Training Issues in Coma Work: edges and personal freedom

Ever since I joined my husband, Amy, in his work with people in comatose conditions, I have been confronted with many of my own feelings and growing edges about life, death and my ability to communicate with people in deeply altered states of consciousness. I have been teaching coma training classes in Portland as well as workshops with Amy in different places around the world for a number of years. In these classes and seminars I have found that other people also discover central growing edges which arise as they train in this work. By edges, I mean those exciting moments when we come to the boundary of our known identities and are challenged to consider new thoughts and behaviors. Coma training, therefore, is intimately connected to the personal development of the caregiver. It has been important to expand my view of training to include focus on the personal work of the coma worker. In this article I address some of the main edges or problems that repeatedly arise in the course of training and suggest exercises for working on these developing aspects of ourselves as coma workers.

In Amy's pioneering work on coma he says that "as long as the body lives, consciousness is possible." This central belief in coma work, where we facilitate the person's inner process, calls for a new palette of skills for working with such states. In his book Coma: Key to Awakening he provides tools to join someone in an altered state of consciousness, help connect that person to her or his inner process and help this process to unfold. These skills make it possible for doctors, nurses, caregivers, hospice workers, friends and family to communicate with someone even if she or he is not talking, or is in a deep trance and not communicating in the "normal" ways we are accustomed to.

There are many skills which are helpful in working with people in comas. I will not expound on these skills or theory here.2 Let me simply mention that anyone interested in working with people in comatose states needs some awareness training to follow and assist those in deeply internal and withdrawn states. Training in working with non-verbal signals, sounds, movements, visualization, body feelings,

See Arnold Mindell, Coma: Key To Awakening (Boston: Shambhala, 1989) 97.

The reader can find practical tools, theoretical background and case stories of coma work in Coma: Key to

Awakening. Kay Ross' article in this journal is also a useful introduction to the medical view of comas and a

comparison with the process-oriented approach. See also Stan Tomandl's manual, "Coma Work and Palliative Care:

An Introductory Communication Skills Manual for Supporting People Living Near Death," for practical exercises in

coma work. For an introduction to hospice work, see McLeroy et. al, "You Are Not Alone: A Handbook for Hospice

Caregiving."

touch and work with the breath are important. In addition, some knowledge of dreamwork and imagery, childhood dreams, normal psychotherapy, family and relationship work are helpful. There are also particular methods and theoretical considerations which concern differences between metabolic and structural comas. Metaskills such as an openness to mysterious events, belief in what is happening, patience and compassion are central to coma work.

Training and personal edges

Amy and I have discovered that learning to work with people in comatose states often brings up personal growing edges in students and caregivers. Training in this area causes many of us to consider our own altered and introverted states. We are confronted with our feelings about life, humanity, and death. Excitement and fear appear in almost everyone approaching the topics of personal expression and freedom in working with people in comas. The sense of intimacy and contact brings up many personal issues for trainees. It has become apparent that coma training is inseparable from a deeper exploration into the caretaker's personal work.

Given this context, training becomes a fascinating journey into the psychology of the "coma worker." In the following pages, I address some of the most prevalent personal edges which emerge in coma training. These include: 1) Edges to altered and internal states. 2) Edges about death. 3) Edges about making sounds and using movement and touch with people.

I want to stress, however, that certain people are exceptionally gifted in coma work. They have an ease with and an uncanny knowledge of altered states.

These people often feel more at home with people in comas than they do with people in "normal" states of consciousness. You notice these individuals by their ability to get close to the comatose person, by their fluidity in non-verbal communication, and by their special compassion towards others.

Our altered states

A central ethical consideration of coma work is that if we are not able to relate to someone in an altered state of consciousness, then we as coma workers must change, not the person in the coma. We need to develop and learn communication tools that help us join the comatose person in her or his altered state and particular communication system. Research has shown that people in comatose states are working on themselves and need time to process internal experiences without the distractions of normal life.

I remember, for example, walking by the bed of a young man in a hospital. He had suffered from brain damage and at this point his eyes were open and he was sitting up in bed. He was singing and humming to himself. The nurses came in and asked him if he knew which day it was and where he was. The man did not seem to notice their questions but continued to sing and laugh. He was obviously in an altered state from the states we are accustomed to. His feedback system was altered in that he did not reply directly to their questions and he was operating in a very different time and space from the nurses' everyday reality.

Yet the fact that someone is not communicating in customary ways brings many of us unexpectedly to an edge. Some of us feel fearful, uncomfortable, or awkward. I think that this lack of comfort derives

There is much research to be done in coma work. I encourage anyone who is working in this area or has the chance to work with someone in a coma to keep detailed notes so that statistics can be compiled.

In Japan many students were very skillful in this work. They seemed at ease, in our training seminars, with the comatose person, were very intimate and followed each signal with utmost care. Perhaps it is the emphasis on inner life and meditation which made these Japanese people so sensitively attuned to this type of work. An altered state of consciousness is a state of consciousness which is different from the one we normally identify with. Amy says that "In altered states, such as those we encounter in dying processes, feedback to questions about everyday realities is diminished or absent. People cannot enter and leave these states easily. They seem absent, their memory may be disturbed, and they usually have poor space and time orientation." (Mindell, Coma 55). Mindell, Coma 102.

from a lack of familiarity with our own altered states. We are accustomed to living in ordinary reality and often disavow the spontaneous altered states that come up throughout the day. Therefore, we are shocked, surprised and uneasy when sitting with those who are living and expressing themselves in an "altered" manner compared to consensus reality.

In order to understand what a comatose state might be like or mean for a given individual, and to access personal altered states, it may be useful to try this exercise:

Lie down and imagine that you are in a deep trance state or coma. After a few minutes ask yourself: "What purpose might this state have for me? What might this state bring me? What meaning might it have for me to be in such a deep and internal state?" A second stage to this exercise, for training purposes, is to ask, "If someone were to assist me with my inner work from the outside, what could they do that would be helpful? What would be less helpful?" For example, how would you like this person to approach you? What kind of touch or verbal communication would be most helpful to you? What would be most disturbing?

Increased awareness and comfort with our own altered states is not only healthy but will also make it easier to be with people in comas, giving us a deeper understanding of what the comatose person may be experiencing. To further develop ease with altered states of consciousness, try to catch the flickering of altered states as they arise throughout the day. Notice when your attention drifts and something new is trying to arise. Notice the tendency to withdraw when you are with people and try to appreciate and follow these signals. Experiment with an openness to these altered states and try to help them unfold with inner work tools.

For example, if you are talking to someone and you notice that you are looking down and fading out of the conversation, follow this tendency to go inside. Find out what channel your process is flowing in at the moment Are you seeing, feeling or hearing something or is movement happening spontaneously? Focus on the channel that your experiences

are flowing in, amplify this, and add other channels to help fill out and unfold your experience. Perhaps you will discover that you need time to be quiet or want to change the subject. If possible, bring this information back into your relationship with the other person, thereby enriching your interaction.

This kind of fluidity with inner work tools is, in general, excellent training for working with anyone in a deeply inner state such as coma, catatonia, withdrawal or depression.

Fear of death

The fear of and confrontation with death has been a most apparent and important aspect of my own work with comatose people and in coma training. Coma workers are sometimes faced with their own mortality and that of others, with memories of or grief over past loved ones who have died, and with fears of death and the dying process. The panic and fear some of us associate with death cause us to freeze in the presence of someone who may be dying and to project our own feelings about death onto this person.

In a new forward to Coma: Key to Awakening, Amy and I address this issue and possible avenues which may be helpful in working on our own issues around death and dying:

The entire work with people in altered states of consciousness is complex and difficult, not because it is difficult to work with people in these states, but because many of us are not at peace with our own death. On the one hand, learning about death and dying is a matter of practice, and on the other it is a matter of personal development or inner work. Fantasies about dying for those of us in the midst of life often mean learning to let go of aspects of ourselves which are tired and worn out. Our inability to let go and let things happen, inhibits life by resisting death. There is a time for this fight of course, but if we continue to hang on and form sentimental ties to aspects of life which need dropping, we also hang on to the dying person and make life and death unnecessarily difficult for her or him.

See Nisha Zenoff s manuscript "From One Mother to Another: Journey Through Grief and article "Grieving: A process-oriented perspective" for further discussion of grieving and methods of working with grief.

The less centered we are ourselves in the processes of life and death, the more we inhibit the client's awareness and communication on these topics. Ill people are often uncomfortable speaking with others who seem against disease, death or permanent injury. The more open and detached we are about such states, the better it is for everyone. But the only way to get there, is to work on ourselves. The method of "practicing your death," facing the various feelings and unfinished business around your own demise still seems the easiest way to begin in this area.

Therefore, the fear of death may not be due only to the fact that we will actually die, but also to the drive for certain aspects of our identities to drop away so that new aspects of ourselves can be born. In some of our training seminars, Amy and I have given an exercise on "practicing your death." This means imagining that you die and letting go of parts of yourself that you no longer need; then, following your fantasies of what wants to live on, imagining what new parts want to be born and identified with.

For example, I remember a woman who experienced herself as depressed and plagued by internal criticism. She had constant fantasies that she would die. When she lay down and pretended that she did die, she imagined that she floated up in the air and looked down upon the earth. She suddenly broke out into uproarious laughter. She felt detached and could see that her ordinary troubles were not really very important. She imagined flying in the air feeling as free and playful as a bird in the sky. This woman's death fantasies were an attempt to drop her identification with her depression and identify with the childlike, free, and detached part of herself.

Amy has also said that much of our fear of death is connected with the fear of being trapped in vegetative states which cannot be used.10 Many of us fear

that if we were to fall into a comatose state, we would be trapped, lonely and unable to make use of the state. This may be due to a lack of working on our altered states before we enter the dying process and to not asking others to relate to us when we are in altered states. No wonder we feel lonely, afraid and unable to maneuver in deeply altered experiences.11 Inner work practice helps reduce the amount of time spent in these states where we are unable to make use of our experiences. This fear may be alleviated in part by practicing inner work skills which help us navigate through deep inner experiences. It may also be helpful to ask others to be with us in these states.

Working with non-verbal processes and personal freedom

The goal of this work is to join the comatose person where he or she is and assist with the unfolding of his or her experiences. The coma worker notices tiny responses and signals and communicates in a similar manner to the comatose person. The kinds of interactions which are most helpful should match the types of signals and reactions that occur. The best interventions are those that are happening already.13

Many people, due to a lack of familiarity with altered states, resort to their normal ways of communicating when confronted with someone in a comatose or withdrawn state. Many of us are shy around people who are not talking. Some feel awkward relating to another person who is lying down, who may be silent or making unusual sounds, does not look them in the eyes, makes tiny movements of the eyebrows, pushes with the heel of the foot, or purses the lips.

Amy once said to me that the client has all the options, and the therapist seems to have none! The client appears to have more fluidity with altered states

8 A new edition of Coma will be published by Penguin-Aikana in the Spring of 1994.

For further discussion of this point, see Arnold Mindell, The Shaman's Body (San Francisco: HarperCollins, 1993) Chapter 11.

Mindell and Mindell, Seattle coma seminar, 1991.

11 Mindell, Coma 47-48. 12

Mindell, Personal communication. 13

Mindell, Coma 54.

and we as helpers are often stuck in the ordinary realm of communication without the flexibility to follow what is happening. We end up, for example, talking to the person as if she or he were in an ordinary state of consciousness and expecting answers in like manner.

Learning to work with comatose patients challenges us to communicate in the most elementary ways. This includes using sound, movement, bodywork, touch and imagery. Comas due to brain injury particularly require the development of this skill. How, for example, will you communicate with the movements of the mouth, the eyelids, or the breath? How will you react to quick sounds, coughs, jerks of the hand, or a push of the heel of the foot? How do you work with signals which you do not initially understand? One student recommended that we remember what it is like to communicate with a baby in order to access this type of communication style.14 Can you remember what it is like to communicate with someone without access to ordinary words?

Let's look at some of the edges which arise in response to this type of communication.

Working without content

Working nonverbally demands that we follow the person's internal experience of her or himself without necessarily knowing the exact content of the experience. We must try to follow and unfold information in a contentless way using blank accesses in sound, movement and touch. Many people are shy to follow and interact with these seemingly contentless processes and tend to interpret information instead of allowing it to unfold in its unique way.

The kinds of signals we see in comatose states manifest from internal processes and do not match our usual associations to these signals. For example, a frown may not be a sign of unhappiness, but

could be an attempt to focus on an image. We are challenged to put our ordinary assumptions aside and develop a beginner's mind which notices and supports the various signals and processes as they emerge. We are reminded of a central aspect of Process Work which is related to the Buddhist concept of "right understanding." Right understanding means that we cannot understand the flow of the river by standing on the outside and deciding what it means. Instead, we must get into the stream of experience and through this, true understanding will follow. This requires an open mind and heart which supports and follows the mysterious unfolding of nature. Perhaps we are challenged most strongly to follow this type of understanding when working with people in comatose conditions.

Try, for example, following your own process throughout the day with an open mind. Do not interpret what is happening but support and allow it to unfold and express its own wisdom. Interact with the part of yourself that wants to interpret as opposed to letting nature explain itself to you.

Edges to making sounds

A most useful intervention in coma work is making a sound of affirmation in response to signals that you notice from the comatose person. A simple vocal response to tiny signals gives the comatose person the feeling that you are present with her or him, in her or his process.

In many of the dyad exercises in my classes I ask that one person act like the "coma worker" and the other person lie down and pretend that she or he is in a "comatose state." In order to experiment with sounds, one exercise involves the person in the "comatose state" making slight sounds and the helper experimenting with vocal responses.

No one in my classes was aware ahead of time how shy he or she would feel when trying this exercise. For many, it was the most difficult and scary

Thanks to Debbie Hart for suggesting this.

See Mindell, Coma 60-68 for a more detailed discussion on using blank accesses, not interpreting and training

exercises for working with movement, auditory, visual and proprioceptive experiences.

Personal communication with Amy.

In their review of Coma in Common Boundary, July/August 1990: 44, Stephen and Ondrea Levine describe this kind

of communication as letting "life in, to listen with a clear mind and open heart."

exercise of all. People felt embarrassed or ashamed and many had strong edges which prohibited them from making any sounds. When I suggested that someone sing a comforting lullaby to the person she was working with, the helper squirmed and blushed and found herself at a very central edge in her life to making noise or to expressing herself at all. Difficulties in making sounds brought up all sorts of blocks around speaking out, tightness in the throat, memories of having been silenced as a child and fear of being vocally expressive. Learning to communicate through sound with a comatose person requires a certain amount of inner freedom. It is a break with our culture, an alteration from many people's upbringing.

One way to work on your own edges in making sounds is to pretend that you are a child and make all sorts of goofy sounds. Imagine that you did not know words yet but could only express yourself through tones. If you are unable to do this or feel uncomfortable, find out who or what is against you doing this. What holds you back? Continue by working on the process between the one who makes sounds and this inhibiting figure.

Edges around touch and movement

Intimacy and touch

One of the biggest edges in coma work is the ability to be close and intimate with the comatose person. For example, when I have suggested that the "helpers" in my class go very close to their partner who is playing the "comatose" person and whisper into that person's ear, some helpers stayed quite far away. Many kept a distance because of shyness, a lack of comfort with such closeness, intimacy issues, or out of fear of being intrusive.

What about intrusiveness or intimacy? Amy has said that your intent is more important than anything. If your heart is in the right place and you really want to be helpful, then the comatose person will feel that. He has also said that he never met anyone in a comatose state who did not like intimate contact when it was done with extreme sensi-

tivity to feedback. They felt just the opposite. People love compassionate focus! People may experience you as invasive if they are in the mood for normal communication, but this is not the case with someone in a comatose state. They appreciate the kind of intimate and helpful communication that you can bring.18 Hospice workers whom I have met have said that people in comas need lots of body contact and tactile stimulation, especially if the person has been in the hospital for a long period of time. They said that people who are in comas for a long time so appreciate the intimacy, touch and contact we can give them.

The ability to use touch in a compassionate way makes it possible to assist the comatose person in his or her expression and the unfolding of his or her process. I remember a woman, for example, whose head was turned slightly to the side. When her head, cheek and neck were stroked lightly in the direction her head was facing, she turned her head further to the side and tears began to flow out of her eyes. The turning of her head to the side was a signal which, when followed with touch, allowed her to connect with her need for love and caring.

What is the goal of touch and bodywork? Amy has said that, for those individuals who are in comas as a result of structural injury, touch and movement are important because the comatose person may not have the motor apparatus to respond and execute outwardly what they would like to do. With help, they can begin to make these movements. For those in metabolic comas, the motor apparatus is present, and touch allows them to unfold the experiences they are having. In all cases Amy has said that the goal of touch and bodywork is knowing that the body is dreaming, then helping the person become conscious of her dreaming process and helping the person connect to an inner awareness.19 He expresses the importance of this kind of touch as follows:

...we must not forget that many people going through these altered states need our help to realize their total selves. Indeed, they want intimate communication. Many prefer it to ordinary

Mindell, Control Case seminar, Fall 1992. Mindell, Coma 97.

loving compassion. For without it, a special moment can be missed as the mind spins wildly in a turbulent river flowing to the sea.

People who do this naturally seem to relate to the comatose person as if he or she were a close friend. They have a special love and appreciation for the individual and their unique process and a kind of open touch that allows the process to unfold.

One way of working on intimacy is to practice with another person. Approach the person and notice the kinds of feelings you have as you get closer. Take time to process these experiences. Also, experiment with the sense of touch with someone else. Go slowly and ask yourself what it is like to touch someone else, what feelings come up inside of you, what are your edges and how do you feel about contact and people?

Movement

Many of the signals of comatose people are movement signals such as slight motions of the mouth, the arms, the legs, heels, and eyebrows. It is sometimes helpful to use movement to test the limbs, for example, by slowly lifting the arm from the bony part of the wrist, to notice what kind of movement responses you receive and to help the inner dreaming process to unfold.

We worked once with a man who had been in an accident and suffered from massive brain damage. He had been laying passively in a coma for many months. When we first saw him, his hands were tightly clenched in a corticoid posture because of the brain injury. Assuming a beginner's mind, and believing that the hand signals might not only be due to his physical condition, we slighdy pulled on his fingers to see how he would react. In response, he clenched his fists more tightly. As we continued, he began to bend his elbows and pull his arms in, as we pulled away from him. We were suddenly involved in a pulling match! Finally he started to make growling noises and even began to lift himself out of bed! It turned out that he had previously been a weight lifter and had not used his muscles or strength for many months! At this point, a relative

in the room made the comment "Oh, there he goes again, bragging about his strength!"

Movement is one of the most forbidden channels for many people. Those of us who have learned to sit quietly, to inhibit our movements and movement expression are confronted with new edges. Experiment with your own freedom in movement. Simply begin to move and notice the kinds of inhibitions which arise. Which movements are forbidden? Is movement forbidden all together? What stops you and how will you process this further?

Experiment with moving someone else. How do you feel as you do this? How much ease or comfort do you have? Don't forget to use movement with clients in ordinary states of consciousness, as many of us revert solely to verbal communication here as well. It is not only fun to work with movement but it will also provide more ease in movement work with people in comatose states.

Conclusion

Research has shown that people in comatose states appreciate the intimacy and assistance a helper can provide to access and unfold their inner experiences. Working with people in comatose states requires that we as helpers and caregivers confront some of our personal edges connected with such issues as intimacy, fear of death, altered states and personal expression, particularly in the expression of sound, movement, and touch. By focusing on these edges in our own lives and in coma training, we may become more free to communicate with people in comatose states, and we will learn more about our own inner lives, our feelings about life and death, and our relationships to others.

Amy Mindell, Ph.D., has a diploma in Process Work and a Ph.D. in clinical psychology. She has a private practice and teaches in Portland, and gives seminars with her husband Amy in many places around the world. She is especially interested in coma work and training and is also an artist, singer and writer.

Bibliography

1. References
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3. Mindell, Arnold and Amy. Coma Seminar. Seattle, June 1991.
4. Mindell, Coma 102.
5. Mindell, Arnold. Coma: Key to Awakening. Boston: Shambhala, 1989. (New edition to be published by Penguin-Arkana, Spring 1994.)
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11. Ross, Kay. "A Journey through the Minefield of Unconsciousness: A Comparison of the Medical/Nursing approach with Process Work." Journal of Process Oriented Psychology Fall/Winter, 1993: 23-31.
12. Tomandl, Stan. Coma Work and Palliative Care: An Introductory Communication Skills Manual for Supporting People Living Near Death. White Bear Books, 1991.
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14. Zenoff, Nisha. "From One Mother to Another: A Journey through Grief." (unpublished manuscript, 1988)