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Mindfulness in mental illness - Kedar Nath Dwiedi

Kedar Nath Dwivedi
Mindfulness in mental illness



Mindfulness is a word from the English language, meaning awareness or heedfulness. Expressions like 'mind your language', 'mind the step', or 'mind the gap' (between the train and the platform) clearly convey this sense. However, in this paper, I also wish to refer to the Buddhist concept of it. Buddhism began in the 6th Century BC and used Pali, the popular language of the time. In Pali, there are three related concepts: Sati (mindfulness), Samadhi (absorption) and Bhavana (meditation including Sati, Samadhi and Panna or wisdom). Four aspects of Sati are described in the Satipathan Sutta, i.e. Kayanupassana satipatthan (awareness of body parts and functions such as, breathing), Vedananupassana satipatthan (awareness of sensations and feelings), Cittananupassana satipatthan (awareness of thoughts, category of consciousness etc.) and Dhammananupassana satipatthan (awareness of mental hindrances etc.) (Tin, 1989).

It is important to appreciate that this concept of mindfulness (Sati) implies a meta perspective as well, so that one is constantly aware of what the mind is doing. We may be engrossed in fantasies, thoughts, wishes, feelings, recollections, planning etc. but not realise that fact at that time (i.e. lacking in mindfulness). Achieving mindfulness is not easy and one has to put an effort and practice it as a kind of meditation (Bhavana). One of the most common methods for developing this is to practice 'anapan' or awareness of breathing. We are always breathing but seldom notice it, e.g. the touch of the breath at the nostrils. Repeated practice makes it easier.

We tend to assume that we are usually aware of our mental activities and therefore there is no need to do anything to improve or cultivate this any further. This in fact, is a mistaken belief. For example, if some one says something insulting, hurtful or nasty, it is natural for us to feel hurt or angry. This happens very fast and our breathing, heart rate, blood pressure, skin conductance etc. all change suddenly. These may change without our knowledge and certainly without our permission. We also continue to remain in such a state of mind even after the person has stopped being hurtful. The mind keeps going over and over the said phrases, the demeanour, the tone, the look, the accent and so on. The mind gets glued to these mental objects (which are just memories in this instance) which keep stirring up the feelings of hurt, anger etc. Even if someone else may be nice to us, we might not notice this because the mind is too busy with the other (hurtful) mental object.

Eventually, may be after an hour or so, we might feel not so churned up, those feelings might go out of our consciousness and become latent or dormant. However, later in the day even if we are in a pleasant situation, we might suddenly remember the incidence and once again the heart rate, breathing etc. would change dramatically. No one is insulting us then, it is purely a memory but the mind treats it as if it is real. Even the next day, the day after and so on , the same thing may happen again and again. People who have had very traumatic experiences know how distressing these flashbacks can be (Dwivedi, in press).

Similarly if we watch a horror film at night, most of us would feel scared, although there is no real creature or blood, but only glass screen, light, shade and electronics, as if the mind becomes unaware of such realities. An erotic film can in a similar way produce arousal in the viewer, although no one is doing anything in reality to him or her. Thus, our minds are very skilled in mixing the real with the unreal, as if these are water and milk.

When one feels hurt, angry, upset etc., the feelings if intense can spill over into vocal or physical actions. So, one might respond to an insult by becoming insulting oneself, verbally or physically hitting back. In this way, there seem to be three layers, i.e.

the dormant or latent stage,
mental objects in the consciousness stirring up feelings and
spilling over into actions affecting external objects.


One of the Burmese Buddhist teachers, Ledi Sayadaw (1981) who lived from 1846 to 1923 likened this to 3 levels of fire in a box of matches. Fire usually manifests whenever a match is struck. This is the second level of fire and is analogous to a mental object striking on the consciousness and stirring up feelings. The third level of fire is when the burning match comes into contact with flammable objects analogous to the emotionally charged person coming in contact with an external object and the intense feelings spilling over into vocal and/or physical action. However, the first level of fire is inherent, latent or dormant in the box of matches analogous to latent or preconscious predisposition for feelings such as, anger and so on.



This latent predisposition (Anusaya, in Pali) is a product of illusory processes creating a deep sense of self. In the presence of Anusaya, when a mental object strikes the consciousness, the feelings are stirred up because of poor mindfulness. It is because of poor mindfulness that a mental object is not appreciated as only a mental object (ideation, memory, image etc.) and is responded to as if it is a real object. The second level i. e .the stirring up of the feelings and the mind getting glued to it, is called Pariyuthana (in Pali) as if obsessed with the mental object. The third level or physical and/or vocal actions (Vitikkama, in Pali literally meaning transgression) arise if the relevant physical object comes into contact in the presence of Pariyuthana and poor volitional control.

Accordingly (Dwivedi, 1990), the Buddhist approach has been threefold: cultivating volitional control (i.e. Sila or practice of observing precepts), mindfulness (Sati and Samadhi to recognise mental objects as such and to be able to keep them at bay) and wisdom (Panna to gradually cut through the illusory processes that create this deep sense of self).

When we look at a stationary ceiling fan, we see three distinct blades, but as the fan moves fast enough the blades appear to merge into one. Similarly when we watch a cartoon film, we see creatures moving, thinking and doing things, although we know that these are simply still drawings that have been projected at a very high speed. It is this rapidity of change that creates the illusory processes. According to Buddhism, our minds operate in terms of Khanas ('mind moments'), there being 17x10 21 khanas in the blink of an eye. The sense of I, mine, me, my and that of constancy, agency, continuity, solidity in objects and relationships is the result. This is the fundamental reason behind all our suffering. Cutting through these illusory processes is not easy and can be a many lifetimes’ job.

From the Buddhist point of view, true insight or wisdom is an experiential phenomenon. It should not be confused with intellectual understanding, faith or belief. Knowledge is described to be of three kinds: Shrutmai (derived from others e.g. by reading books, listening to talks, and so on), Chintanmai (deduced through observation, experimentation and research) and Bhavanamai (experiential). For example, one can get an idea of the quality of food in a restaurant by reading the endorsements and the menu or looking at the pictures of the dishes. This is similar to knowledge (e.g. about mind-body processes) gained by reading books, watching television and listening to talks. One can deduce a better impression by looking at the delight or disgust on the faces of the customers actually eating in the restaurant. This is similar to a physicist who has investigated the nature of the universe and has firmly come to the conclusion that there is nothing solid or substantial and that everything is in a state of flux, changing, impermanent, soulless, agencyless and illusory. This is still far from being enlightened, because it is not an experiential insight. Just as one gets an idea of the true taste of the meal by eating it, an enlightened person (in the Buddhist sense) actually experiences the mind-body phenomena as illusory, unsubstantial, transient and agencyless (Dwivedi, 1994).

An essential ingredient for achieving such a wisdom is the quality of the mind. Wisdom comes when there is mindfulness and full concentration. Full concentration means a penetrative and continuous unshakeable concentration from moment to moment. In this way, mindfulness is a tool and wisdom (or enlightenment) is the goal and is seen as the perfect state of mental health in Buddhism.

Thus, Buddhism has a very clear concept of mental health promotion and how to achieve this. Mindfulness is the most important tool for this purpose. The Western mental health professionals have also begun to use mindfulness as a tool for prevention, treatment and rehabilitation as regards mental disorders. However, it is not essential that any tool for promotion can be equally beneficial for treatment. We all know that jogging can be very beneficial to health promotion but harmful if we have a broken leg. A Plaster of Paris could be helpful for such a leg but harmful as a means of health promotion for unbroken legs.

If we are suffering from a psychotic disorder, for example, it may be very difficult to follow instructions and practice mindfulness. Some clinicians have even reported deterioration in mental state in such situations. However, in most other situations, it can be rather beneficial.

Reviews of psychological mechanisms involved in meditation, psychophysiological changes, and therapeutic effects of meditation suggest various advantages (Walsh, 1979), for example, release of tension, availability of affect, openness, receptivity, sensitivity, better management of pain, performance and learning and reduction in psychosomatic symptoms, anxiety, hostility and in dependence on alcohol and drugs.

Just as the development of walking, talking and sphincter control is greatly influenced by parenting, the development of emotional management skills are similarly affected (Dwivedi, 1993, 1997a, Dwivedi & Varma, 1997a, 1997b). As there is no state of weatherlessness, there is similarly no state of emotionlessness. However, the emotions may be too subtle and preconscious and we become aware of them only when they intensify and break through into our consciousness. Even at the subtle level, they play an important role in a variety of mental functions, such as, information processing, cognition, motivation and so on. Mindfulness meditation helps to expand our consciousness and thus get in touch with such subtle emotions and thereby impact on a variety of mental functions.

Some excessively intense emotions can become traumatic and overwhelming and can trigger a chain of disastrous consequences such as, violent or destructive acting out, alcohol and drug abuse, psychosomatic illness and even psychogenic death. One may feel that such an emotional state is going to be everlasting and may not appreciate the fact that all emotions are only transient. With the help of mindfulness meditation, if one does not fight, indulge or actively avoid, they will just run their course. In fact, like taming a tiger, their energy can be harnessed for creative and constructive purposes (Dwivedi, 1996a, 1996b, and 1997b).

Human beings are symbolic mediators who can make mountains out of molehills. Through mindfulness one realises that the mind is filled with thoughts that constrict and distort our awareness as if in a state of being hypnotised by them. Through mindfulness one begins to see the thoughts for what they are, i.e. unsubstantial. It is like focussing on the empty sky, watching the clouds come and go, transient, impermanent and changing. The emphasis is on letting go, non-attachment. One begins to appreciate that the feeling of I, me, or self is just one of the numerous thought forms that flit in and out of consciousness. They seem to have a will of their own, and it is futile to control them. Most schools of psychotherapy also aim at exploring and correcting these distorted and erroneous conceptual models of reality including that of suffering, a symbolic state.

Therefore, many psychotherapists have started using mindfulness as a part of their approach (Walley, 1995). Use of mindfulness meditation in the clinical context has been reported by Deatherage (1975), Walley (1986) and Kabat-Zinn et al (1992). Epstein (1995) has shown how the Buddhist approach including mindfulness can complement, inform and energise the practice of psychotherapy. Behaviour Therapy approach for achieving relaxation also uses aspects of mindfulness practice. The Dialectical Behaviour Therapy for the treatment of severely suicidal and self harming patients diagnosed as suffering with Borderline Personality Disorder, uses mindfulness as an essential ingredient (Lineham, 1993). Jon Kabat-Zinn (1996). has developed a programme to cope with stress, pain and illness using mindfulness meditation. John Teasedale (personal communication) has found that group intervention programme incorporating aspects of mindfulness based stress reduction (as developed by Jon Kabat-Zinn) when applied to patients with recurrent depression currently in remission, is effective in halving relapse rates in patients with three or more previous episodes of depression.

In the light of the above, mindfulness meditation appears to have an enormous potential for its use as a tool by the practitioners, planners and researchers of mental health promotion.



References


Deatherage, G. (1975) The Clinical use of mindfulness meditation technique in short term psychotherapy. Journal of Transpersonal Psychotherapy. 6 pp.133-42.

Dwivedi, K. N. (1990) Purification of Mind by Vipassana Meditation. In: J. Crook & D. Fontana (Eds) Space in Mind: East-West Psychology and Contemporary Buddhism. Shaftesbury: Element.

Dwivedi, K.N. (1993) Emotional Development. In: K.N.Dwivedi (Ed.) Group Work with Children and Adolescents: A Handbook. London: Jessica Kingsley.

Dwivedi, K.N. (1994) Mental Cultivation (Meditation) in Buddhism. Psychiatric Bulletin, 18: 503-504.

Dwivedi, K.N. (1996a) Culture and Personality. In: K.N. Dwivedi & V.P.Varma (Eds) Meeting the Needs of Ethnic Minority Childre. London: Jessica Kingsley.

Dwivedi, K.N. (1996b) Facilitating the development of emotional management skills in childhood: A programme for effective self regulation of affect. In: D.R. Trent & C.A. Reed (Eds) Promotion of Mental Health. Vol 6. Aldershot: Ashgate. Pp.107-113.

Dwivedi, K.N. (Ed.) (1997a) Enhancing Parenting Skills: A Guide for Professionals working with Parents. Chichester: John Wiley.

Dwivedi, K.N. (!997b) Management of Anger and some Eastern Stories. In: K.N. Dwivedi (Ed.) The Therapeutic Use of Stories. London: Routledge.

Dwivedi, K. N. (Ed.) (in press) Post Traumatic Stress Disorder in Children and Adolecsents. London: Whurr.

Dwivedi, K.N. & Varma, V.P. (Eds) (1997a) Depression in children and Adolescents. London: Whurr.

Dwivedi, K.N. & Varma, V.P. (Eds) (1997b) A Handbook of Childhood Anxiety Management. Alsershot: Arena.

Epstein, M. (1995) Thoughts without a Thinker: Psychotherapy from a Buddhist Perspective. New York: Basic Books

Kabat-Zinn, J. (1996) Full Catastrophe Living: How to cope with stress, pain and illness using mindfuness meditation. London: Piatkus.

Kabat-Zinn, J., Massion, A.O., Kristeller, J., Peterson, LG, Fletcher,K, Pbert, L., Lenderking, WR, and Santorelli, S F (1992) Effectiveness of a meditation based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry. 149, 7, pp. 936-943.

Lineham, M. M. (1993) Cognitive Behavioural Treatment of Borderline Personality Disorder. New York: The Guilford Press

Sayadaw, L. (1981) The Manuals of Buddhism. Rangoon: Department of Religious Affairs.

Tin, U C. (1989) Knowing Anicca and the way to Nibbana. Heddington, Wiltshire: Sayagyi U Ba Khin Memorial Trust, UK.

Walley, M. (1986) Applications of Buddhist psychology in mental health care. Ch. 11 In: Claxton, G. (Ed.) Beyond Therapy. London: Wisdom Publications.

Walley, M. (1995) The attainment of mental health - Contributions from Buddhist Psychology. In: Trent, D. & Reed, C. (Eds) Promotion of Mental Health. Vol 5. Aldershot: Ashgate.

Walsh, R. (1979) Meditation Research. Journal of Transpersonal psychology. II, 2, pp.161-174.



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Dr. Kedar Nath Dwivedi, MBBS MD DPM FRCPsych,

Consultant Child, Adolescent and Family Psychiatrist,

8 Notre Dame Mews,

Northampton NN1 2BG

Discussion Forum

Meditation - Guardian article 09/04/2010

Started by Adrian Philip Debney (Kalyanaka) Apr 9, 2010. 0 Replies

There's an interesting article in G2 of the Guardian today about meditation being used to manage anxiety, anger and depression. It reflects the current interest in meditation techniques and is a…Continue

Mental health - the practical role of Buddhism

Started by Adrian Philip Debney (Kalyanaka). Last reply by Katrien Sercu Feb 19, 2010. 10 Replies

Thankyou for the chance to offer this little group for your consideration. I will try again to offer my thoughts on this subject without deleting it.There is much interest in the role which Buddhism…Continue

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Comment by Andrew Seddon on March 28, 2010 at 14:41
Yes it's a difficult subject..meditation can be very helpful as in my case, but part of the problem especially around mild obbsessive/compulsive symptoms is the inability to maintain the practice in a disciplined manner..
Comment by Robert McCarthy on March 25, 2010 at 8:29
Thank you Helen for your caring words and i feel sad to hear that your family feels a similar pain. yes so hard to know what to do- i asked the police to take anica to involuntary care, despite several recent local deaths of young people similar to my daughter when resisting police arrest. and yes so hard to reach our chldren when they are held in their drug damaged way- we were told today not to hold much hope for anica finding any good living through this. and that i already knew. metta feels unconditional, but distancing is necessary, especially in the times when there is little that can be done. Namo Amida Bu
Comment by Robert McCarthy on March 21, 2010 at 22:06
It is best to write in terms of distance, and because i know your distance is intimate and personal I am drawn to write here Adrian. the close distance is the details which bring up too much pain. they would open a readers heart, as they do mine. and i only intently go to that place when i can act in some way. like now when anica is at a physical place i can find her and also in a state of mind i can reach her. but when that changes so too the distance needs to move. cannot stay so close then without serious harm to myself from pain and impotence to act. and we dont control the distance all that much either. well to attempt to do so is a good learning about samudaya. Anica is 22 now and this all started nearly ten years ago. so, in writing here i add another voice that opens a door to others to share and find a place of support, that gives purpose. and yes Adrian, i work with the services and find so much compassion in the workers. Namo Amida Bu
Comment by Adrian Philip Debney (Kalyanaka) on March 21, 2010 at 11:39
Thankyou. Robert the truth is I don't know. Clearly I have Schizophrenia so have some experience. But I am a father too with a daughter and the truth is that I don't know how I would respond - though I imagine that my heart would break as it does as I try to imagine your situation. I hae agood relationship with my daughter though she is only 10. However it is always upermost in my mind that it is a wild world and part of my own insecurity about her future is twofold. Firstly in realising that she'll go and do as she pleases one day and secondly in wrestling with my belief however misguided that the role of a father is that of protector. Fatherhood, like motherhood I am sure, comes at a price. However, you are not alone - fathers share a deep fellowship Robert.
And I think that you are right. Love, unconditional is the biggest weapon against the vagaries of modern life - of that I am convinced. Though only because it took me forty years to see it in concrete terms. And it is a jungle out there in the fullest sense. From a practical point of view as both a schizophrenia sufferer and as a professional involved latterly with addiction I know that success with addiction is improving, that it is slow and that the success stories I have been involed in all hae a central theme - that of persevering love and value. The language of many people caught up with addiction repeats the same themes - that of alientation, worthlessness and 'no alternative'. So, there has to be an antidote to each of these if only we could find them. But success is rarely trumpeted and each person is complex. And it would be naiive not to mention how many people don't escape.
But fathers and mothers are still in a very influential position and there is a payoff in what you are doing. I have seen it. Work with the services, show your daughter the love and patience which you speak of. Your own inner resources may be wearing thin but press on. If I sound patronising then forgive me.
If I can be of any support privately then do please get in touch via my wall and I will try to offer this to you. I have faced big odds myself and I know that it can be easier to fight a battle in an army of two, three...
Courage my friend and thank you.
Comment by Sujatin on March 21, 2010 at 10:20
Hear, hear, Kalyanaka!
Comment by Robert McCarthy on March 21, 2010 at 10:15
hi Adrian, i am still unsure whether i should write on your wall or write here, and thats to do with my own side. I have been reading the letters in this group and very much appreciate the love shown here. my daughter is being held and medicated involuntarily regarding schizophrenia, drug dependency and all that goes with it. and i try to reflect the love i know, try to open my daughter to metta, to respond with love to the suffering around her. and after another month or two she will be back on the street- each time the hope is maybe this time she finds a good way through. very difficult Adrian, what to do. Namo Amida Bu
Comment by Adrian Philip Debney (Kalyanaka) on March 21, 2010 at 8:49
Hello - am back after a short absence. I was catching up on various forums and noticed many questions being asked about whether people with mental illness should become involved in Buddhism. Alarmingly, many disucssions posited the idea that one should become 'stable' before doing so.

Now I find this unhelpful in the extreme. The main concerns centre around the idea that Buddhist practice can in some way destabilise one's mental wellbeing. Some believe that because Buddhism asks us to question the self, the personality etc, that this may become dangerous in some way for those with personality disorders. Why? For me it depends upon the starting point and the position which some Buddhist schools adopt. I believe that the way in which many sufferers are treated in the first place is problematic. In many cases a person with some form of mental suffering feels an acute sense of isolation - within and without. One of the most important factors in supporting people is that of unconditional acceptance. Many look for this in vain their entire lives and do not find it. Buddhism offers in the first place a belief in self acceptance as well as, in many cases, a 'place' of safety. It's called love folks and it's not rocket science.

The Buddha, as far as my own understanding is concerned, did not turn anybody away until they were 'fit' enough. No one was denied the chance to develop spiritually. Of course, there may be instances where a certain practice was limiting in some way, but as I read it the Buddha and indeed many spiritual leaders, was ready to offer some guidance. One is not expected to navigate the ego alone necessarily.

On the news this morning there was a piece on offering therapy to sufferers more rapidly rather than a prompt route into day centres and drugs. This is important because there is a strong line of argument that BUddhist practice can serve as a therapy. Does one have to get sorted before entering therapy then?
I find it alarming that some Buddhists would seek to exclude. Further, it is also alarming that so much is made in the first instance of the 'cerebral' side of Buddhism. That attitude that Buddhism is a journey into existential reality, ultimate nature, enlightenment and other psychoacademic ideas. Have a look around for yourself. This really is the sales pitch of many Buddhist stall holders. Being new to Buddhism, the spiritual aspirant - perhaps suffering in some way - may be alienated from the start. Love for all sorts of people doesn't have a condition of entrance. Perhaps one may want to explore the various strands of Buddhist thought and culture. Fine. But if I don't want to deconstruct the ego or obtain Nirvana - will I be accepted anyway? Will I be able to lead the spiritual life? If I had gone to the Buddha and asked to join him despite suffering an illness of the mind would he have turned me away? Would he have said get some treatment first and then I'll consider it? No. His message was and is very simple. What do you think? What would you say if a sufferer wanted to join you on your journey?

It is sunny here. I'm off to my little plot. Everything the Buddha stood for is there. I don't have to ask it if I'm well enough to join it. I just can. I say to all the imperfect people in the world: 'come and tend the Buddha's garden - all are welcome'.
Namo
Amida
Bu x
Comment by Adrian Philip Debney (Kalyanaka) on February 18, 2010 at 8:56
Article: Meditatation and depression or the hidden potential! http://www.purifymind.com/MeditationDepression.htm
Here is an interesting article on the use of meditation and depression. It explores how the practice of meditation can bring about a change in perception in people with depression and a better quality of life as a result.
It looks at the physical practice and makes crucial links between those beliefs and mental states which can occur as ideas and beliefs in depression but which build themselves into large mental constructs. Often, depressive patients describe how they feel that these constructs gradually overcome them and become their sole reality.

Articles such as this are, I feel, helpful. Kyabgon Rimpoche here describes how meditation can provide a route firstly to become still, and latterly to begin to deconstruct the terrible houses in which sufferers find themselves inhabiting. In effect, meditation can be an opportunity to let the bricks and mortar fall to the ground. Many people are scared to do this. I have sonetimes heard people say that all they have is their illness. The implication is that to let go of this is to become nothing. I guess the thought can be very frightening. But Rimpoche here suggests that there is a sense that one can try it and see, become used to the idea and then to see that it is indeed possible to build a different house.
Much Buddhist teaching is aimed at this idea of allowing different identities to fall away and to directly experience freedom as a result. The description of depression, even on a quick google, is very much a description of the cycle of suffering with its rupas, kleshas and skandhas. In a state of disease these cycles repeat endlessly and increase in intensity and volume. The person can too easily 'become' them. I AM depressed. Language is interesting to observe because it says alot about the way in which a person relates to illness.

But this article is also very uplifting - in some quarters it may be controversial. This is because Rimpoche suggests that in fact depression may be positive. He posits the idea that it may lead to a heightened awareness and indeed may teach us much about the reality of life. Suffering and recovery he says, are a journey, and this journey can be liberating. 'Depression does have the potential
to give us insight into our lives and the world which we live in'.

For me, this is a profound statement, but one which my experience of schizophrenia and belief reflects. One has to be careful of course. I don't wish for people to suffer in order to have spritual awareness, but in some ways we come to the spiritual journey through suffering anyway. But Rimpoche is arguing that depression may in fact lend value to our lives in some way. The key word is potential.
What do you think?
Comment by Adrian Philip Debney (Kalyanaka) on January 21, 2010 at 9:19
I have added an interesting article which addresses the subject of mindfulness in mental illness. I add this in light of both the subject of this group and the recent media attention given to these practices.

My main criticism of much writing on this subject is the overtly academic nature of them although in fairness they are mostly written for therapists.

Here, Dwivedi offers a fair summary of the practice and its benefits altough he draws attention to the shortfalls too. I take some issue with his assertion that the enlightened mind is seen as the epitome of perfect mental health however.

This poses two questions though. Firstly the question of what enlightenment actually is. And secondly, this might challenge the ability of mental health sufferers to advance spiritually. Is enlightenment not within the grasp of those so afflicted? Some people of course would say that their difficulties added a spiritual dimension to their lives which they had hitherto lacked. Is ill health an impediment in this way?
Comment by Adrian Philip Debney (Kalyanaka) on January 20, 2010 at 20:48
Thank you Simon. I will look forward to hearing your thoughts - you clearly have much experience to share.
Yes, I too like the idea of the wounded healer. This encompasses a useful human tenet doesn't it? That we might help others as a result. Isn't compassion borne out of this in some measure? That our suffering can spur us to action against the suffering of others? It has it's detractors of course, but it works just fine for me thankyou very much.
Peace to you.
 

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