The Nest in the Stream

by Michael Kearney MD

  It seemed clear to me and my coauthors that traditional models of self-care, which emphasized the importance of having “good professional boundaries” to protect ourselves from the stresses of the workplace, coupled with replenishing programs of rest and renewal outside the workplace for when we are off-duty, were only part of the solution. We argued that, in addition to these traditional models of self-care, we needed ways of practicing self-care that would both protect and replenish us within the workplace.

  We proposed a model of self-care based on self-awareness. Here self-awareness, which we described as a combination of self-knowledge and mindfulness, is in itself protective, allowing us to self-monitor and consider how we are going to respond moment by moment in any given situation. It allows us to choose to step back or ask for help from other members of our team when we need to, and it allows us to move in closer to our patients when we want to. If our choice is to stay with the one who is suffering, our heartfelt presence opens a channel of connection, which lessens the intensity of the patient’s distress and allows us both to emerge enriched by the encounter.

  At the time I was writing the JAMA article, I had been in the field of end-of-life care for almost thirty years. I was working full-time as a physician with hospital and community-based palliative care teams, and as medical director of an inpatient hospice in Santa Barbara, California. While I loved the people I was working with, I noticed that I was no longer excited, as I had been in those early years at St Christopher’s, to go to work each morning. Instead, I was feeling emotionally and physically run down most of the time. I no longer had that inner “hum” that had been there in the past, which came from knowing that I was in my chosen profession and doing the right work. Even after a restful weekend, my energy was flat. More often than not, I felt unhappy with the quality of my work. I had the pervasive feeling that I was not doing what I really wanted to do and was doing too much of what I did not want to do, and I frequently found myself fantasizing about leaving medicine. I remember the moment I realized one evening, as I was reading a paper on the symptoms of burnout, that I was experiencing every symptom on the list: that I was burnt out.

  I asked myself how this could have happened, given that I had been practicing both the traditional and self-awareness models of self-care I was promoting in the article. I had good boundaries around my work and I took vacations. I had been in therapy and clinical supervision for many years. I practiced mindfulness. I worked with my dreams. I exercised. I gardened. I did not smoke or drink. I was happy in my home life. Again and again, I returned to the thought that maybe I was no longer doing the right kind of work. Maybe the issue was that the river of my soul had turned and was moving in a new direction, leaving me high and dry in the rut of my old day job. Or was it that I underestimated the toll of organizational stress, the slow grinding down that comes with having to wrestle every day with the cold, gray bureaucracy of health care?

  It was around this time that I took a scheduled summer vacation. I spent two weeks with my family in West Cork in Ireland. I had a wonderful time and returned to work rested and replenished. I remember my first morning back, walking into the inpatient palliative care office at 9:00 a.m. that Monday morning. One of my colleagues commented on how relaxed I looked. We chatted a little and then began the morning routine of going through our list of patients, triaging as we went who would see whom.

  The nurse who had worked the weekend filled us in on each patient. The first person she talked about was Frank. Frank was fifty-three years old and had a long history of lung disease. He now had anoxic brain injury following a heart attack and cardiac arrest. He had been on a ventilator for several days and attempts to wean him off had so far been unsuccessful. He was a widower and caretaker of a young family, including a ten-year-old daughter with severe disability from cerebral palsy. He had no advance directive and was “Full Code” (meaning that everything possible would be done to resuscitate him in case of a cardiac or respiratory arrest). There was disagreement between the patient’s children and his siblings about the future direction his care should take. A family meeting was scheduled for 10:00 a.m. Without pause, the nurse moved on to the next patient, a forty-two-year-old woman with advanced ovarian cancer who was suffering pain and vomiting due to bowel obstruction, and the next, a thirty-six-year-old man with a nonhealing compound fracture of his tibia and fibula with osteomyelitis, acute on chronic pain and opioid tolerance, and the next, a ninety-six-year-old woman who had had a massive stroke and shown no signs of improvement in almost a week but whose daughter wanted everything done, including placement of a tracheostomy and a feeding tube. These were just the first four patients; there were twelve more to go.

  As I listened to this litany of human suffering, I felt like a soft-shelled crab. It was painful to hear these stories. I noticed that I was tightening up and pulling back to try to protect myself from what I was hearing. It was just too much. I found myself thinking that those of us who work with pain and suffering every day hugely underestimate the toll our psyches are taking. We focus on fixing what can be fixed and having the conversations that can be had; we negotiate the politics and the egos of the workplace; we do our best with the family dynamics; meanwhile, we have already started to engage with the next story of suffering, and the next, and the next. At that moment, I became aware of what felt like an old, aching hurt in the center of my chest. I saw that good boundaries, enjoyable times out, and even self-awareness practices were simply not enough. I remembered Dr. C., the medical oncologist we had interviewed for our JAMA article, who had said, “The stuff that burns me out has nothing to do with loss; it’s fighting with insurance companies.” And I realized that for me, in contrast to Dr. C., it was the opposite: it was precisely the accumulated losses and daily encounters with human pain and suffering that were burning me out.

  Neither of the two ways of being with pain that I had learned so far, what I have called the medical model and the path of the wounded healer, were of much help to me here, in the face of such suffering. As I thought about this I slowly began to realize why. What I had learned so far had taught me a lot: from the medical model, I had learned how to diagnose and treat another’s “fixable” pain, and, with the path of the wounded healer, I had found a potentially transformative way of being with another in their “unfixable” pain. However, what was totally missing was any real instruction on what to do with my own pain. I had not been taught about what to do with what I was experiencing in the face of another’s anguish. I saw clearly that it was precisely this—not knowing what to do with the pain I was experiencing—that was leading to my feeling overwhelmed and burnt out. I knew that I had to find another way, a better way, of being with pain.

  In my quest to find another way of being with pain, I want to share seven stories of encounters I had with other-than-human nature. While these stories are personal in a subjective and biographical sense, my hope is that the effect on the reader may be like time spent alone in the wilderness, or like sinking your hands deep into soft, dark earth and letting your fingers linger there for a while. Time spent in and with other-than-human nature, with an attitude of deep listening and respect, can reorganize us into someone closer to our original selves.

  I share these stories in the spirit of the Buddha’s teaching on the nature of suffering and the nature of healing, the Four Noble Truths. The First Noble Truth is the truth of suffering: suffering exists. I share these stories because we are suffering, and the Earth is suffering. The Second Noble Truth is the truth of the cause of suffering: suffering has a cause. I share these stories because suffering comes from our clinging to the delusion that we are separate from the rest of nature. The Third Noble Truth is the truth of the cessation of suffering: healing is possible. I share these stories because our suffering ceases when we know that we are inseparable from the rest of nature. And the Fourth Noble Truth is the truth of the path to the cessation of suffering: there is a path to healing.


  I share these stories because connecting to other-than-human nature helps us to remember that we are seamless parts of the living whole, that we are all “relatives.” Each story expresses how we can find healing through what Jon Young, tracker, author, and leader in the new nature movement, calls “deep nature connection.”1 Connection with other-than-human nature is a powerful medicine. I have experienced this personally through my experiences on the Red Road and in times I have spent in the natural world.

  Nature connection, the process of connecting with other-than-human-nature through sensory awareness, is a deceptively simple yet extraordinary practice that can bring us insight and healing. As we connect with other-than-human-nature we realize that our world consists of countless other lives, each with their own uniqueness, and aliveness, and awareness, and that no single life is autonomous; each life exists only and because of its relationships of interdependence with others. Nature connection is about allowing this understanding to wash through us, helping us to remember that our deeper identity is one of what Zen Buddhist teacher Thich Nhat Hahn calls “interbeing.”2

  I have seen how, when nature connection happens in even very small ways, it can bring us from isolation to relatedness, ease our pain, and improve the quality of our lives. The more deeply we experience our interconnectedness with the rest of nature, the more awake and alive we become, and the more we care about others and our world.

  The stories that follow tell of how, through increasing immersion in the teachings of nature, I came upon a way of being with pain that I have found to be personally transformative. Here was a way of being with pain that enlivened and sustained rather than deadened and drained; a way of being with pain that awakened compassion and a yearning to ease the suffering and enable the healing of others.

  FIRST

  COLMAN’S WELL

  At the turn of the new millennium, my marriage of twenty-three years ended. As part of a turbulent and traumatic process for everyone involved and through circumstances not of my choosing, I did not get to see my three daughters, who at that time ranged in ages from sixteen to twenty-one, for over a year. During these hardest of times there were moments of respite. My meditation practice helped, as did time in nature. Late at night I took long walks in a cold wind under the stars on Sandymount Strand in Dublin.

  Later, back in my small, upstairs apartment, in what became a ritual of surrender, I would lie face down on a wolf robe (fur) in front of a small homemade altar of meaningful photos and artifacts, and find some respite in the softness and smell of the fur and the solidity of the floor. I found solace in the words from R. S. Thomas’s poem “Here”: “It is too late to start/ For destinations not of the heart. / I must stay here with my hurt.”1 At times, I found that I arrived at a deeper spaciousness, a peace of heart, and that I could breathe again. I missed my daughters intensely. I was reminded of the unrelenting pain of homesickness I had experienced during the six years I spent at boarding school. The school was in the west of Ireland, on rolling farmland dotted with lakes and old oak forests. I remembered how then, as now, I had wandered with an aching heart out on the land. I remembered how, then, as now, when I had sat and watched and waited, I had felt less alone.

  It was late afternoon at the end of January 2000 as I approached the little forest over stony ground. I was careful about how I placed my feet on the limestone slabs that had been rounded by millennia of Atlantic rain and winds. When I came to the trees under the hillside, I knew that I had arrived. There was the well; a horseshoe-shaped stone structure about as high as my chest, with water flowing into it at its base from the passing stream. Looking over the sidewall of the well, I saw that its soft muddy bottom was covered with crystal clear water a few inches deep. All around were trees and ferns and dappled light.

  This well in the Burren in County Clare dates back one-and-a-half thousand years to an early Irish monastic settlement founded by Colman Mac Duagh, a bishop in the early Irish church. It is still a place of pilgrimage for many who came there to pray. Pilgrims leave token offerings of little pieces of brightly colored cloth hanging in the branches of the willows growing over the well.

  On this particular day, I was aching and confused, feeling severed from my daughters. I had come here because I knew it as a refuge, a sacred place, a place of beauty. I had come because I knew there would be no judgment here, and no explanations needed. Here was a place where I could be my undefended self.

  I found a flat, dry patch of ground alongside the stream, close to the opening of the well, and lay down. I was physically and emotionally exhausted. I closed my eyes. My body felt like lead. I collapsed onto the cold, firmness of the rock. Lying there I could hear the trickle of the water flowing over stones just inches away. There was birdsong, and the brushing of the leaves of the willows overhead. I could picture their branches, arched and sweeping back and forth. Even though all was dark, there were flashes of gold as spots of sunlight touched my face. And all the while there was the hungry, ragged aching in the center of my chest.

  I don’t know how long I had been asleep when I was awakened by an unusual sound nearby. For some time, I continued to lie there without moving, listening with my eyes closed to what seemed to be a scratching noise. When I opened my eyes, I saw a robin, with his small brown body and russet breast. He was directly in front of me, maybe three feet away, at the edge of the stream. He continued to scratch the ground, flipping over stones, hunting for insects. He stopped. He was even closer to me now. I was still lying there on my side, facing him. He raised his head, tilted it slightly, and looked right at me. I found myself looking into the tiny black pool of the robin’s eye. For maybe two or three seconds he held my gaze; then he turned away and went back to hunting and feeding.

  I watched the robin as he continued his winding journey downstream and out of sight. Then I turned over, lay on my back and looked up. I could see patches of blue sky through the green canopy of the overhead trees. I noticed that something had changed in how I was feeling that was difficult to put my finger on. It was as though my heart had come into a steadier beat. Or that something had opened in me that felt like remembering, or being remembered.

  With this an image came. I saw my three girls. They were here too, but they were not alone. My eldest daughter, Mary-Anna, was with my grandfather George, sitting, as a younger version of herself, on his knee, as if he were telling her a story. My middle daughter, Claire, was with my mother, Anne, both standing side by side, smiling and looking alike. My youngest daughter Ruth was with my grandmother Delia, who had her arms around her. I was still aware of the aching but it was different now. Its edges were softer and it seemed to be reaching out to the rocks and the trees rather than pulling back into itself.

  When I was preparing to leave the well, I could not find my glasses. I had laid my new, very expensive glasses on the ground when I lay down. Now they were gone and, despite thirty minutes of searching, they were nowhere to be found. As I walked in a blur across the limestone paving back to where my car was parked, Rainer Maria Rilke’s words came to mind: “The work of the eyes is done. Go now and do the heart work…”2

  SECOND

  THE OTHER SIDE OF THE ROAD

  In November 2007, I was in Gardiner, Montana, adjacent to the northern entrance of Yellowstone National Park. I had been fascinated by wolves for some time and was following their reintroduction into Yellowstone with avid interest. Up until then I had only ever seen them in captivity. I wanted to see a wolf in the wild and had arranged to spend a day in the park with a wolf biologist. We did see some wolves that day but only as small specks through binoculars, and, although we did have encounters with bison, elk, coyotes, mountain sheep, and a golden eagle, I was disappointed as I returned to my motel room. Later that evening I went back into the park alone.

  I decided to go to the west side of Yellowstone to visit an information center there before it closed. As I drove along, I passed large herds of
elk on the land to either side of the road. A car approached me, flashing its lights. I realized I was driving too fast and slowed down. Another car approached, also flashing its lights. I understood then that the drivers were warning me about something up ahead, so I slowed down even more. As I turned the next corner, I saw what appeared to be a large gray dog approaching on my side of the road. I pulled my car into the curb on the opposite side and slowed to a halt maybe fifty yards ahead of what I now realized was an approaching wolf.

  The wolf continued to come toward me, staying by the tree line at the side of the road. He was going where he was going and he did not seem too bothered by my presence. As he passed me, his gait was graceful and effortless. His mouth was slightly open and he was looking straight ahead.

  I understood that as a visitor to Yellowstone, I should keep my distance from wild animals, and that it could be dangerous, even lethal, not to do so. However, as I watched the wolf walk away in my rearview mirror, I knew I had to follow. I turned my car around and drove along slowly some twenty or thirty yards behind the wolf. He stayed on the left-hand curb and continued at the same pace. For some time we traveled along like this.

  As we turned a corner, I saw a car fast approaching but still some ways off. I accelerated, overtook the wolf, and flashed my headlights to signal to the driver to slow down. He did, and pulled into the curb to let the wolf pass. I too pulled into the curb ahead of the wolf and waited and watched in my rearview mirror as he approached. When he passed he did not look in my direction and never changed his pace. I was aware that my heart was beating fast, yet I felt calm.