This paper, entitled originally 'Spirituality, language and depth of reality', is reprinted from the International Journal of Palliative Nursing, Vol 3 No. 1, Jan-Feb 1997 (subs from £50; Mark Allen Publishing Ltd, Croxted Mews, 288 Croxted Road, London SE24 9BY, tel 020 8671 7521). Rachel Stanworth is a member of the Befriending Network management committee and a researcher, Chaplaincy Department, St Christopher's Hospice, London, supervised by Heythrop College of the University of London.
It is argued that metaphor and symbol may reveal truths as compelling as those disclosed by the natural sciences and that multiple layers of meaning exist in all human activity and expression. Professionals are invited to reflect upon the authenticity of their communication with patients, for the simplest act of care may be deeply significant when a patient feels that their own sense of reality has been recognised.
When religious language cannot explain the human condition, the dimensions and events of life itself carry the deeper significance. A search for meaning or sense, is often prompted by self-examination (Frankl 1992):
Such enquiry carries us to the limits of our self-understanding and existential knowledge, and reflects our ultimate spiritual concerns. The physical and emotional challenges faced by terminally ill people, their diminishing social contacts and ability to perform customary roles, raise perhaps the most difficult question of all: who am I? (Charmaz 1983).
Language is never simply a system of labelling or naming. It is a symbolic means of understanding the world, and when understood as such it extends beyond verbal articulation. The metaphor of tongue extends to all forms of human expression, be they those of the pre-verbal child or of the aphasic adult (Langer 1969).
Each of our movements is also a gesture and we refer naturally to body language, the language of art, music or mathematics. In a sense, the limit of our world, of what we know, is synonymous with the limit of our forms of language (Crossan 1975).
Possibly our capacity to negotiate in some of the subtler realms of language is becoming blunted. If so, this carries serious implications for the scope of our communication and our ability to comprehend reality as experienced by another person. Every incident signifies meaning beyond the immediately obvious, and to restrict interpretation to surface appearances is inadequate (Kearney 1992).
Metaphor thus extends the boundaries of our language and knowledge. Consequently, the significance of patient metaphors should not be underestimated for they may be gateways to their spiritual reality.
"...as a white woman ... you cannot know what it means to me to be dying. In Africa everything to do with death is darkness. You cannot be expected to know these things as I know them." A young single Ghanaian mother of two.
"... there is more than a slight anxiety at the thought of having to die. I go extraordinary and fall into dangerous cracks and crevices from time to time. But I think it is right, a sort of plunging, letting go of your life. Whether I'm capable of it or not I don't know; it's rather like plunging into the sea - it takes courage." Reflections of an elderly woman with Parkinson's Disease.
These patients are dealing with boundary and transition; from dry land to water, from light to darkness, with each metaphor arising from the unique events of their lives; part creating, part revealing that which could not otherwise have been said. However, as the natural sciences dictate that validity and reliability are the exclusive hallmarks of knowledge, we have become more familiar with the quantification of product than the contemplation of process or relationship. Thus we still appear reluctant to accept such imagery as a form of truth.
We, nonetheless, appear to feel more comfortable dealing with the distinct, the material, the measurable. The calculated rate of photosynthesis is somehow more real to us than the vision of the mystic or artist who, looking at the same leaf, detects a shade of blue. The scientific observation is more strictly referential and more easily corroborated, but it fails to explain the enduring appeal of Van Gogh's sunflowers and his insistence that he was painting, "the yellow that is somehow in the shade of blue" (Chipps 1968).
All experience invites depths of perception, for events, objects and artefacts are portals of meaning, often more profound than their immediate or surface impression. For example, one patient with motor neurone disease left her curtains open each night, to gaze at the Crystal Palace radio aerial, as the illuminated mast assumed the guise of a "prayer candle" or "beacon", before she settled to sleep.
Maureen had been a professional woman before she developed cancer of the brain and bowel. She wept bitterly as she described her frustration and anger, the indignities of total dependence, and her mixed feelings towards her elderly parents, for whom she had been providing nursing care for a number of years:
"Normally I'd be able to turn over and get this sputum off my chest. I'm so pissed off, I never smoked a single cigarette in my life. I led a very healthy and active life ... my father looks at me and I feel he keeps thinking why did I have to have a daughter like that? I spent all my time running up and down the King's Road for him ... I did throw that at him and you don't want to but you do. I think our Doctor even said, 'You done this to her.'"
As she was sobbing, and repulsed by the green sputum covering her fingers, warm water was brought and the hands were soothingly washed and patted dry on a soft towel. There was a calmness about the ablution, which was carried out in silence and accompanied by a powerful sense of totality. She only muttered that: 'Something is coming to a natural ending here'.
Nothing more needed to be said. The clearing of her chest seemed to have both a physical and deeper significance. Now she seemed to feel a little more room in which to manoeuvre; perhaps a space in which to nurture a compassionate self-appreciation.
When this level of meaning is perceived, events become experiences. Attempts to standardise the units of exchange in such encounters are of little use, for the vocabulary of spirit belongs to a language of depth, and meaning unfolds in the context of relationship, rather than presenting itself for dispassionate analysis.
Perhaps in palliative medicine more than in any other field, we realise that those topics on which we would most like to speak are precisely those on which we have to remain silent. Yet repeatedly patients remind us that they require someone to share their searching or pain, someone who will listen to their frightening dreams and fears, not someone who provides the pat answer.
"I've been told I've got about nine months left. Am I allowed to talk to you about this? I don't know what is allowed, but it's got so heavy now" - and beating her chest - "I can't bear it." A 41-year-old woman.
"I want to talk about me. I want someone to be sympathetic to me. To hold my hand to listen to me. Someone asked me how I was. I felt so weak and I said so, and then do you know what he said? 'It's because it is so hot in here' and he started to open the windows. That is not what I needed. No wonder he was hot all wrapped up in his outdoor clothes. That is not my problem. I am dying, for God's sake. He made me so angry. I don't want to hear this. I just want someone to be with me and to hold my hand." The plea of a 49-year-old computer operator.
For some patients, an acute awareness of the absence of meaningful communication - not only now in the experience of the illness, but throughout all of life - may emerge, and this can be very hard to bear. One day, a patient was poring over what appeared to be a bank ledger, attacking the figures with intensity. Once an important businessman, now suffering from lung cancer, Conrad had travelled the world with his wife. As he repeatedly scanned the columns he sobbed:
"I've so let my wife down. We were going to have such a wonderful retirement. This is all my fault; she begged me not to smoke. I wish I felt more pain. These have to balance before the night falls but how can they? ... We haven't had a real conversation in nearly all our marriage."
Missed opportunity and regret infuse the frantic desire to set matters straight, while the quasi-biblical "before the night falls" suggests the ultimate gravity of Conrad's situation. Time is fast disappearing and communication now counts in terms of depth rather than extension.
A new temporal perception may invest the simplest act of care with deep significance and carers should try to remain sensitive to this:
"It's only March but it feels most of the year has gone."
"I'm on a different time zone to other people; days are long ... my time is short."
If we accept the invitation to listen calmly to patients, to be present at each moment without distraction, the metaphor, joke or throwaway line, may facilitate a profound disclosure. We can choose our response to comments such as: "l'm heavy enough for ten men - nine dead and one dying." (An 80-year-old man being lifted up the bed).
"I've been kicking the bucket for too long now; that's what that is." (A 69-year-old woman during an examination of pressure sores on her heels.)
We can choose to become aware of whether particular objects or patterns of behaviour may be of symbolic significance. Why should a man waking at 4.40am each day, dressing himself and waking his fellow patients in the process, persistently ask his nurses to weigh him? "Well everything is in the balance now ... ... sleeping is a bad sign; anything can happen to you when you are asleep."
To refer to a statement, artefact or action as only symbolic or metaphoric, and to imply that it is somehow less real than the literal or factual, is erroneous. Unlike the sign, which merely stands for something else, the symbol participates in the reality it attempts to indicate. Fire, for example, may express any number of meanings that are capable of indefinite growth, including: warmth, nurturance, purification, rage, destruction.
Its symbolic comprehension can never be a simple substitution of one word for another. The symbol is thus a catalyst, for it is open and invitational, pointing to alternative and wider possibilities. Symbolic thought enables us to move from one level of reality to another and can help us cope with apparently intolerable situations (Fawcett 1970).
Hazel, an 80-year-old widow, was the source of some bewilderment, by insisting that her dead and dying flowers were left on her locker. This was benignly tolerated as a personal eccentricity, but, as she explained, the flowers clearly spoke to and for her, revealing both sadness and hope:
"I'm keeping those dead ones because they have left their life and this is all that's left of them ... you can see that it is rather beautiful actually, the bits and pieces ... some of them are shooting upwards towards heaven because they have died ... the picture is of what's left of their bodies and the thought heavenwards ... They remind me to let go ... I wonder what it is like after you die."
The wilted flowers and rotting vegetation point to the rhythms of nature, and the possibility of some order to life's patterns. Paradoxically, in their decrepitude, they convey the comforting possibility of value and beauty in decay. By both promising and withholding the possibility of fertility or future life, the flowers hold in creative tension the sense of liminality expressed by Hazel's final remark. By indicating dimensions of reality lying beneath surface appearances, the flowers became a source of energy and comfort for Hazel. Factors which could so easily have been overlooked by an overzealous urge to clean the locker.
There is an ancient idea that the eye of the mind sees concepts, the eye of the body sees objects, and both are dualistic, whereas the eye of the heart sees by entering, by participating. If we are to enter authentic relationships with patients, we must remember to see with the eye of the heart (Side 1995), for although scientific vocabulary allows us considerable control of our world and to work many wonders, it is not exhaustive, it cannot say everything about the human condition.
The poet, novelist, and historian speak in and through symbol and metaphor, but this does not reduce the truth of their statements. Poetic language triumphs through its relationship with life, one of interaction rather than of observation and management. If we are to hear patients we have to be prepared to risk uncertainty and to travel with them to places where there is no expert vocabulary to protect us. This dialogue, however, is not abstract, esoteric or beyond the reach of mere mortals. It is a language which, in our increasing sophistication, we need to remember rather than learn, for it endows and characterises the very essence of humanity.
Interestingly, the Greek etymology of 'symbol' is 'sunballein', meaning 'to connect', suggesting the ability of symbols to hold together apparently contradictory or paradoxical features. A recognition of the subtleties of language will not only disclose the 'connections' which constitute reality as it is experienced by patients, it may foster relationships where - in terms of looking for answers to spiritual questions - professionals are comfortable to be recognised simply as fellow searchers, perhaps with as much to learn as to offer.
Peter, in his mid forties, was a successful builder with a young family. One lung had been removed for lung cancer and he now had metastases in the other. Peter and the author were sitting together one day; Peter seemed to be feeling tense and gratefully accepted the offer to massage his hands with a little cream. They bore the marks and calluses of a lifetime in the construction industry and dwarfed those of the author. Peter began to reciprocate gently and when he was asked which he preferred, to give or receive the massage, the profundity of his answer was compelling:
"I don't know. I like them both. Giving and receiving, for me, that really is the essence of spirituality."
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