Cultivating the Doula Heart

WYD Podcast in conversation with Death Doula Francesca Arnoldy, the author of Cultivating the Doula Heart: Essentials of Compassionate Care. She is the course developer, facilitator, and program director of the University of Vermont Larner College of Medicine End-of-Life Doula Professional Certificate Program. www.contemplativedoula.com
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Cultivating the Doula Heart, with Francesca Arnoldy — Podcast Transcription

Johanna Lunn: Welcome to the When You Die podcast. I’m Johanna Lunn. With me today is Francesca Arnoldy, the author of Cultivating the Doula Heart: Essentials of Compassionate Care. She is the course developer, facilitator, and program director of the University of Vermont Larner College of Medicine’s end of life doula professional certificate program.

Francesca’s goal is to encourage people to hold one another’s hands through life’s intensities and sacred rites of passage. She lives in Vermont with her family, and can be found contemplating birth, death, and leading life with a doula heart on her website, contemplativedoula.com.

Hello Francesca. Thank you so much for joining me today. I’m looking forward to talking to you about your book, Cultivating the Doula Heart.

Francesca Arnoldy: Thank you for having me.

JL: Well, maybe we could just start right off the top. What does it take to be a doula, and what does that mean?

FA: Sure. I’ve been a birth worker for a decade now, so I’ve been working as a post-partum doula, a childbirth educator, and a birth doula. And I used to be more possessive of the term doula and what it entailed and what it meant to me. Explaining the role of a doula to someone who’s unfamiliar, I sometimes get the response, “You know what? I was that for my sister. Or, I was that for my cousin.” And I smile but sort of internally scoff and say to myself, “You’re not a real doula, you know. I trained for two years, and I read all of these books and had a big exam, and had to have things recorded from providers that I worked alongside, and clients, and things, and I continue to educate myself.”

And I have drastically opened my eyes and mind and heart to this idea of a doula becoming an emotional support person for those experiencing times of intensity, including birth, and now, end of life. And so, what it takes to be a doula is someone who is kind and compassionate and who is able to put aside their own agenda, their own to-do list, in order to be fully present with another person and that other person’s journey.

So, it’s much more inclusive to me now, and with the course at the University of Vermont and our training program we have been really pleasantly surprised by the variety of learners that we’re attracting. And we don’t only get aspiring doulas coming through. We have physicians, we have nurses, we have mental health professionals, we have spiritual care providers, we have hospice volunteers. We have people who in their personal lives know of someone close to them who has received a terminal diagnosis, and they’re looking for more ideas and approaches. So, I truly believe that these doula essentials I write about can be infused into many relationships and many types of work.

JL: That’s a very good point. Why do you think that physicians or nurses or other health care providers would want to do this kind of training? What is it that they’re not getting in their own training?

FA: I think it’s for a variety of reasons that I’ve learned directly from these graduates. What they’ve shared is that sometimes they may be moving into a new specialty. Maybe they haven’t worked in end of life yet, so they want to prepare themselves well.

Or for some people they’ve been in this field of providing end of life care, either through hospice, palliative care, even family medicine, for a number of years, decades sometimes even, and they’ve found themselves becoming more and more burnt out, and more robotic in their work. And so, they’re coming through the course with the hope of self-healing and rekindling that initial spark, and also their passion for this career.

JL: That really speaks of people’s dedication to, in many ways, changing the tide around death care altogether. It’s generally protocol driven and trying to find cures, as opposed to supporting someone at end of life. So, that seems very encouraging that times are changing around this whole subject of how we die.

FA: I couldn’t agree more. And I think part of the reason we’re having the reach we have is that we’re out of a medical school at a university.

JL: Right.

FA: So, people are acknowledging that we are featuring a large number of voices, a large amount of subject matter, and various experts, in our course. So, we’re really covering hospice, palliative care, end of life, in all its facets, very comprehensively. That is, grief in a number of modules and then, also, the doula approaches and different tools that you can add to your tool bag.

And when we talk about it in the course, we are asking, “What hats do you see yourself wearing?” As we’re moving through the content together, we’re not only focusing on private practice doulas. We’re asking, “How are you integrating this into your life? Into your work? Into your volunteerism? What does this mean to you and for you?”

JL: Well, I was also going to ask where would you find a doula? So, that seems like where you’re going here.

FA: Doulas? It’s still an emerging career path. So, if you are searching for a private practice doula, that would be hired privately by a client, then a Google search is your best bet. There are some directories that will pop up, and they will feature different states.

We also have a really robust Facebook page: End of Life Doula Community, I believe it’s called. Something close to that. And we welcome the public to join us if they want to be more involved in these conversations, and they want to learn more. And so, we often will have people who will post, you know, “In search of doula for this certain area.”

JL: Hmm.

FA: So, we’ll try to connect people. And also, within our quarterly newsletter sometimes we’re able to put those announcements out to our grad pool for clients, but also for doulas who are hoping to network, and are hoping to work alongside other doula grads.

So, we’re trying to encourage this sort of community uprising of doulas. So that within your town, people will start to recognize you are the go-to person or collaborative person or partnership person they can turn to during these times.

JL: So, a doula could be someone in a variety of settings as well, like hospice and palliative care. Is there any place that a doula wouldn’t be found, so to speak? Or wouldn’t be welcome?

FA: I would say a doula will follow a client to wherever they are considering home at the moment, and we are available directly for that person. So, I wouldn’t foresee any sort of placement facility where a doula would not be welcome. I do think that a doula being largely an unfamiliar role still, would have to be able to present themselves well to the team and quickly explain what it is that the doula is offering that can complement what everyone else is offering.

JL: And can you say a little bit more about what a doula does offer?

FA: Sure. There are different interpretations of this work and doulas will sometimes focus on specific offerings. What we cover, and what we train people to feel comfortable to offer, are things like developing rapport, sitting bedside, sitting in the midst of chaos, finding calm, remaining centered.

And then after that relationship starts to gain traction, and there’s trust that’s being built, then you can get into more of the work, which includes life review, and that could be informal, such as chit chatting and talking or more formal, meaning following a series of prompts, and perhaps even recording those answers. And so, those recordings, which could be video, audio, or on paper, could be a scrap book, could be with photographs, or other mementos, that can become a legacy project, which is a beautiful gift for a client’s loved ones to be able to receive.

And then a doula will also assist with advanced care planning; will look at what do you have in place? Do you have your legal documentation completed? If not, is that something you’re interested in completing? Do you know your options? And then, the supplementary forms. How do we help you envision a more personalized, a more meaningful journey for yourself? And how can your natural network and your care team be more aware of what you’re hoping for, what your preferences are and what any of your fears or anxieties might be? And then, also, vigil planning.

So, we can assist them with that time of active dying, when a person is generally no longer communicative, and can’t verbally express their wishes. How can we help set things up ahead of time, so that each person can feel most safe, comfortable, and respected?

JL: Just to go back to what you said about a life review, I’m kind of curious about that. Why would that be important?

FA: I was recently giving a workshop and remarking how infrequently we give someone center stage. So, we shine the spotlight on that person, and really open up time and space for that person to share without being interrupted, without it being cut short and in front of someone who’s truly, genuinely interested in hearing their story. And doulas I feel are natural story catchers. We enjoy hearing what someone else would like to share with us.

And giving that person time and space to process. They’re going through stories, memories, sometimes hardships, sometimes their life goals that they either attained or didn’t attain, which kind of twisted, turned and led them in directions that were surprising or joyful or disappointing. So, they’re really sort of debriefing life, in general, or sometimes more specific aspects of their life, which is beautiful work at end of life. And we see that it feels more pressing, and there’s often more urgency to surface what has been underneath.

JL: Have you ever had any experiences, particularly around the life review sort of things. I’m thinking of some people I have known who, when faced with their own death, weren’t sure that their life had much value. It seems like being able to do a life review might trigger memories that make them realize maybe they actually had a life they weren’t remembering. As if there was more to it, that there was value.

FA: Hmm. Definitely, we see that. And something that I’ve noticed with our elders currently, as a generational kind of trend, is that a lot of people were raised to not talk about themselves, that it feels impolite to do so, and that they would really rather not brag at all.

JL: Mm-hmm.

FA: So, we have to find more creative angles and questions to engage the conversation, because it’s really not about bragging, it’s about revealing and reflecting. And once we can allow the person to understand that it’s a wonderful gift that they’re giving us, that we’re able to see places through their eyes, or times that we weren’t even perhaps alive for, or to experience, what a gift that is to be able to receive those stories. That can sometimes help encourage someone to open up and start sharing more.

And then, you’re right, they have these moments of, “Gosh,” as they’re just sorting through their own stuff. “You know, I really hadn’t thought about it that way,” or “Wow, this is really a pattern for me,” or “Wow, this really reflects this value that I didn’t realize I held so strongly to.” And so, a lot of insights come from these sessions.

JL: That’s wonderful. I think about what you’re saying, and I think it’s true. We don’t, in our day-to-day lives, carve out much time to listen to other people’s stories. So, it seems at this point, especially, what a gift to have someone who wants to hear you.

FA: Wholeheartedly.

JL: In your book, you have this wonderful quote from Pema Chödrön. I’m just going to read it, and then I’d like to talk about it a little bit.

“Compassion is not a relationship between the healer and the wounded. It is a relationship between equals. Only when we know our darkness well, can we be present with the darkness of others. Compassion becomes real when we recognize our shared humanity.”

FA: So many layers. In our course and in the book and in my own contemplative practice I really do try to investigate that darkness, the pieces of me that I would rather remain hidden in the shadows sometimes. And when I’m able to, with self-compassion, look at them and attempt to heal, then it clears me up to be able to enter into someone else’s time of intensity. If I’m carrying those wounds so close to the surface, I will become so easily triggered by someone else’s pain and suffering.

JL: Hmm.

FA: So, really, to be an effective doula, we need to spend time on introspection before we’re prepared to enter into those times with other people. And we’re equal, we’re humans, and as doulas it’s quite beautiful to me that it’s this relationship of equality and of trust, and it’s not about I’m coming in as an expert on your dying and your living. What I can offer is you having your best experience. And I’m ready to learn from you, as I am a student of my clients, and a student of death. And I have ideas and information that I can offer that could be of value to you.

JL: Yes. It seems like you have to build a certain compassionate capacity, or heart capacity, to do this kind of work.

FA: I think so, especially for it to be sustainable. We hear about burn out and exhaustion so much.

Our chief of palliative care, Dr. Bob Gramling, wrote the forward to the book. And we feature his expertise in the course. He has been wonderfully supportive of the program since its inception. As part of what he offered, he allowed us to see some brain research. This was about suffering. And so, they had one group of people who were trained in empathy and another group of people who were trained in compassion. And what they found was when it was time to go sit with someone who was in suffering, in deep suffering, the people trained in empathy, the parts of their brains that would be triggered were associated with dread. And the people who were training in compassion, the parts that fired off were associated with joy. And not because anyone would take pleasure in witnessing another’s suffering. But there’s this sense of what an honour and a privilege it is to be allowed into such a vulnerable time with somebody else and to not feel we are responsible for rescuing them or fixing them.

JL: Hmm.

FA: That’s not our job or role. Which empathy does ask us to look at: What would I do in this situation? What have I done in this situation? Can I put myself in this person’s shoes? So, we’re expending a lot of energy in that direction versus cultivating trust in that person’s inherent wisdom and strength to move themselves through this process and find their own way out that’s really going to be best for them.

JL: I’ve never heard that before. But the comparison of being empathetic versus being compassionate seems so right on, because you think of empathy as being able to feel the other.

FA: Mm-hmm.

JL: So, it’s really being overwhelmed by that feeling of other. Where compassion is an act of loving kindness towards other.

FA: Right. And in the book I talk about differentiating sympathy, empathy, and compassion. And so, it’s that pitying, that, “I feel sad for you. I feel bad for you.” Or then, “I feel how this feels for you,” which, as we know, isn’t actually possible, but that’s what you’re striving for in empathy. And then, moving into compassion, which is, “I honor how this feels for you.”

JL: Right.

FA: “As a witness, as a companion.”

JL: Yeah. It takes a lot of courage, doesn’t it?

FA: Oh, it does. And we have so many people who enter the course who, well, at workshops, we talk about this theme of not feeling like we are enough.

JL: Hmm.

FA: And it’s something that’s on my mind a lot. In the journals, during Mod 1, we ask about the learner’s fears. And this is a private communication between the learners and me. And so often this fear of not being enough comes up.

JL: Hmm.

FA: “I’m not strong enough. I’m not ready enough. I’m not prepared enough. I haven’t healed myself enough.” And so, I think that these are actually good signs of reverence for this work and of reverence for the intensity of this, for what you’re entering into. And if we lose sight of that, and we all of a sudden feel like, “Oh, I got this. I know just what I’m going to do. I’m the expert on all things death and dying,” then we’re going in a direction that is not going to serve our clients.

So, I try to help them understand it’s a cue. We need to continually work on self-care and contemplating our own stuff, and it’s also just this beautiful sign that we recognize how difficult and complex end of life truly is.

JL: Excellent. I definitely am going to have a doula when my end of life comes, should I be so fortunate as to know.

FA: I hope I will, too. And for my family.

JL: Yes.

FA: I think we’re just not used to seeing our community members, our loved ones, through these times of birthing and dying. So, they end up feeling so incredibly mysterious. And then you’re in the thick of it, you’re in the throes of the emotions, and you have to figure out all of the pragmatic details, all of the practicalities that go along with health care decisions but then also making the planning decisions and then making the services decisions, and then you’re entering into grief, and we’re often feeling like we’re lost and isolated.

JL: Mm-hmm.

FA: And so, a doula can enter in and assess what do you have in place? What is your comfort level? What is your knowledge base? What do you know about what is available to you right now? And how can I help move in or move out in accordance with the other people who are caring for you?

JL: So, speaking of loss, we’re coming up on some holidays that are big ones. And we’re used to having all our loved ones around us. And if someone has passed, that’s a big hole. But also, if someone’s dying, that’s also another shift in the way that we relate to these holidays.

Do you have any advice or help for people that might be going through that now? People who lost someone or they’re in the process of it, and there’s this big celebration, say Christmas, where we’re used to having them be fully alive.

FA: Hmm. It just adds on layers of loss and of sadness and of the realization that things are no longer the same, nor will they ever be. In general, you’ll see a disease process that is continuing to progress, where you have these vivid memories of your traditions and your roles, and it really brings this to mind.

And people end up feeling very raw, very vulnerable, and often quite helpless in the face of this, because they can’t fix it. And not to say you can’t do anything. You can work with it, and you can look for the type of listener who wants to hear, you know, “Tell me about your family traditions. Tell me some of your best memories.”

So, just today I was with my doula client, and I asked him, “Thanksgiving is coming; do you have any plans for Thanksgiving?” And so, we talked about that, and then I asked what their favorite foods are that they usually prepare, and my client was able to share memories with me.

And through that sharing you can often get to the core values and the top priorities, and that’s where you have some creativity. Can you continue to honor those priorities for this person, even though mobility has changed, and even though eating habits may have changed? And especially in the time of grief. If a person’s physical presence is no longer there, how can we consider some rituals during that time?

And I think that some of us feel very pressured to remain stoic and to pretend that stuff away. When really, even though it’s difficult to allow tears and grief into the holiday when it’s a time of gathering, if you can do so in a way that’s intentional…

JL: … Mm-hmm…

FA: … it can usually lead to a lot more healing and expressions with people who you gather, who are your loved ones. It can be a wonderful time, but it also can be a time of… for some people, if it’s very fresh.

JL: Mm-hmm.

FA: They decide to skip it for a year, and I don’t think there’s anything wrong with that. I think that there’s no right or wrong way to grieve, as long as you’re really being true to where you’re at.

I know of a person that decided to just skip the holiday completely. Instead, next year, they’ll start to think about, “Okay, how do we rework this holiday now with our current family unit, which is different? How do we want to reimagine this, at this point, moving forward?”

JL: Are there other rituals that could be shared by a family who’s had a loved one pass away?

FA: Sure. There are so many ways that you can personalize it. I think, for example, we have Thanksgiving coming soon. If you could imagine if you wanted to set out a place for that person or set out a special altar for that person with some photos, a bowl, a beautiful family heirloom bowl, and you have a note pad or paper. Write down your favorite memory of Uncle Joe, and then you all put it in there. And then, during a toast or a blessing or something before you eat, you could pass those around, welcoming the memories of Uncle Joe to be with you and doing it in a way that feels like you’re gathered, and you’re with your people, and there’s love surrounding it.

And you’re not ignoring what’s truly there. What we hear so often from grievers is that people don’t want to ask them how they’re doing or about their loss, because they’re afraid to remind the griever of the person who’s died. Mourners will tell you, time and time again, “I have not forgotten. Believe me, I have not forgotten. And if you invite me to talk about that person, if I feel strong enough or compelled enough at that moment …. That person existed, and this bond continues with me even in this person’s absence.”

So, that’s one example. You could also do something in their honour. Maybe Uncle Joe loved cats, and so, you gather up a bunch of cat toys and cat food and give it to your local shelter in remembrance of Uncle Joe.

JL: That’s wonderful. I love this idea of sharing memories of people at the table. That’s lovely.

FA: Mm-hmm.

JL: I know that in some instances it might not be exactly the right thing, but in others it’ll be spot on. And that’s part of the diversity of humans and all the various ways in which we grieve.

FA: Definitely. And maybe it’s not read aloud. Maybe it could be a little scrap book or journal that you make for Aunt Sue, who was Uncle Joe’s wife, and she gets to take it home and read it when she’s having moments of feeling alone and lonely in her grief.

JL: It’s very hard in our society to know. We’re not really comfortable with death, so, we do tend to avoid people who’ve had a great loss, and we don’t know how to talk to them. So, I love what you’re saying about reminding people that for the person who’s had a loss in their life, their mother, their best friend, their husband, their brother, sister, they haven’t forgotten it. So, being able to talk is a big gift.

FA: Mm-hmm. Definitely. I worked with a place of worship last December, leading up to the holidays, and we gathered, and we talked about our own losses, and we read a book together about grief.

And one of the women shared that after her Mom had died, and everything sort of calmed down, the dust had settled, and people had mostly gone back to their lives, she was at the grocery store one day, just trying not to lose it, trying not to cry…

JL: …yeah…

FA: … in the middle of the grocery store, and she looked around her for a minute, and she said, “How do they not know? How do people not know how much pain I’m in right now?”

JL: Right.

FA: And if we could remember that more often, that people are carrying around pain and suffering and grief and loss, and we don’t see it. We don’t hear it, generally, anymore. There aren’t these overt signs. But if we just know that there’s the chance that that person could be just barely holding it together to get her sandwich supplies and have a little more patience and understanding for humans, in general…

JL: …Yeah.

FA: Yeah.

JL: Oh, gosh. That’s so true. That’s so true. And it’s certainly true about grief and loss. I did a documentary on forgiveness and focusing on people who had lost a loved one to murder.

FA: Hmm.

JL: So, it was a pretty heavy and shocking thing to not have the grace to be able to say goodbye. One of the people whose stories I’ve told was saying, “You know, I’ll be going along, keeping it together, feeling okay, and then all the sudden, I’ve fallen into the darkest pit of despair. And I never know when I’m going to fall in there.”

FA: Hmm.

JL: “I have learned to know that I will get out of it, and I’ll keep going forward, but that grief isn’t a linear thing at all.”

FA: Right, right. It crashes over you, washes over you. I can’t see the light of the other side, but it will come.

JL: Mm-hmm.

FA: But that initial time, especially when you haven’t quite built up that sense of resilience, is very difficult.

JL: Yes. Resilience. Well, Francesca, this has been an amazing conversation, and I love the work that you’re doing, that you have put together a training program with the University of Vermont and are creating a doula nation! We need a doula nation!

FA: [laughs]

JL: So, thank you so much for that, and for your very beautiful book, and the time you spent with me today.

FA: Thank you for the opportunity. I really appreciate it.

JL: Well, you’re very welcome. And we will have your website available for people. A real, rich assortment of good information. It’s been a pleasure, thank you.

FA: Thank you.

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