Please record the number of minutes you spend on homework practice each day. Please

indicate what practice you performed and for how long. Please enter “0” if you do not

practice on that day. *Please note that Day 1 is the day directly following the course

meeting.

Practice done Day 1* Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

3 minute pause/meditation (in minutes)

Body Scan

(in minutes)

3 deep breaths

(in minutes)

Resourcing (in minutes)

Other (Please specify activity)

Below please indicate the approximate number of times during the day (if any) that you

found yourself using information or techniques learned in class. This can include any

activity that you have consciously chosen to perform in a new way, or times that you

think about something in a new way

(e.g. you were more mindful of what was happening, or you paused before responding)


APPENDIX B (continued)

Times Daily

Below please indicate your overall level of emotional stress today. Use a rating scale of 0

– 10 with 10 being extremely emotionally stressed and 0 being not emotionally stressed

at all.

Emotional

Stress Scale (0-10)

Comments:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

PLEASE BRING THIS LOG WITH YOU TO YOUR NEXT CLASS


APPENDIX C

CARING TOOLS POCKET CARD

CARING FOR YOURSELF

PAUSE

GROUND IN THE BODY

3 DEEP BREATHS

FEEL YOUR FEET

RECALL A RESOURCE

NOTICE WHAT YOU ARE FEELING

OFFER YOURSELF KINDNESS

LISTEN DEEPLY FROM THE HEART

CARE FOR THE BODY


APPENDIX D

TIPS FOR PATIENT CARE ACTIVITIES: PENDING STAGE OF DYING

Stage of Separation:

o Separation: loosing meaning (e.g., objects, family, health) ▪ Finding meaning: art/beauty - create beautiful space - helps with

opening ● drawing mandala, ● create altar with sand tray approach with patient’s meaningful

objects in their surroundings (can invite children in this), ● create scrap book of photos, poetry, record/write down patient’s

life stories into a book that can be given back to patient ● finger labyrinth ● how to ask open ended questions

o tell me about your life

o what has given you joy in your life o what has been important in your life

▪ Expressing feelings (love, betrayal, gratitude, reconciliation)

● Go Wish cards ● Family around bedside: invite family to tell stories/memories

had with patient ● Ask counterintuitive questions: what is something you would

really like to remember, do you remember how your mother

smelled, do you recall the first time you ate xx, what was that

like; or your first date… ▪ If worried/distressed: Inviting patients to take part in meditation or

reflection moment during times of stress/worry/pain

● ground yourself first ● Suggestions:

o Breathing in, I calm body and mind Breathing out, I let

it go ● Saying a prayer OR you seem anxious today would you like to

try something to help you relax? doing breathing, feeling body

in bed ● FOR SELF: Connecting to the moment: looking out window

at nature, listen sounds in the room, touching person mindfully,

take few sips cool water, breathe deeply in/out and relax the

body ● If you are not feeling connected to the person: imagine person

as family member or as one who has given others life,

protection, nourishment, kindness


APPENDIX D (continued)

o Stage of Transition: where outside world connections are being let go (may be

chaotic with body thrashing, etc.)

▪ being present, music/singing, hand massage

o Stage of Active dying: no longer alert

▪ be present without fear

▪ Support to family members

▪ Follow lead of primary caregivers

Source: Ostaseski, F., & Halifax, J. (2014, August). Rituals of dying. Workshop at Upaya

Zen Center


APPENDIX E

OBSTACLES AND TROUBLE SPOTS IN CAREGIVING

Heroism: Give up control, take a rest; make room in your life so you get some perspective. Burn-Out: Pace yourself, find rest in the midst of circumstances, practice self-care; involve

others.

“Knowing what is best”: All the truth of each situation to emerge without our having to

direct it. Not knowing as a way of being.

Distrust and Insecurity: Part of our work is to support each other, part of it is to practice

letting to. Be open to whatever arises and trust is one the most important elements.

Being Controlling: Let the dying person do what she/he wants for a long as she/he can. Do

not take over this person’s life as they are losing it, trust the person’s inherent wisdom.

Inanimate Object: Even if someone is in a coma, never underestimate the impact of your

presence, including your speech and thoughts.

Attached to Caregiving Role: Sharing the responsibility of care has many benefits, including

helping us to deal with our own issues of attachment.

Hiding behind Caregiving: Stay open to your discomfort, use it as an opportunity to see your

expectations, fears and concepts; your suffering can be a catalyst for compassion.

Clinging to the dying person: Do not overstay your welcome. Some people die after their

relatives have left the room. It is better to ask what is needed and desired than act from

assumptions. Interfering in a fundamental way: Sometimes caregivers talk too much, give unwanted

advice or try to divert or entertain the one who is dying.

Loose sense of boundaries: Dying is about letting go of relationships, be aware of our

motivation and questioning. Let kindness and unconditional love guide you in how to be

present.

Transference and countertransference: The caregiver can appear to others like a guardian

angel and the next moment a demon. Do not personalize anger or criticism. When like and

dislike appear practice equanimity.


APPENDIX E (continued)

Unconsciously wanting gratitude and reassurance: Let go of your hunger for gratitude and

acknowledgement completely; it is not about your needs.

Bringing personal problems into caregiving situations: Sharing your problems with the

dying person may not be the best strategy for creating trust and intimacy.

Becoming spiritually inflated: We do not always know what is spiritually right for the

person. Consider impermanence and not knowing.

Notion of a good death: Give it up, each death is unique. Do no put pressure on the dying

person; relax and let go of your expectations. Concealed or unresolved grief: Use your grief as a way to deepen your compassion and

bring practice into your life and the life of the world.

Idiot compassion and impatience: Your intolerance of pain and fear can lead you into very

dangerous territory. Death has its own timing. Miracles happen at every step of the way,

even when suffering is acute. Learn to be in the present moment.

Source: Handout from “Being with Dying“ retreat, Upaya Zen Center, 2002


APPENDIX F

FIVE REMEMBRANCES

I am of the nature to grow old.

There is no way to escape growing old.

I am of the nature to have ill health.

There is no way to escape ill health.

I am of the nature to die.

There is no way to escape death.

All that is dear to me and everyone I love are of the nature to change.

There is not way to escape being separated from them.

My actions are my only true belongings.

I cannot escape the consequences of my actions.

My actions are the ground upon which I stand.

- Anguttara Nikaya 5.57

Metta Institute PO Box 2710, Sausalito, CA 94966 (415) 331-9600

www.mettainstitute.org

http://www.mettainstitute.org/

http://www.mettainstitute.org/


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Acknowledgements

Many lives and labors contributed to this work. I am grateful to the hospice volunteers at

Waldo County Hospice Volunteers for taking part in the compassion and self-care training,

for offering their time and wisdom for our gatherings, and their depth of sharing with one

another. Also without the response of “YES” to an unknown entity, myself, from the Flic

Shooter, the hospice volunteer coordinator, this training opportunity would not have been

possible. I want to thank my husband, Hank, for his deep support and keen insight of the

dharma that helped guide my development of the training and refine the program as it was

being offered.

In addition, the guidance and spiritual support from Lama Willa Miller, my spiritual director

during the chaplaincy program, was integral for revealing a grounded place to act from while

serving others. The training for this project was not about me, and simply an offering to be

received, or not. Letting go was a constant theme from conception to conclusion, as well as

finding my voice.

The Upaya Chaplaincy Program served as inspiration, training material, and a source of

compassion that allowed me to conceive of the project and to complete it. I offer deep bows

to Roshi Joan Halifax, Aine McCarthy, Alan Senauke, Pierre Zimmerman and the many

wonderful dharma practitioners that served as faculty for the chaplaincy program. Also, I

have much gratitude for my new dharma brothers and sisters in cohort six that laughed and

cried with me and gave me love.

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