Santa Fe July 30-August 3, 2012

May 31, 2012    SPECIAL OFFERS
    Registrants: If a friend of yours registers for this conference, we will
refund $100 to you. Y
our friend can register at the special price of $395

   Three or more people may register together for $395 each.

Meet and Greet!

Dear Colleague,
Come to the bar/lounge at La Fonda (with the dance floor) 4:30-6:30 Monday afternoon and meet your colleagues.(no-host bar) Everyone please wear your name-tag.
Looking forward to seeing you there.

Jacqueline, Denise and Barry

We invite you to join us for our exciting, stimulating, life-affirming conference in Santa Fe July 30- August 3, 2012. Our meeting will be held at La Fonda on the Plaza, one of Santa Fe’s finest hotels. The presentations will probe into the relationships between the artists’ psychodynamics and the Art they will create. The Santa Fe Opera will perform Puccini’s Tosca and Bizet’s The Pearl Fishers while we are there. Santa Fe is alive in the summer with Opera, Fine Restaurants, Museums and the colorful Plaza across the street from our hotel.

Monday July 30, 2012

Coffee will be available each day prior to the presentations

Welcome: Jacqueline Panter, MA, MS & Barry Panter, MD, PhD

8:30AM The Co-Evolutionof the Upper Limb and Brain: Possible Implications for Art and Music Therapy 
Stephen Baird, MD
9:30       Arts In The Holocaust – Testimony, Reconciliation And Healing Carol Baird, MA
10:45-12:45 Mozart: The Mind and Music of a Genius. Piano Presentation  Richard Kogan MD

2:00-4:00 Discussion Groups: Monday & Thursday

Tuesday July 31

8:30 Termination Issues in Psychotherapy: How Much Is Enough? John Graham, MD
9:30 Creativity & Couples: Using Movie Messages in Marital Treatment  Valerie Shinbaum, MS, LPC
10:45-12:45 “The Creative Brain”: A Neurologist Looks at George Gershwin and the Biology of Creativity.
 Presentation with Piano, Samuel H. Markind, MD  ( I have been a Principal Investigator (PI) for clinical trials of a compound called Bapineuzumab for several years.  As a PI, I have a contract whereby I am paid for performing work according to a study protocol.  Over this time, different companies have owned the compound.  At first, Elan owned it, then Janssen owned it, now Pfizer owns it.  Because payments are sometimes delayed, I listed all 3 companies.  Nothing about these studies relates to my presentation.  

2:00 In the Eye of the Beholder: The Psychology of Blindness & Visual Impairment Nalin Mehta, MD
3:00 Creating Sacred Space: Rescuing Death from Medicalization. Hanno W. Kirk, PhD, LICSW

Wednesday August 1

8:30 Revered Genius or Social Outcast? The Pain and Privilege of the Gifted Mind
Shelley Joy, M.A., LMFT, LPCC
9:30 “The Suppressed Memoirs of Mabel Dodge Luhan: Sex, Syphilis, and Psychoanalysyis in the
 Making of Modern American Culture”  Lois Rudnick PhD
10:45 Creativity: What is it and How Do We Measure it?                   John Goff, MD
11:45 Talk, Wine & Psyche-Dionysus, Transcendence & Madness
Rod Birney,MD & Suzanna Nadler M.Ed
2:00 Writing Off Old Age: The Joys and Trials of Creative Writing in Retirement 
John Meeks, MD and Bethany Baxter
3:00 Becoming a Person of Destiny: Discovering & Fulfilling Life’s Purpose,
Ken Hultman, EdD, LPC

Thursday August 2

8:30 The Clinician’s Use Of Self & The Therapeutic Alliance In Couple’s Therapy.
                          Roy Resnikoff, MD
9:30 Art And The Brain, A Neuropsychiatrist Goes To The Gallery” Jeffrey Clothier, MD and Clint Kilts, MD
10:45 The Healing Power Of Sacred Music: Meditations, Mantras, And Music
Robyn Greene, LMFT
11:45 Tributaries of consciousness: From Shamanism to Near-Death Experiences
Mitch Liester MD & Rev. Steve Alsum  DISCLOSURE STATEMENT FROM DR. LIESTER: I am a promotional speaker for Forrest.  This means I give presentations to other physicians about the antidepressant, Viibryd.  Our presentation has nothing to do with this medicine or their company.  So, I will be promoting neither during the talk

Friday August 3

8:30 A Nightmare on Elm Street, Dream Master: The Development of Identity Roy Hamilton, PhD, HSP-P
9:30 Creative Nightmares James Pagel, M
10:45 Learning Self-Regulation Through Play – The Joy of Parallel Process Mixed with Evidence Based
Treatment                                              Cynthia Dodge, Ph.D.

The Mary Lou Panter Scholarship is available for this conference: (tuition, transportation, lodging and $500), please go to


Optional Workshops (additional Continuing Education):

Mon & Thurs. 2-5 Professional Ethics (3 Hrs each day.Take one or both)$50 each day.John Graham, MD
Mon 2-5 Integrating Dionysian Transcendence Into Clinical Work. Rod Birney, MD 3 Hours CE $50
Monday 2-5 I Surrender: Falling In to the Authentic Self through Writing $50 Shelley Joy LMFT LPCC

Thurs 2-5 Experiential Clinical Supervision: Therapist-Couple Personality Interactions RoyResnikoff, MD 3 Hrs CE $50.
Thurs 2-5 Discovering the Self Ken Hultman, EdD, LPC

Friday 2-5 Healing the Self Through Self Portraits Amy Stein,MFA, ACPMH 3 Hrs CE 3 Hours $50

Accreditation: The American Institute of Medical Education is accredited by the ACCME to provide continuing medical education for physicians. AIMED designates this live activity for a maximum of 27 AMA PRA Category 1 credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
APA: The program is co-sponsored by The American Institute of Medical Education and Wisdom Wave. Wisdom Wave is approved by the American Psychological Association to sponsor continuing education for psychologists. Wisdom Wave maintains responsibility for this program and its content..
AIMED also is approved for Social Workers, (#886589292-9784) MFT’s, Counselors, RN’s & others. Please call if you need more information. Additional Hours are available by attending the workshops.

Accommodations: We have arranged for special rates at a number of hotels Please call the hotel of choice directly, mention Creativity and Madness to obtain the group rate

La Fonda 800-523-5002 $219
Eldorado Hotel 800-955-4455 $199
Inn of the Governors
– 800-234-4534 $209
Garrett’s Desert Inn – 800-888-2145 $119/$129
Hotel Santa Fe 800-825-9876 $149
Chimayo (Plaza Real) – 877-901-7666 $159
St. Francis – 800-529-5700 $159
The Lodge – 888-563-4373 $109

Hilton Hotel – 505-988-2811 $179
Sage Inn 505-982-5952 $99
Marriott Courtyard – 800-777-3347 $109

The Santa Fe Opera will be performing Puccini’s Tosca on Monday July 30th and Bizet’s The Pearl Fishers on Tuesday July 31st and others on August 1, 2 and 3. Please call the Opera directly for more information, tickets, shuttle, etc. 800-280-4654.

Registration Fee for 28 Hours of CE is $525 (accompanying registrant $450), (800) 348 8441 or Fax (323) 874 5503 email:

Travel Information and lowest airfares and car rentals please call The Travel Station (800) 990 2282. Additional Information about Santa Fe:;

Cancellation Policy: $100 prior to July 1, no refund thereafter. We suggest you obtain Travel Insurance which is available from The Travel Station or online.


Valerie J Shinbaum, MS, LPC, MAC, NCC

Handout – July 2012

Creativity and Couples – Using Movie Messages in Marital Treatment

Part One – Does the Institution of Marriage Stand a Chance in Today’s World?

I believe in marriage, as an institution, as a concept, as a lifestyle choice. I think lasting

lifelong marriage between two people is possible, even in this time where one of two marriages

ends in divorce. Not great odds, to be sure. But as long as there are humans on the planet, there

will be people with the biological drive to connect emotionally and intimately and want to share

that connection in the same household. And for many of those humans, that means marriage,

with all of its messiness and drudgery, the routine, the boredom, and the taking for granted of

each other.

Let’s stop for a minute and remember that the wedding is not the marriage. It’s easy to

make a great party for a day, and to wear the pretty dress and the fancy tux and get the presents

and eat the cake and dance with friends and family and have that celebration. That’s just the

beginning. I haven’t met a couple yet that didn’t have detailed memories of their wedding day.

Not that those detailed memories are always positive. But all the same, every married individual

I’ve encountered has stories to share about the wedding day. That’s a significant milestone

marker and easy to document, catalogue and review. It’s in the day to day, in and out, hard work

of marriage where the details get much more fuzzy and less specific. It’s where couples get

bogged down in maladaptive coping strategies, difficulty with communication, built up

resentments based on failed expectations and disappointment, lack of similar goals, and the

overall letdown that is the real life, real world of a shared life with the same person.

So why do it in the first place? Why get married at all? Here’s where the movie

messages begin. In the film “Shall We Dance?” Susan Sarandon’s character explains, “We

need a witness to our lives. There’s a billion people on the planet….I mean what does any one

life mean? But in a marriage, you’re promising to care about everything. The good things, the

bad things, the terrible things, the mundane things….all of it, all of the time, every day. You’re

saying your life will not go unnoticed because I will notice it. Your life will not go un-witnessed

because I will be your witness.”

The above quote is a positive interpretation of how people feel about being married. And

it comes from a place of strength, positive self-esteem and peace within themselves. But many

times this is not the reason people want to be married. The idea drummed into us by family,

religious organizations, and societal messages in general is that to be unmarried is to be ‘alone’

and to be ‘wrong’ in some way. For many people, to be alone is a concept too difficult to face.

For this reason, many people get into a state of desperation that they must find someone to marry

otherwise there will be some kind of negative impact on their lives. When this happens, self

esteem flies out the window and rather than entering into this important relationship from a place

of strength, abundance, calm and peace within themselves, we have folks rushing to connect with

other in haste and out of fear.

This is shown in the film “The Mirror Has Two Faces” with Jeff Bridges and Barbra

Streisand, who enter into a marriage based on Bridges’ notion that their marriage be based on

friendship and common understanding and interests, because he has found that to be passionately

and romantically involved with someone never works out for him. Streisand agrees to this

arrangement because she has feelings for Bridges but also because she is coming from a place of

low self-esteem, loneliness and neediness. Ironically, Streisand’s character is a college professor

who lectures about love, passion, and all of the positive things that romantic love can provide.

Valerie J Shinbaum, MS, LPC, MAC, NCC

July 2012

page two

Part Two – Saving the Relationship or Not? Reasons Why Couples Enter Treatment

So the marriage begins and the two people in it might realize that they are not as

committed as they thought they were, or they realize the other person doesn’t love them as much

as they thought, or they become bored living with the same person day after day, or kids coming

into the picture and that creates chaos, or the dynamics of family create a negative impact on

either or both members of the couple, or all of the above. The honeymoon is over, the thank you

notes have been sent, real life happens with a vengeance and this can be a wake up call.

I have read many times that real love begins when infatuation ends. This is the real life

mentioned above. But for so many couples, when real life sets in and the hard work of marriage

begins, it becomes evident to one or both that they can no longer avoid or hide from problems

between them. Some of the problems include difficulty with communication, not being able to

disagree like grownups, not getting past resentments, not letting go of expectations, not bringing

family of origin issues into the marital relationship, and a host of others.

The film “The Story of Us” with Bruce Willis and Michele Pfeiffer, illustrates a number

of the above points. They are a married couple with teenage children, who choose to try

separation during the time when their children are at sleep away summer camp. When they

separate, they continue to communicate with each other and their conversations are spent

reflecting on the tale of their married years together. In one scene, they are discussing a couples

therapist they had seen who talked about not bringing family of origin issues into their marriage,

specifically into their intimate life. In the next scene, Willis and Pfeiffer are shown in their bed

and next to each of them are the actors who play their parents. A good point though, in that so

many couples are caught up in a power struggle of sorts where they believe however their

parents did something was the only ‘right’ way for it to be done. Simple things like how to load

the dishwasher or how to fold the towels in the linen closet can become huge hot button issues.

There are two more films that point out how easy it is to get caught up in negative

patterns of communication but also show the difficulties for couples to connect after the romance

has waned and real life sets in. In “The Break Up” with Jennifer Aniston and Vince Vaughn,

there is a scene where they are throwing a dinner party together and afterwards, Jennifer Aniston

asks Vince Vaughn to help clean up and he says something to the effect of wanting to do it later

and the situation erupts into an argument during which Jennifer Aniston says “I want you to want

to do the dishes.” This illustration of the expectations each person has of the other points out

how those expectations lead to resentments and then to anger and then to arguments. But in the

beginning of the film the tale of this couple is told through photos of their early courtship, and

they seem so connected and happy with each other, or more accurately with who each other is.

So how did they go from being in love to being enraged?

The film “About Last Night” with Demi Moore and Rob Lowe is another example of a

couple who fall in love, move in together very quickly and then experience the growing pains of

how living together ups the ante of the relationship stakes. Demi Moore says to Rob Lowe at

one point “I thought it was supposed to be how it was with my parents.” There we go, back to

those expectations based on the marriages of our parents.

For the reasons above and many more, when things unravel, one or the other member of

the couple might call and ask for some therapy to try to improve the marital relationship and/or

to save it.

Creativity & Couples: Using Movie Messages in Marital Treatment Valerie J Shinbaum, MS, LPC, MAC, NCC

July 2012

page three

Part Three – Assigning the “Homework” of Movie Messages

With any couple, if there is willingness from the start to work on the issues mentioned

above – unmet expectations and their related resentments, difficulty in communication, not being

able to argue like adults, waning romantic connection, and many others – then that willingness

needs to come from both parties. If both members of the couple are committed to staying in that

couple relationship, then couples treatment can and often does work well.

In assigning ‘homework’ movies may be used. The couple is instructed to watch the

movie once for the story – not to try to relate to any character, but just to see the story for what it

is. After that, the couple might be asked to each watch the film separately and come up with

some points that they might relate to or disagree with, or ways in which they might see their

partners’ traits in one or more characters in the movie. The assignment of the homework gives

me a lot of information about the couple that I can use. Example: one person in the couple

watches the film and the other chooses not to do so. This helps me gauge the couple’s

willingness and commitment to therapy and ultimately to their marriage.

The overall idea is to remind couples that their problems, while unique to them, might be

more common across the board than they realize. Sometimes by the time couples come to

treatment, they are so beaten down by the repetitive negative patterns of behavior that they

believe they have the world’s worst marriage. In those instances viewing couples in movies

might remind the couple in treatment that any couple relationship is not without its problems.

To illustrate this, I offer one my favorite films of all time – “Two For the Road” with

Audrey Hepburn and Albert Finney. In this film, we watch the story of a ten year marriage told

in the present and also in flashback to earlier years of their courtship and marriage. Of course it

doesn’t hurt that the film is set in a glamorous French backdrop, but regardless, the emotional

pain of both individuals comes across clearly. There is also humor in the story, and this is what

sustains the couple throughout their many quarrels and other obstacles as they revisit the tale of

their ten years together. Sometimes I assign this film just to remind couples of how provoking

marriage can be, and how through the ups and downs it’s good to be reminded of the beginning

to see how far they have come.

At the beginning of any couples treatment I do history gathering anyway, and ask each

member of the couple to give their own version of the beginning to the present day. One film

points this out well. Throughout the film “When Harry Met Sally” with Meg Ryan and Billy

Crystal, director Rob Reiner has inserted interviews with older couples, each telling the story of

how they met and fell in love.

Valerie J Shinbaum, MS, LPC, MAC, NCC

July 2012

page four

Part Four – The Creativity of Couples – How Do They Make It Work?

With regard to the above, I mentioned humor as a necessary tool for couples. It helps to

be able to laugh in certain moments. “The Four Seasons” is a story of three couples in long

marriages who are good friends and who travel together every season. Two of the three couples

demonstrate marriages that are healthy and working. These two couples – played by Alan Alda

and Carol Burnett, and Rita Moreno and Jack Weston – are not always in a positive place. But

there is definitely humor in each of their marriages and there are a number of scenes which

illustrate this point. They can be arguing one moment, and at some point the argument crosses

over the line into humor. These moments show the resilience of individuals in long coupled

relationships to be flexible enough to be able to disagree and get past their disagreements. The

love they feel for each other overrides their conflict and the conflict is resolved. In one scene,

Len Cariou asks Alan Alda about his marriage to Carol Burnett. Alan Alda explains that

sometimes he and his wife are so in love that they can’t wait to see each other, and at other times

they drive each other crazy. This is a key point to any long relationship but is especially true in a

relationship where two people choose to share a house, bed and life with each other.

Another key point is to remember that what happens in each marriage is unique to that

individual couple. In “Sex and the City Part 2,” Carrie Bradshaw says it best: “Every couple has

the right to make their own rules.” Even if the “Sex and the City” television series and films are

often over the top, there are some important messages to be found buried under all of those

wardrobe changes and outrageous fashion choices. The point of that statement about each

couple making their own rules is important to bear in mind when working with couples and goes

back to expectations. No matter what we might think we want, we need to sort out which parts

of what we want are what we think we’re supposed to want as dictated to us by our families,

other couples, our friends, society, etc. Then we get to the real thing, which is what we actually

do want, with no influence at all from any of the above voices. What is important is each person

finds his/her own voice, which enables them to be so much more capable of being a healthy

evolved grown up on his/her own. Think how much healthier that will make them if/when they

decide to enter into a romantic relationship like marriage.

In couples treatment it is important to remind couples of some key points. One is a

question I always ask couples to consider when a conflict comes up. I ask them to remember to

say “Do I want to be right, or do I want to be happy?” Another question I ask is “How important

is this really? Will it still matter in ten minutes, ten hours, ten months or ten years?” I also use

written exercises during sessions to get more clarity if the couple is on the same page, and I ask

couples to consider gratitude for one another. Sometimes in a moment of conflict, the best thing

a person can do is be conscious of gratitude. What does the other person bring to the relationship

that makes staying with them worthwhile? In his pamphlet Defining Mental Health as a Public

Health Issue (copyright September 2005), William Glasser MD talks about the seven caring

habits that improve all relationships: supporting, encouraging, listening, accepting, trusting,

respecting, and negotiating differences. All of these ‘habits’ are indicators of the health of each

individual in the relationship not to mention the health of the marriage. And that is a key point

as well – for both individuals to remember that there are three personalities in a marriage – each

individual and the one they form together as a couple. It is essential for each person to maintain

his/her own ‘individualness’ in order to bring more to the marital relationship.

Valerie J Shinbaum, MS, LPC, MAC, NCC

July 2012

page five

Part Five – When Couples as Clients are Past the Critical Point – Ending With Honor

No matter how much two people may try to work things out in order to stay together, in

some instances there is a point at which the forward motion of a marriage comes to an end.

Perhaps the marriage ends because of infidelity, addiction, or abuse. Perhaps the individuals in

the couple realize they have outgrown each other and are no longer able to grow together.

Perhaps one individual grows tired of the other and wants something else or someone else.

There may be a thousand different reasons why a marriage ends in divorce. Sometimes divorces

are acrimonious, full of power struggle, bitter disagreements over everything from children, to

money to even household items, as pointed out by Billy Crystal who stars with Meg Ryan in

“When Harry Met Sally.” Newly moving in together couple Carrie Fisher and Bruno Kirby are

setting up their apartment and Crystal and Ryan drop by with a housewarming gift. Billy Crystal

has just run into his ex wife who left him for another man, and in the aftermath of that painful

moment, he says the following: “Right now everything is great, everyone is happy, everyone is

in love but you got to know that sooner or later, you’ll be screaming at each other about who’s

going to get this dish. This eight dollar dish will cost you a thousand dollars in phone calls to the

legal firm of that’s-mine-this-is-yours.”

Is it possible to end a marriage with honor? And I’m not talking about the concept

known as ‘good divorce.’ Seriously, if divorces were so good, we’d all be getting one! I’m

talking about finding ways to work through the process of feeling feelings. Remember hate is

just as strong an emotion as love. And when a person has strong feelings for someone even if

they are negative that is an indicator that the person still cares on some level. Being aware of

this can be helpful in working with couples on civility and dignity during a separation or divorce

process. So when the couple is sitting in your office screaming at each other, there are coping

strategies for getting through those difficult and exhausting sessions. These strategies have to do

with changing the mood in the room through tone, eye contact, and setting clear boundaries. It

all goes back to communication, regardless of whether the couple is working toward staying

together or stepping apart.

Another component is acceptance. Acceptance of the fact of the separation or divorce is

important in trying to get past the anger and hurt to a place where if couples need to stay

connected they can do so without continued acrimony. Remember Glasser’s seven habits? They

work here too. Even when a relationship has reached its demise, civility is a worthwhile goal. In

the classic love story “The Way We Were” Robert Redford and Barbra Streisand just can’t work

out their differences in order to stay married. It’s clear that they love each other but in the end

they can’t live together. They end their marriage with respect and dignity, even though they

know they still love each other. Of course it’s a movie, but it makes a worthwhile point for

couples if they choose not to stay together.

Along with acceptance, the reality is that life moves forward and people need to learn to

function in a post-marriage world. At the beginning of “Kramer vs. Kramer” Dustin Hoffman is

bewildered by Meryl Streep’s choice to move out and to leave him with their six year old son.

As a newly single father, Hoffman’s life seems to unravel when he attempts to juggle work,

which has been all consuming, with his duties at home, which his wife was responsible for prior

to her exit. In several scenes throughout the movie, Hoffman is portrayed as feeling his feelings

– anger, confusion, sadness, disappointment. As the film progresses he finds contentment and

happiness – figuring out his life without his wife, and being able to navigate the post-marriage

landscape of raising a child. We might not like the new reality, but let’s face it – life happens.

Valerie J Shinbaum, MS, LPC, MAC, NCC

page six- July 2012

Part Six – Changing Our Choices – What to Do Differently the Next Time Out

In “An Unmarried Woman” with Jill Clayburgh and Alan Bates, Clayburgh’s husband

has an affair and moves out to be with the other woman. Jill Clayburgh goes through stages of

grieving and eventually finds her way into a new relationship with Alan Bates. But in this

relationship she works much harder at not making everything about her new romance. She

realizes one of the mistakes she made in her marriage was in depending on her husband for

everything – financial support, constant companionship, the things we hope for with any

marriage but which we also realize leave us vulnerable if that relationship doesn’t last. It goes

back to coming to any relationship from that place of abundance, strength within ourselves and

peace of mind about life on our own.

The above is true for both genders. The film “Bye Bye Love” with Randy Quaid, Paul

Reiser and Matthew Modine takes a look at the lives of three divorced fathers and their

perspectives on divorce. The film follows these three men as they handle their ongoing

relationships with their ex-spouses, their changing relationships with their children and their

attempts at rebuilding their social lives. Each of them comes to a realization or epiphany about

the mistakes they made in their marriages, and ways they appreciate their ex spouses.

Repeating patterns are an issue for couples in attempts at romance following divorce. This

happens frequently because many times after a divorce, the first thing on a person’s mind is to

‘get back out there’ and prove to him or herself that he/she is desirable, attractive, that someone

else will want them again. However, what they might find is that similar issues, which occurred

in the marriage that didn’t work, come up again with new potential romantic partners

An illustration of the above happens in the film “Stepmom” with Julia Roberts, Ed Harris

and Susan Sarandon. This film offers a closer view a couple in a new relationship while the

conflicts from the prior marriage continue to work their way into the new relationship. Ed Harris

and Susan Sarandon were college sweethearts who married young and had children and then Ed

Harris’ career as a lawyer and Sarandon’s decision not to work outside the home create distance

between them that leads to divorce. Along comes Roberts, a never married successful fashion

photographer with whom Harris falls in love. But there are moments when Ed Harris puts his

career ahead of this new relationship too, which is the chief complaint Susan Sarandon had about

him. Harris is seen falling into his old patterns of expecting the woman in his life to look afer his

children. Roberts goes along with this to the detriment of her own career goals and choices.

Many times individuals who see their new romances heading south and realize there are

patterns they are repeating which were partly the cause of the demise of their marriages are

astute enough to come to therapy in an attempt to do things differently for a more positive

outcome. They might come to therapy on their own or with their new romantic partner. During

those sessions, lots of residual feelings may come up and may be directed toward the new

romantic partner. These feelings need to be felt and attributed to the relationship to which they

belong, not displaced onto the new relationship.

The work with couples is multi-layered. Sometimes I think I should wear a black and

white striped shirt and have a whistle to use. At other times I’m in awe of the way couples

willing to utilize the tools they are taught come back to report their improvements. Through it all

I’m honored to join with couples in their process of sorting through feelings whether attempting

to reconnect and find their way back to the love they know they have, or finding ways to part

civilly and respectfully if a couple decides to no longer continue with their marriage. By

enhancing the couples work using movie messages, the outcome of treatment can lead to skills

building, letting go of expectation-based resentments, and ultimately creation of positive change.



Creating Sacred Space  Creating Sacred Space: Rescuing Death from Medicalization.

Skills for Transforming

End of Life Care

Hanno Kirk, PhD, LICSW

To comply with the ethics rules of the various

boards/associations, I declare that I do not have

any affiliations with, or financial interest in a

commercial organization that could pose a

conflict of interest with my presentation.

Hanno W. Kirk,


Medicalization of Death

o Major shift since WW II

o End of life happens in hospitals

o Separated from family

o Physicians as experts

o Terminal disease = pathology problem

o End of life decisions become medical treatment




Medicalization of death


Death in America

• Sensationalized in the media

• “Splatter Deaths”

• Devoid of emotions

• Desensitized to reality of death

• Medicalization hides process of dying

o No experience with final stages of disease

or dying ->

o Fear and avoidance

• Few families can discuss it

• Few persons plan for it


Impact on Advance Directives

o Avoidance

o Discomfort opening the subject (denial)

o Superstition- discussion will make death more likely

o Patient Fears

o Permanent loss of decision making

o Use to deny regular medical care

o Irrational fear of “death panels”

o Medical PoA could be used to take over

financial assets



The Fight Ethic

Patient Perspective

• Fighting  the Disease

• Seen as Duty

• Expectation of Brave Struggle to the End

• Family and Patient co-opted

• Submit to extraordinary treatment measures

• Pain/discomfort accepted as part of struggle

• Refusal to entertain terminal prognosis

• Seen as “Giving up”


The Fight Ethic

Physician Perspective

o Illusion of Control

o Aggressive treatment will win the battle

o Interventions will pull patient through crisis

o Duty to Stave off Death

o Duty to give hope to patient and family

o Emotional resistance to stop curative effort

o Switching to palliative care seen as defeat

o Unwillingness to communicate bad news

o Patient/family wishes, emotional needs



The Fight Ethic

Family Perspective

o Duty  to support aggressive treatment

o Faith placed in medical technology

o Encourage patient to continue the struggle

o Avoids discussion of comfort care (hospice)

• Halts discussion of preparing for dying

• Seen as undermining patient’s resolve

• Keeps family in denial

• Stifles grief process

• Creates “false hope”



False Hope

• Hope as distracting us from seeing Reality

or the NOW

• Continued faith in medical technology

• In spite of clear signs of terminal decline

• Hope for miracle

• Needs sustained faith

• Doubt seen as insufficient faith

• As undermining possibility of miracle


Impact of False Hope

• Fight the Disease to the End

• Dies while expecting cure

• Conspiracy of Silence

• No one dares break silence

• Each alone with feelings of agony, guilt, fears, doubts

• Negative self worth

• Insufficient faith, not worthy, abandoned by God

• Patient Dies “Alone”

• Without closure with loved ones


False Hope

Impact on Grief Process

• Prevents anticipatory grief

• Conspiracy of silence-> suffering, bottled up


• Complicated grief reaction after death

• Frustration -> Anger

• Retrospective bargaining (If only I had…)

• Over missed opportunities to talk and share

• To alleviate pain and suffering

• Remorse, guilt for not having achieved closure

• Depression over failure of faith/hope efforts



Addressing False Hope

• Assess patient/family readiness to hear “bad


• Interactive discussion

• What do you think is happening to you?

• What do you expect to happen?

• How do you see the medical treatment going?

• What experience have you had with others who

have had the same condition?

• …others who have died?


Educate Family

• On disease process

• Sherwyn Nuland: How We Die

• On line research

• Therapy Options

• Pros for continuing curative efforts

• Hope, extra time

• Cons

• Degraded quality of life

• Post operative debility, pain, cognitive impairment

• Side effects of chemo, radiation

• No time for achieving closure


Educate Family

• Medical System Bias

• Towards continuing treatment

• Unwillingness to “concede defeat”

• Automatic life sustaining procedures

• Implications

• Conflicting goals among doctors

• Doctor who offers hope

• Danger of medication mistakes

• Need for Care Conference

• Involving medical team, patient/family



Advocate for Family

• Go-between patient/family medical system

• Get family permission for advocate role

• Assess patient/family goals

• Hoping for cure?

• Holdouts

• Secrecy Issues

• Cultural Issues

• Family Dysfunctions

• Readiness to hear bad news?


Communicate with Med team

• Contact medical care team members

• Making yourself heard, respected

• Offer self as communicator, facilitator

• Emphasize usefulness for helping family


• Bringing family information to physicians

• Offer to plan and coordinate care conference

• Assistance in communicating bad news


Communicate with Med team

• Poll care team members on treatment goals

• Curative vs. palliative?

• Is there consensus?

• Differences among specialists?

• Is each aware of the goals of the others?

• Being a communication bridge between


• Remind physicians to give family time to

achieve closure before death

• Inform that treatment till the end leaves no time



Educate Physicians

• On family

• Psychosocial evaluation

• Who is involved, key contacts

• Cultural, religious issues

• Readiness to accept bad news

• Family holdouts, possible conflict

• Guidelines for communicating bad news

• Interactive process

• Give time for family to absorb

• Brief on goals for care conference


Care Conference

• Arrange time and place

• Inform all participants

• Checklist of must topics for physician(s)

• Review medical condition and changes

• Results of curative efforts thus far, latest tests, etc.

• Evaluation of pursuing curative goals

• Discussion of palliative care as new direction

• Reassurance about continued treatment of routine needs

• Discuss effects of life extending measures

• Discuss pros and cons of DNR, tubes etc.

• Remind physician(s) to write orders


Facilitate Terminal Care

• Choice of Alternatives

• Limited by availability and resources

• In hospital palliative care

• Intense care needs, usually short term

• Inpatient hospice

• When skilled needs too big for in home care

• Family unprepared for in home

• Space, lack of caregivers

• In home hospice care

• Emotional advantages



“What’s the Prognosis?”

• Asked by either patient or family

• For planning purposes

• For reassurance

• Make it an interactive process

• “What are you expecting to happen?

• “What does your inner voice tell you?”

• “What experiences have you had with..

• Others who had the same condition?

• Others who have died?

• Avoid precise answers

• Give range of time

• Suggest getting affairs in order


Palliative Care Options

• Choice of Alternatives

• Limited by availability and resources

• In hospital palliative care

• Intense care needs, usually short term

• In patient hospice

• Need for skilled care high

• Family unprepared for in home

• Space, lack of caregivers

• In home hospice care

• Emotional advantages


Family Conference

on in-home Hospice care

• Prepare inform family

• Hospice representative, clergy, yourself, local adult

family members, speaker phone for non-local adults

• Care Arrangements

• In whose home?

• Principal care giver(s)?

• Need for respite care schedule

• Who is also willing to give direct care?

• Who is willing to contribute financially for

hired help?



Family Grief

• Preparing family

• Assess family readiness to talk about preparing

for death of family member

• Encourage expressions of fears, concerns,


• Overcoming the aversion to talking about death

• Educate

• Explain stages of grief

• How it applies in preparing for the loss

• Mutual support for each other’s grief process


Shifting the Focus

• From curative to comfort care

• Patient’s illness no longer primary focus

• Attention to creating peaceful zone of rest

and comfort, and inner healing

• Monitoring pain control


Anger- Fear

• Dealing with anger

• Part of grief process

• Why me? At God, medical establishment,


• With self. For not being good enough.

• Fear of punishment

• Identification with past mistakes

• “I am that bad person, parent, etc.”

• Mistakes seen as unforgivable

• Increases fear of death



Unfinished Business

• Memories of Guilt, Shame

• Identifies with image of self as lacking merit

before God

• Increases anxiety

• Can magnify physical pain

• Regret over things said

• Angry judgments, criticism

• Regret over things not said

• Unexpressed feelings of love, appreciation


Finishing Business

Goal: to relieve guilt, create self-forgiveness

• Feelings of regret, guilt shame

• Give dying person chance to talk about feelings

of regret. Just listen, don’t minimize or dismiss

• Accept apologies and plea for forgiveness.

• Family members offer apology for past strife

• Modeling acceptance and forgiveness

• Invoking religious models of divine forgiveness

• Humor: “I’m not OK, You’re not OK, and

that’s OK.”


Dealing with Pain

o Fear and anxiety about pain -> increased

perception of pain

o Buddhist teaching of “going into the pain,

becoming the pain” -> substantial reduction in

the perception of pain -> reduction in suffering

 Resource: Chapter “Working with Pain in Stephen Levine’s

Who Dies: an investigation of Conscious Living and Dying

• Reading aloud from Levine book, or scripture

• Guided imagery, music for comfort and

reducing pain

• Gentle massage, reassuring touch



Creating Sacred Space

Family role

• Emotional support for dying patient

• Focus on the person’s need for touch,

expressions of love and reassurance

• Support for dying patient’s struggle to

accept the approach of death

• Supporting each other through grief



Being There:

Life Review Process

• Listening, Attending, Supporting

• Encourage family to facilitate sharing

• If patient lucid enough

• Get children, grandchildren involved

• “Tell me about your growing up”

• “Tell me about the time when…”

• Reminiscing as Life Review

• Bring out photo albums

• Stories of good times, hard times, successes and



Self Acceptance

Goal: move from psychic pain to self

acceptance (Despair -> Integrity)

• Teaching the Art of Letting Go

• Resource: Stephen Levine-Who Dies: An Investigation of

Conscious Living and Dying

• Identifying with past successes-mistakes as false

images of Self

• The true Self (Spirit, Soul) as separate from ego

beliefs about who we are

• There is only the Now and what we can do to

achieve harmony with those around us



The Emergence of

Sacred Space

Achieving closure, getting ready for

the transition

• Continue expressions of love

• Ask if anything more to say

• Drifting in and out of consciousness

• Affirm what the dying person says he/she



End of Life Visions

Harbingers of impending transition

Weeks, hours and/or final moments


Seeing, talking to departed relatives

“Crowded room” gatherings

Spiritual visions

Going on journey

Normalize for dying person

Encourage patient to share with family


Final Instructions

Goal: informing family what to expect

• Terminal Drop Stage

• Serial shut down of physical systems

• Food (liquid) can no longer processed

• Creates toxins-> physical pain ->cognitive


• Stop nutrition

• Stop hydration when body produces little or no




Final Instructions


Goal: informing family what to expect

• Breathing becomes irregular

• Function of pain meds

• Gasps of air, not sign of discomfort

• Gurgling, choking sound

• Caused by thin layer of fluid on vocal chords

• Atropine, scopolamine patches can prevent it

• Death

• Don’t panic, don’t call an ambulance

• Call hospice, and inform them.


Hope is an orientation of the spirit,

an orientation of the heart.

It is not the conviction

that something will turn out well,

but the certainty

that something makes sense

regardless of how it turns out.

Vaclav Havel, Poet, Writer

Former President of Czechoslovakia



• David Kessler- Visions, Trips, and Crowded

Rooms: Who and What You See Before You Die

• Stephen & Ondrea Levine- Who Dies?: An

Investigation of Conscious Living and Conscious


• Sherwyn Nuland- How We Die: Reflections of

Life’s Final Chapter

• Elisabeth Kübler-Ross & David Kessler-On Grief

and Grieving: Finding the Meaning of Grief

Through the Five Stages of Loss


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