My Father, if it be possible, let this cup pass from me; nevertheless, not as I will, but as thou wilt. (Matthew 25:39).
An early draft of this paper was presented at the Orthodox Christian Association of Medicine, Psychology and Religion (OCAMPR) conference on "End of Life Care" at Holy Cross School of Theology in Brookline Massachusetts, November 7-8, 2008. It was to be the Psychology portion of the presentation on this topic. Let me up front tell say this it is am impossible task to separate, psychology, from the meaning of life fundamental to those who are committed to Christ. This is another way of saying that Christ's teachings are integrated with psychological intervention at all levels and all persons. But isn't this the synergia, which is OCAMPR? It is seen visually in the OCAMPR logo, the three concentric circles Body, Mind and Spirit intersecting with each other. So my ministry and this article is essentially: is a cooperation, or joint agency, that includes God and the contribution of God's gift to mankind of intelligence, the fruit of which is research clinical science and the mystical healing gifts of His Church toward the cure of body, mind and spirit.
In His goodness, God created the material universe; "In the beginning God created the heavens and the earth" (Genesis 1:1). Then "God created man in His own image; in the image of God He created him; male and female He created them" (Genesis 1:27); the "Lord God formed man of the dust of the ground, and breathed into his nostrils the breath of life; and man became a living being" (Genesis 2:7).
Mankind is meant for paradise, and paradise is eternal life in God. St. Isaac of Syria gives us an insight into this anthropology (Alfeyev, 2000). God indwells in man as a temple, The person of Christ is the fullest realization of this indwelling. Man in turn was created with the potential of admitting the fullness of the Divinity and endless existence. Referencing St. Isaac, Alfeyev says: "Every human person is provided with five 'incomparably great gifts': life, sense perception, reason, free will, and authority."
Illness and death, then, are foreign to the original purpose for which God created us. God never ceased to love that which He created. Rather, He wanted to test His creation. God wanted to see if Adam and Eve loved and would obey Him. After man's creation, God commanded, "Of every tree of the garden you may freely eat; but of the tree of the knowledge of good and evil you shall not eat, for in the day that you eat of it you shall surely die" (Genesis 2:16-17). We know our ancestors failed this test.
Life a Gift From God
It would not be wrong to say that not only does God create and sustain the existence of the entire universe, but to consider also that the gift of life even a single breath given to man, whom He created in His image and called to be like Him, is a grace beyond measure. This is so succinctly stated by our Holy Father St. Basil in the Anaphora prayer of his Divine Liturgy: "With these blessed Powers, O Master who lovest mankind, we sinners also do cry aloud and say: Holy art thou, of a truth, and all-holy, and there are no bounds to the majesty of thy holiness, and just art thou in thy works; for in righteousness and true judgment has thou ordered all things for us. When thou hadst created man and hadst fashioned him from the dust of the earth and hadst honored him with thine own image, O God ."
Christian Values: Following God's Will and Passing into Eternal Life
When it comes to the transition between life, death to this life and transition to eternal life, humanly we can pray the same anguishing prayer of Christ in the Garden of Gethsemane:" "My Father, if it be possible, let this cup pass from me; nevertheless, not as I will, but as thou wilt." On the other hand we can be firm in our conviction that death is a joyous transition to another life, a blessed life partaking of the Divine Nature (cf. 2Pt. 1:4) for all eternity as when as St. Ephraim the Syrian (1997) reflects on those who in this life were committed to Christ:
Those who labor, and accomplished strugglers of piety, rejoice at the hour of departure. Seeing before their eyes the great labor of their struggle, vigilance, fasting , prostrations, prayer, tears and sackcloths, their souls rejoice when they are summoned from their bodies to enter into repose.
This combination of human sorrow in our human nature felt as such a sense of loss is joined with spiritual joy a sense of hope and trust in the Almighty Father. This is seen the beautiful prayers the Orthodox Christian prays while immersed in the depths of human grief, mourning and sorrow, but united with the spiritual mind of Godly triumph as Holy Friday Evening Lamentation Service so elegantly interlaces (Saturday morning Matins prayer by anticipation).
In a grave they laid thee,
O my life and my Christ:
And the armies of the angels were sore amazed,
As they sang the praise of they submissive love
Who will give me water
For the tears I must weep
So the maiden wed to God cried with loud lament
That for my sweet Jesus I may rightly mourn.
I am rent with grief,
And my heart with woe is crushed and broken,
As I see them slay thee with doom unjust:
So bewailing Him His grieving Mother cried.
Dirges at the tomb
Goodly Joseph sings with Nicodemus,
Bringing praise to Christ who by men was slain,
And in song with them are joined the seraphim.
To thy Grave comes bringing,
Dear Christ, its dirge of praises.
Death Himself by thy Death
O my God, hast thou slain
By power of thy Godhead
Grant thy Church peace,
And thy flock Salvation,
By thy Resurrection.
Reflections on God's Mercy
There is no man who liveth and sinneth not. These words are know to every Orthodox Christian. Those about to pass into eternal life and their family as well. Of course preparation by a deep repentance and confession of sin, anointing with the Holy Unction and and parkaking of the Divine Mysteries is an essential preparation. When this cannot be done, in cases of sudden and unproved death and even in cases in which all recall the sins of their past life reflection on God's mercy is healing. Consider all of the references to God's mercy, the scriptures, the Church Fathers and the Liturgy.
The psalmist says: "Surely goodness and mercy shall follow me all the days of my life; and I shall dwell in the house of the Lord for ever" (Psalm 22: 6). Other noteworthy psalm prayers: "Do not thou, O Lord, withhold thy mercy from me, let thy steadfast love and thy faithfulness ever preserve me!" (Psalm 39: 11); "Have mercy on me, O God, according to thy steadfast love; according to thy abundant mercy blot out my transgressions" (Psalm 50: 1). "Answer me, O Lord, for thy steadfast love is good; according to thy abundant mercy, turn to me" (Psalm 68: 16) " who redeems your life from the Pit, who crowns you with steadfast love and mercy, " (Psalm 102: 4); "Praise the Lord! O give thanks to the Lord, for he is good; for his steadfast love [mercy] endures for ever!" And in the Book of Wisdom (6:6) we read: "For the lowliest man may be pardoned in mercy, but mighty men will be mightily tested."
In the Holy Gospels we see constant references to the mercy of Our Lord, God and Savior Jesus Christ:
But he, desiring to justify himself, said to Jesus, "And who is my neighbor [was asked Jesus by the self justifying lawyer]?" Jesus replied, "A man was going down from Jerusalem to Jericho, and he fell among robbers, who stripped him and beat him, and departed, leaving him half dead. Now by chance a priest was going down that road; and when he saw him he passed by on the other side. So likewise a Levite, when he came to the place and saw him, passed by on the other side.
But a Samaritan, as he journeyed, came to where he was; and when he saw him, he had compassion, and went to him and bound up his wounds, pouring on oil and wine; then he set him on his own beast and brought him to an inn, and took care of him. And the next day he took out two denarii and gave them to the innkeeper, saying, `Take care of him; and whatever more you spend, I will repay you when I come back.' Which of these three, do you think, proved neighbor to the man who fell among the robbers?"
He said, "The one who showed mercy on him." And Jesus said to him, "Go and do likewise."" (Lk 8:29-37).
We are to act like the Samaritan. Did not Jesus Himself tell us to be merciful: "Blessed are the merciful for they shall obtain mercy" (Matthew 5:7). From the cross: not only did He say about His executioners " Father, forgive them for they know not what they do!" but also, showed us how God reconciles those who sin. God's conditions for reconciliation and repentance, are so merciful, as to almost go unnoticed.
Consider St. Luke's report of the two thieves on their crosses next to the crucified Jesus: One of the criminals who were hanged railed at him, saying, "Are you not the Christ? Save yourself and us!" But the other rebuked him, saying, "Do you not fear God, since you are under the same sentence of condemnation? And we indeed justly; for we are receiving the due reward of our deeds; but this man has done nothing wrong." And he said, "Jesus, remember me when you come into your kingdom." And he said to him, "Truly, I say to you, today you will be with me in Paradise (Luke 23: 39-49) (emphasis added). It is Important to reflect on the words of St. James " yet mercy triumphs over judgment."
The Holy Fathers on God's mercy
St. Ephraim the Syrian tells us: "Only hope in the manifestation of Thy Grace, O man-befriending Master, consoles me and keeps me from despair. Whether Thou so desirest or not, save me, O all-good Lord, according to Thy great kindness."
"God's mercifulness is far more extensive than we can conceive." (St. Isaac of Syria quoted by Brock, 1997). God's love according to St. Isaac is the driving force of all He has done, He is doing and He will ever do. God-loving Bishop Hilarion Alfeyev (2000) quoting St. Isaac the Syrian notes: "In love did He [God] bring the world into existence; In love is He going to bring it into that wondrous transformed state, and in love will the world be swallowed up in the great mystery of Him who has performed all these things; in love will the whole course of the governance of creation be finally comprised."
It is only in the context of understanding God and all His works as Love that St. Isaac's understanding of the end of time becomes comprehensible. St. Isaac writes: "Accordingly the kingdom and gehenna [hell] are matters belonging to mercy; they were conceived of in their essence by God as a result of His eternal goodness That we should further say or think that the matter is not full of love and mingled with compassion would be an opinion laden with blasphemy and an insult to our Lord God. By saying that He will even hand us over to burning for the sake of sufferings, torment and all sorts of ills, we are attributing to the Divine Nature an enmity towards the very rational beings which He created through grace; the same is true if we say He acts or thinks with spite and with a vengeful purpose, as though he were avenging himself."
With this in mind, St. Isaac's reference of God being in hell, still trying to draw the demons and those there to love Him, is humanly fathomable. St. Isaac, based on his "mystical union of with the love of God" (Alfeyev, 2000), would consider the final judgment, as described in the Parable of the Last Judgment (cf. Mt 25: 31-4): the separation of the sheep from the goats to be the state of the soul at death. But a state not final or irreversible. Both demons and sinners would still have the possibility to respond, by God's eternally enduring merciful loving grace, so "they will gaze towards God with the desire of insatiable love " This is not saying universal salvation will occur; it merely describes the disposition of God, Who is ever eternally loving, merciful and ready to forgive.
Trust in God's enduring mercy
What a beautiful way for us to pray for God's mercy and to show mercy and love to all who have attempted or succeeded in committing suicide. Elder Paisios of the Holy Mountain tells us: "We must always be considerate and lenient to our fellow men, so God can also be the same with us" (Ageloglou, 1998). Our commitment to God is to put all our trust in Him. Let us pray the words of King David as he fled from Saul: " This I know, that God is for me. In God, whose word I praise, in the Lord, whose word I praise, in God I trust without a fear" (Psalm 56: 9-11).
Targets of Intervention
The persons in need of intervention are the child of God coming to the end of life and his/her, family, close friends and caretakers. The issues of concern of both groups could overlap but are likely to be different as well. The main focus of the dying person may be issues such as the loss of personhood, and value. They also may be suffering great discomfort including pain, loss of dignity, concern about loss of control, loss of meaning in life, being a burden to family and friends and the indignity of dependency on others (Back, Wallace, Starks, & Pearlman, 1996; Canetto & Hollenshead, 1999). The dying person may also be burdened by grieving over the effect of their death to their survivors especially if they are responsible for the welfare of others.
Physicians typically want to preserve hope in a physical cure. They have difficulty telling patients and family when a cure is not possible. Some physicians also have difficulty discussing basic patient choices such as hospital or home treatment, breathing machines or feeding tubes, and comfort care.
Medical education has often not included palliative or comfort care and compassionate care near the end of life. Some physician s believe that they must do everything to prolong life regardless of the pain and suffering involved and fear that offering comfort care may suggest they have given up or failed. Discussing issues of Orthodox Christian teaching and the ethics of end of life care is critical in such situations.
Field and Cassel, (1997) and Lo, Quill, and Tulsky (1999) suggest although not traditionally a part of medical training palliative care be introduced in end of life discussion. As such issues are so complex Cummings (1998) has recommended they be addressed by an interdisciplinary team. Psychologists and chaplains would be 'team members/" Of course, for Orthodox the inclusion parish priest would be essential. Not incidentally this is one important reason to introduce such pastoral care in seminary curriculums and mandatory continuing education for Orthodox clergy.
Assessment should include the following areas: overall care quality, sources of suffering, palliative resources and interventions, estimated course of illness, cultural issues, cognitive impairment and emotional distress, grief over what was done or not done (sins? failures?) in life. Legal and economic issues should also be appraised.
The impact of death on the family is should also be looked into from the viewpoint of the dying person as well as the family and friends left behind. It is very important to for the Orthodox Christian psychologist and priest to have a sense of the level of spiritual development of both the person coming to the end of their lives and their family. Careful assessment of current dysfunctional cognitions must also be made. The dysfunctional cognitions include:
- Selective Abstraction: The focusing on one event while excluding others..
- Arbitrary Inference: Drawing a conclusion unwarranted by the facts in an ambiguous situation.
- Personalization: Interpreting a general event in exclusively personal terms. Polarization: Perceiving or interpreting events in all or nothing terms. Generalization: The tendency to see things in always or never categories.
- Demanding Expectations: Beliefs that there are laws or rules that must be always obeyed.
- Catastrophizing: The perception that something is worse than it actually is.
- Emotional Reasoning: The judgment that one's feelings are facts.
Increasingly clinicians dealing with death and dying issues have seen the importance of dealing with philosophical: 'meaning of life' issues. This means assessing the 'world view' of the person approaching death and the grieving loved ones. (Malkinson 2007).
Death and loss is an existential confrontation with who we are and our meaning in life. For the committed Orthodox Christian, Christ is the meaning of life: God's Love, Mercy and Will, and the grace we receive to respond with hope and trust, is the foundation life's meaning. Some marginal Christians however , will not have construed the meaning of life in Divine terms. Assessment of the spiritual level of all and careful guidance by committed caregivers to help those construct a view of death and grieving issues is necessary.
The Paradox of a Good God Permitting Evil
One major spiritual issue that is common to many end of life situations is the paradox of the love and mercy of God and the unfairness of the end of life process (Morelli, 2006a). It is just this issue however which confound both Christians and non Christians alike. The age old question: How can a good God permit such an unexplainable death? Such calamities are perceived as evils by those who ask.
This question did not escape our holy spiritual father St. Peter of Damaskos, who wrote:
I was also astonished how God, who is good beyond all goodness and full of compassion permits all the many and various trials and afflictions of the world. Some He allows as sufferings conducive to repentance. These include hunger, thirst, grief, privation of life's needs, abstinence from pleasure, the wasting of the body through asceticism...anguish, fear of death...the dismay, the oppression, the throttling of the soul in this world and in the next.
And they there are all the dangers facing one in this world: shipwrecks, illnesses of every kind, lightening, thunder, hail, earthquake, famine, tidal waves untimely deaths-all the painful things that God allow to happen to us against our will." The saint lists also the sins of mankind among calamities: "wars, the tyranny of the passions; the derelictions, dislocations and vicissitudes of life; the anger, slander and all the affliction that we of our own will bring upon ourselves and one another against God's will. (Philokalia III p. 75-76).
In the Orthodox funeral service, we pray the Idiomelon by St. John of Damascus: "I called to mind the Prophet, as he cried: I am earth and ashes; and I looked again into the graves and beheld the bones laid bare, and I said: Who then is the king or the warrior, the rich man or the needy, the upright or the sinner?" Or, in the words of a popular contemporary song: "Is that all there is?"
But St. John of Damascus' prayer does not end there. Because of Christ we have divine eternal meaning. The last line of that Idiomelon is, "Yet, O Lord, give rest unto Thy servant with the righteous." Later in the funeral service we pray, "May Christ give thee rest in the land of the living, and open unto thee the gates of Paradise and make thee a citizen of His kingdom."
The meaning of illness and death is eternal life. In counseling those dying and their families I try to emphasize, life is a gift from God and a great mystery. "Even a single breath is His gift." I also point out that we see the 'little picture', with dimmed and partial understanding: "For now we see in a mirror dimly, but then face to face. Now I know in part; then I shall understand fully, even as I have been fully understood. So faith, hope, love abide, these three; but the greatest of these is love." (1Cor 13: 12-13).
Individualizing Intervention: Psych-Spiritual Stage Assessment
As in all psychological interventions, it is important to let the patient describe the death and dying process in their own terms. I have outlined above a rather complete Orthodox theology of death and end of life care based on the meaning of our lives as Christ and His Church has taught us. However great clinical sensitivity and spiritual discernment is needed to put this into practice with individual. Preaching is definitely not appropriate.
After the dying person or grieving family member tells their "life story" as they are confronting the end of life, the meaning of life as known to us as Orthodox Christians can be kindly and wisely inserted in an empathic loving conversational manner. Asking what the meaning of a particular passage in Scripture may be a start. Reflecting on one of the teachings of the Spiritual Fathers of the Church., might be another helpful way to point to the ultimate Divine meaning in life. Helping the dying person and their family that in the Kingdom of God, those blessed will now have a new vocation and mission: to pray for us, intercede for us and will always be with us. Such reflection can be integrated with the prayers and healing of the holy mysteries of the Church.
Orthodox Christians in the beginning of their spiritual life may need more help in appreciating the mystery of God and the good that we cannot now perceive: "Behold, I make all things new." (Rev. 21: 5). Those more advanced can more easily grasp this because trust in God and abandonment to His Providence and Will has become enlivened in their hearts. Incidentally, psychologists are counseled by professional organizations such as the American Psychological Association (http://www.apa.org/pi/eol/homepage.html) to use the spiritual values of their patients and their families in end of life care-thus such intervention may be considered a psychological intervention as well.
The preponderance evidence of clinical research indicates irrational thinking, also known as cognitive distortions in producing dysfunctional emotions and the cognitive-behavioral intervention in treating such cognitive errors is indicated. (cf. http://www.orthodoxytoday.org/Indexes/Morellix.php). This would be especially relevant to end of life care because of the emotional distress felt by both the dying person and the grieving family The main cognitive distortion related to sabotaging patient endurance is over-evaluation or catastrophizing. It is especially important in end of life care, not to be forceful in challenging and restructuring irrationality. Everyone is hurting. A kind empathic suggestion to consider alternative ways of looking at a distorted thinking process, would be recommended.
Healing: Linking Body, Mind, Spirit
Identifying and disputing these cognitive distortions, identified by the clinical research studies of behavioral science is not dissimilar to the Spiritual Fathers who said evil thoughts have to be acted on to "rebuff them" (St. Symeon the New Theologian, Philokalia IV) Modern psychology gives us more tools to do this (Morelli, 2006c,d).
The Church Fathers, especially those involved in spiritual direction (Hausherr, 1990) would surely have welcomed such procedures. These fathers often employed the disputation process in spiritual guidance. The disputational or challenging questions are:
- Where is the evidence (the evidence for the evaluation)?
- Is there any other way of looking at it (e.g. re-rating the calamity)?
- Is it as bad as it seems (how does the previous evaluation compare to the re-evaluation)?
- What is the effect of holding onto my distorted thoughts (what would happen if I changed my thinking)?
A technique effective with over-evaluation or catastrophizing is the "Mental Ruler Technique". Please note this 'ruler is 'Ruler on a Human Scale'. The ruler 'tool' involves evaluating the calamity situation on a zero to 100 scale. The zero end of the ruler is made using the most pleasant thing one could picture happening to you (Burns 1980, Morelli, 1987) "in the entire universe". Parishioners or patients infrequently have trouble imaging a very pleasant event (zero). Sitting on a sun drenched tropical beach is a typical image. Those seeking counsel often n need great help however, imaging a worst event (the 100 end of the ruler). Patients or parishioners I counsel frequently characterize 'the death of loved one', especially a child, as the "most awful thing on earth" - often such responses are couched in sanitized and/or abstract terms. The person being counseled has to be helped to make the worst event (the 100 end of the ruler graphically concrete (see Morelli, 2006b).
Caveat: Validate Grief but do not Endorse Catastrophe
While a counselor certainly must help a person with the grieving process allowing in particular, the expression of feelings, he must take care not to endorse a catastrophic mental ruler appraisal by saying "Oh! Indeed how awful how terrible." For example, while the loss of a child is tragic and the cause of great sorrow and grief, unless it reaches the scale of "100" it is not the "most awful thing one can suffer."
A Vivid Concrete Catastrophe (100 on the Mental Ruler)
On a human level in helping the committed Christian or patient to counter this I offer the example the un-sanitized, quite concrete example of a true event: a medical missionary in South East Asia several years back who suffered a horrifying death. His captors placed chopsticks in his ears and hammered them in a little each day until they penetrated his brain and killed him.
The Spiritual or Eschatological Ruler
In the case of the spiritual virtue of patient endurance of the approaching end of life must be evaluated in the eschatological scale of the Kingdom of God (Morelli, 2008). This is can be easily seen in a very simple comment of death made by a very holy elder of the Church recently deceased. Elder Paisios of the Holy Mountain (Ageloglou, 1998) remarked: "When I see Christians cry because their fathers passed away, I am upset, for they neither believe, or understand that death is simply a journey to a life of another kind."
This almost shrouded comment actually contains the brilliant pearl of the center of spiritual wisdom: All is God, all else is meaningless. Did not St. John tell us:
Father, I desire that they also, whom thou hast given me, may be with me where I am, to behold my glory which thou hast given me in thy love for me before the foundation of the world. O righteous Father, the world has not known thee, but I have known thee; and these know that thou hast sent me. I made known to them thy name, and I will make it known, that the love with which thou hast loved me may be in them, and I in them (John 17: 24-26).
The challenge of the Christian: Lack of Human Understanding but Complete Trust in Christ
Surely catastrophic evaluations on a human level frequently broadcast a lack of commitment to Christ and His teachings on a divine level. Surely the commitment of the Christian is in a God Who freely gives life and calls us back to Him. God does all for love and even though some events are beyond our understanding, we can nevertheless know that some events have a greater, higher, and divine purpose even when we don't see what they might be. This gives an entire different meaning to the quote of St. John in the Book of Revelation (1:8): "I am the Alpha and the Omega," says the Lord God, who is and who was and who is to come, the Almighty."
In this regard we contemplate the words of St. Isaac the Syrian:
A time of trial is beneficial to everyone: the diligent are tried so that their wealth may increase; the lax, so that they may be preserved from harm; those spiritually asleep, so that they may prepare themselves for watchfulness; those whose who are far from God, so that they approach Him; those who are God's close associates, so that they may come closer to Him in freedom of speech (Brock, 1997).
Thus to patiently endure: "Rejoice always, pray constantly, give thanks in all circumstances; for this is the will of God in Christ Jesus for you" (1 Thessalonians 5: 16-18)
The Ultimate Healing in Union with Christ: Victory
The Christian view however, sees an eternal dimension to all illness, death and ultimate healing by the possibility of being united with Christ in paradise. The suffering of Christ on the cross, for example, has eternal ramifications in that the power of sin and death was destroyed when Christ destroyed death by being resurrected from the dead.
St. Basil's anaphora prayer (the prayer read before the consecration of the bread and wine in the Orthodox Divine Liturgy) reads: "Having descended into hell through the Cross, that He (Christ) might fill all things with Himself, He loosed the pains of death, and rose again from the dead on the third day, making a way for all flesh through the resurrection from the dead."
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