Basic Attendance: Full Presence Caregiving

Fruition of Mindfulness

The practice of "Basic Attendance"  in many ways is as old as the human experience itself ….one individual caring for another in a time of need;  caring with body, mind and spirit….. wholly present.  This 'whole presence' in caregiving is at the heart of the vision and discipline of Basic Attendance as practiced in the Windhorse approach to care here in Boulder, Colorado.  This approach to caring for others, whether dying, aging or experiencing extreme states is inspired by the Contemplative traditions as taught at Naropa University also in Boulder.  Eastern and Western traditions and practices that cultivate the synchronizing of one's body, mind and environment provide the ground and path for cultivating this presence.  In particular, the practice of Mindfulness-Awareness meditation has been key in the development of this ability to be present with warmth and awareness. 

We have all heard the adage, "Know thyself". This practice as taught at Naropa University has this intention inherent in its method.  There are many forms of meditation;  some focused on relaxation and calming and others focused more on practicing being present with whatever arises in the moment on an inner or outer level of experience. The Mindfulness practice referenced here is more akin to the latter.  This practice of presence or nowness helps to strengthen our ability to return to our immediate experience with a sense of openness, curiosity and an expanded awareness.  We might also add another adage along with Socrates' imperative above and that would be to  "Befriend thyself".  What can also occur as we get to know ourselves better is that we see our wisdom and confusion more clearly, so, this practice also has, as its bedrock, the experience of making friends with oneself as well, which is the basis for befriending the world. 

You might ask how this applies to working with elders and those dying.  As caregivers in such situations, we all have had a full range of feelings and experiences when faced with a person who is declining either physically or mentally and know that such experiences can bring up very deep, core issues such as our own fears of losing control of our minds, bodies, lives.  We can have visceral experiences of tasting our own death and coming face to face with this reality.  The poignant and potentially painful vigils held with those dying can dissolve the barriers between us and can cause us to recoil or open to the inevitable.  

In offering care and presence as a family member or a caregiver, if we have spent time with ourselves plumbing the depths and textures of our fears around aging and dying, we are more likely not to react out of that fear when faced with our loved one or client.  It is possible for us to acknowledge our feelings and fears like an old friend, breathe out the tension and struggle and then respond to or simply be with the person we are caring for in a more skillful and compassionate way.  The practice of mindfulness can help to cultivate a clarity around those moments when we could either react, suppress or respond to our world.  Also, with this befriending, we can actually experience a  feeling of warmth toward ourselves and the other person, rather than judging ourselves and others.  So, basically, this process of coming back to our experience in the moment can cultivate qualities of openness, clarity and warmth towards ourselves as well as toward our world and others we encounter or are serving.

        As this process deepens with ourselves, we can find that this openness, clarity and warmth, which are fundamental qualities to the human experience and named in Buddhist teachings as an 'Awakened Noble Heart', can help us to be more available to another's suffering, confusion and need.  So, in a sense, we find ourselves moving toward such experiences rather trying to shy away from them to protect ourselves.  

Also, by so doing, we find that these experiences with others serve as beacons on our own path of awakening to these qualities.   In this Basic Attendance work, we often talk about this mutual path quality.  Thus, we think of it as  "care giving and care receiving" as coined by one of our staff members.  This being a more apt way of describing this process and care.  We become teachers for one another on our mutual journeys.  In Eastern teachings, generosity is defined as a giving and receiving practice.  

Another vivid expression of this approach and attitude toward this work is expressed in what are called teaching slogans. These basically are pithy statements that serve to remind us of the view.  One such slogan that evokes this approach is, 'No Escape, No Problem'.  So, basically, taking whatever we might preconceive of as an unworkable situation, rife with claustrophobia and bringing this attitude of workability to it, by virtue of our intention to come back to the moment.   So, everything we encounter becomes part of this intention to be present.

This approach is also embedded in the name and symbol of " Windhorse".  This term is widely referenced in  Eastern cultures and represents a fundamental energy inherent in the human experience, that can be evoked, cultivated and roused to heal ourselves and others. This energy is likened to the term "chi" also in Eastern traditions.  

Through the practice of synchronizing body & mind in a contemplative discipline i.e., mindfulness meditation, yoga, or tai chi, the possibility of being present in groundless and uncertain moments  is more likely to occur.  This is the healing energy of 'Windhorse'.  This method of being with others has been practiced in Contemplative settings and was also named and developed further under the late Ed Podvoll, MD whose book, Recovering Sanity, a Compassionate Approach to Understanding and Treating Psychosis, includes a chapter entitled: Learning Basic Attendance.  This chapter presents the 10 skills of Basic Attendance that expand on this notion of presence.  These skills aren't necessarily linear nor meant to be a recipe but rather guideposts.   The ten skills are:  1) Being Present 2) Letting In 3) Bringing Home 4) Letting Be 5) Bringing Along 6) Recognizing 7) Finding Energy 8) Leaning In 9) Discovering Friendship 10) Learning.   These expanding skills can arise from the ground of presence as skillful means in attending to our loved ones and clients.

Being Present: is the on-going touchstone as one practices Basic Attendance.  

When I am with an elder or a dying person, I can notice the contrast between my speed of mind and the slowed down and potentially spacious process of the person I am attending.  Noticing this contrast brings me back to the moment……  Entering the environment of a dying person invites an attunement to the ever present nowness of the situation.  When attending my dying mother, returning to the rhythm of her breathing, the temperature in the room, her level of pain…..touching in on my level of pain with her dissolving and coming back to the present….cultivates an opening rather than a closing down to what is.  

Letting In: This speaks to the natural process of having an experience of actually touching into another's state of mind.  For example, after feeling the contrast of my speedy mind, I can open to this other quality of mind whether it is slow, spacious, anxious, fearful, or depressed or I can retreat further into my mental speed and need to distance.  Letting In is the practice of  opening to another person's felt experience.  As a person is dying, their state of being can be highly agitated, as in "terminal agitation".  I was present at another family member's dying as she went through this process.  Two days prior to her passing, she was very accepting and open-hearted about her impending death and even named the actual day she would then pass.  As the days unfolded, she moved into an agitated phase…..a group of us family members were surrounding her during these last hours holding her and the space for her karmic unfolding.  It was as if we were a mandala of open hearts breathing with her….letting in and letting go. 

Bringing Home: This refers to the practice of including mundane activities in the discipline of Basic Attendance.  Synchronizing body, mind and environment in any activity such as doing the dishes, attending to a client's personal care needs, preparing meals, or relating to the trash.  There is no limit to the practice opportunities here.  Again, the environment is a reflection of the mind and the mind is a reflection of the environment.  I have witnessed family members attending so precisely to a deceased patients' environment with such care and attention.  Folding the ancestral blanket around the body with great precision and intention as they attend to their grandmother and prepare her for the prayer vigil.  Each act is imbued with meaning.  

Letting Be:  This has to do with a sense of equanimity in one's care….not being so attached to outcome that we are totally focused on results.   It is rather remaining open to the unknown of the situation which can be chaotic, groundless and changeable and actually suspend judgment about one's effectiveness. Of course, this is a challenging middle path to practice and, again, is cultivated with Contemplative disciplines and the practice of letting go of one's agenda.  

Bringing Along:  This speaks to the possibility of bringing your world into your caregiving and not narrowing down into being task driven alone.  When possible, you can include your interests as well as elements of your life i.e.. family stories and favorite books. With one particular client of mine, it was a common practice to include my daughter playing her cello for her when possible and then to actually have her play for her during the last few hours of her life.

Recognizing:  This refers to the possibility of wisdom and sanity being present in the most painful and confused states of mind and body.  An 85yo elder I worked with who wasn't particularly known for her kindness with her own family and who had significant dementia,  would give us advice about our own lives when asked….and shared a wisdom that reflected her deep concern, caring and understanding.  Recognizing these moments and reflecting back their wisdom can provide a rare moment of kindness toward themselves.  

Finding Energy:  This has to do with the potency of the perceptual field and the possibility of connecting with sounds, smells, tastes, visual perceptions and touch as a means of expanding their world.  Even if a person is in significant decline, the sense perceptions can be soothing and relaxing.  A staff member working with a woman with severe depression has started taking walks through the neighborhood and tasting the fresh fruit from the trees along the way.  The smell and taste can be a bridge to awakening from the narrowed world of her depression. 

Leaning In:  This refers to the compassionate skill of sensing when to lean into rousing a person and when to let be.  Again, this occurs within the practice of being present and attuning to another person's rhythm and ability in the moment.  We all know that it is often a judgment call when attending a declining person as to whether to lean in to rouse them or sense the rhythm of their need and choice to withdraw. 

Discovering Friendship:  This can arise within the context of such intimacy and is marked by practicing honest communication and authenticity in the relationship.  The fruits of this sense of friendship can create an environment of relaxation.  There isn't necessarily a need for the caregiver to take refuge in a particular role.  It is very common for our clients and their families to feel that we are extended family with them.  Authenticity in relationships fosters a deep trust and bond as we experience these thresholds in life.  

Learning:  This aspect is about the mutual path quality of practicing caregiving in this way.  We are learning as much or more from our clients and consciously pay attention to the moments of transmission.  Also, in practicing openness to our present experience, this shared journey informs our path as we face our own edges and uncertainties about life and death.  We also have had clients share their transmissions with us in a very direct way with their writings, videos, art work and spoken recordings….all passing on the wisdom of their lives.  These are precious legacies that we share in our community.  

So, these skills are aspects of the practice of Basic Attendance, which arise out of the mindful and aware sense of presence and thus aren't considered techniques.  The result of the experience of meeting your inner and outer experience with more of a sense of openness, clarity and warmth can manifest in this way.  Also, since Basic Attendance is very ordinary yet profound, there is a quality of it being accessible to everyone.    

Emery, Kathy, "Basic Attendance: Full Presence Caregiving."  Natural Transitions, Spring 2013, Volume 3, Issue 1, pages 6-8.