Close to the Bone. Jean Shinoda Bolen

creates, or in the fearful half-light of the psychological underworld, patients enter the realm of Ereshkigal, when they reach the point of realizing that their old self and old life are dead, at least for now, perhaps forever. For the soul, this can be a turning point: facing the possibility of disability or death can be reorienting, it can bring about a massive change in priorities and bring to the forefront questions of meaning and meaninglessness about how we are living our lives, about what really matters, and whether we matter. For the ego that had maintained the illusion of control over fate, this is often the lowest point. For the person, if ego turns to soul to lead the way through the underworld, there will be unexpected discoveries. For it's not what happens to us, but how we respond that ultimately matters and shapes who we are from inside out.

      Responding to Unchosen Circumstances

      Ever since I read Viktor Frankl's book Man's Search for Meaning,³ I have had an appreciation of a spiritual and psychological reality: that no matter how little control we may have over circumstances, even in the most terrible situation, we have a choice of how we will respond. This insight is empowering. Frankl and all of his relatives were taken into Nazi concentration camps, where every one of his family members perished. In this situation, there was no freedom, no choice about what or whether one would eat or work or be sent to the gas chambers the next day. The prisoners were starved and beaten, their legs became swollen with edema. They were stripped of identity, reduced to a number, and denied basic human dignity. And yet, even here, there were choices to be made at a soul level. Some people just gave up, others acted in the same inhuman way as their captors toward weaker inmates, and still others shared what they had, maintained loyalties, and even sacrificed themselves so other prisoners might survive longer. In this apparently meaningless and inhuman existence, Frankl noted that there remained a choice of attitude to take. He emphasized that the search for meaning is essential, and that the will to live depended upon it. If suffering or dying is the task, doing it well or poorly is a choice.

      Many years ago, I met with the nursing staff of the Planetree model unit following two deaths that occurred within days of each other. The nurses were in grief and in guilt and needed help with feelings stirred up by these deaths. Both patients were men who had died of AIDS. One of them was someone that the staff had come to know well and love, over years of multiple hospitalizations. They admired his courage as they helped him through his relapses, and with a post-hospital follow-up program, maintained contact with him during remissions. They were emotionally as well as professionally invested in his struggle. His death was mercifully peaceful and a personal loss to most of them. Their reaction to him grew out of his response to his fate: like a man dealt a bad hand but playing it well, he put his energy into living as fully and as long as he could. The other man was characterized as the most disliked patient any of them could remember. Efforts to help him were met with profanity, kindness was ridiculed and thrown back in their faces sarcastically. He was uncooperative, unappreciative, and full of hate. Bitterness, rage, and resentment were his response to having AIDS. He upset and disturbed other patients. He made it difficult to put in IVs or draw blood, and as he wished AIDS on others, contamination by his blood was a frightening possibility. Nurses came to hate him and dreaded the next incident he would provoke. Some found themselves wishing he would die. Their negative feelings were so at odds with their intellectual grasp of why he was behaving this way and their sense of themselves as good people and professionals, that when he died, alone with no one who mourned him, they were filled with guilt and shame. Both men shaped the last part of their lives by how they responded to having a fatal illness and how they treated the people around them. The legacy of feelings that they left behind grew directly out of these choices.

      The choice of how we respond to what happens to us usually remains, no matter how difficult the course. When we lose this choice is difficult to determine, because even when there is mental clouding, character seems to remain and influence response. It is not just circumstance that shapes us, either. Adults who have retained the capacity to love and hope and have faith and did not become like the people who abused them in childhood, somehow drew upon an inner wisdom and chose not to do to others what was done to them, or give up on themselves or on people, or succumb to hopelessness or cynicism and self-pity, choices that others in similar circumstances have made that diminish spirit and soul. Variations of these same choices of how we will respond and what we will become as a result, present themselves over and over to all of us in life. If our character and development of soul is shaped by us over time in much the same way as clay is worked upon before it must go through the fire, then we are both the artist and the work itself. We are a work in progress until the final touch. How we respond when we suffer shapes us, and what we do when we know we are dying makes a difference if we truly are spiritual beings on a human path.

      Living in the Shadow of Death

      One out of seven women will get cancer of the breast and one out of three people will get cancer in their lifetime. Often the diagnosis is made in prime adult years, way before it feels as if it is time to face the possibility of dying.

      Appearances make the parallels to being in the midst of a holocaust graphic. Patients with either progressive disease or those in the throes of aggressive chemotherapy or radiation therapy often lose appetite and weight. They can begin to resemble inmates of concentration camps, where Viktor Frankl learned about choice and survival of spirit in the midst of pain, deprivation, malnourishment, and suffering. Between the illness itself and treatment, there is often pain and suffering. There are times when food cannot be kept down, or cannot be absorbed. Malnourishment is common. While there are no barbed fences, the necessity of being in a hospital linked to an intravenous bottle is as confining. In a hospital as in the concentration camps, people live in a valley of the shadow of death, susceptible to feeling powerless and in danger of giving up.

      In radiation-therapy waiting areas in large medical centers, patients become aware that they are not alone in their suffering, that they are not the only one. Just as Frankl noted the way inmates responded, similar observations can be made in hospital settings. One such observer, Phil Head, a contributor to a series of essays in When the Worst That Can Happen Already Has, described what he saw. “You watch the ones who sadly give up. They don't walk into the room and say, ‘I give up, I have cancer,’ but in the way they accept the treatments and the way they relate to the other people, you know they've given up…. Then there are the people who try, to the best of their abilities, to spread a little fellowship and humor. From the very beginning, humor for me was a big help. As long as I was able to laugh at myself, the treatments, and my circumstances, there was hope.”⁴

      Humor is an expression of spirit and fellowship in the midst of a descent into the underworld. It's a means of commenting on reality and getting through uncertain times of risk and pain. (Frankl described humor at Auschwitz and Dachau as among “the soul's weapons in the fight for self-preservation.”) When one has been stripped of the outer garments of dignity and there is no visible means of security, humor comes from the soul's perspective and laughter changes our biochemistry and psychology.

      While humor may seem irreverent and far removed from a five-thousand-year-old goddess myth or the two-thousand-year-old Easter story, myth and humor have much in common in helping us through a period in the underworld. Both feed the spirit and are expressions of the unconquerable element in us. Humor and myth provide perspective on our suffering and make pain easier to bear. Each also is a commentary on there being something more to what is going on than meets the eye.

      Entry to the Underworld: Ready or Not

      There are many good reasons for an immediate admission to the hospital, such as traumatic injuries from accidents or violence, severe burns, a likely myocardial infarct, hemorrhaging, being unconscious, having a raging fever—any state in which immediate care could make the difference between life and death. At Los Angeles General County Hospital, where I interned, anyone who arrived in a critical condition was called a “red blanket.” The patient was immediately put on a gurney, a red blanket (in actuality, a bright red sheet) was thrown over him, and an attendant wheeled the gurney on a nonstop