By Kathleen Quinn, Psychotherapist and integrative healthcare practitioner.
“It’s a strange thing about the human mind that, despite its capacity and its abundant freedom, its default is to function in a repeating pattern. It watches the moon and the planets, the days and seasons, the cycle of life and death all going around in an endless loop, and unconsciously, believing itself to be nature, the mind echoes these cycles.” Nicole Krauss, 2015
A year or so ago I was invited back to a college to meet with nursing programme administrators. I had been there about 10 years previously but as there had been a turnover in faculty in those intervening years, I was not sure that anyone would remember meeting me. Some of the old vanguard were there though, and in the meeting I challenged them again to consider innovations in the nursing education and some of the difficulties involved. I anticipated there would be resistance to some of these ideas, in part because the discovery process requires health professionals –as a first step in developing an awareness process that becomes the foundation for safety, communication and self-care –to slow down. In the course of the meeting I said, ‘The faster you all go, the slower I will go’.
After I presented, a senior person (who I remembered from my previous visit) said that she thought my work would not be useful because I was ageing and slowing down! This made me realise once again the importance of teaching the teachers how (nursing) professionals can improve their own self-care, and the lives of their students, patients and colleagues, by cultivating awareness and creating a peaceful productive environment in which to sustain their working life. When thinking too fast we make more mistakes and we communicate poorly. Common responses to the mistakes we make are emotional –denial, shame, anxiety, anger –which if they persist drive us into burnout. By reducing burnout we also reduce medical errors, which in the US cause nearly a thousand deaths a day.
The unconscious at work
“…when something happens to us, we do not experience all of it at once. Experiencing is a process that takes place over time. It involves neurophysiological and somatic work on the part of the person to whom the experience happens”. (Browne, 1990)
Since 90% of memories and mental processes are unconscious, we are more unknown to ourselves than we are known. In Socratic thinking, unless this ‘unconsidered self’, can come to awareness and be acknowledged we will live blind and bumbling. In my own life and teaching I have found that combining journaling with mandala work helps bring the unconsidered self’s unconscious processes into awareness. Over a lifetime each of us will come to some sort of insight about our own interior being. Usually, it happens through slow seepage of unconscious material into conscious awareness. Our Freudian slips sometimes show things we did not mean to reveal, but there are other ways for hidden experiences to arise into consciousness: psychotherapy can accelerate the integration process; accidents, mistakes or errors may invite us to reflect on why they are happening; we can pay attention to dreams and their metaphors, and on what we project onto others or what we reject and why. They all tell us a lot about ourselves.
Known to self
OPEN SELF Information about you that both you and others know
HIDDEN SELF Information about you that you know but others don’t know
Unknown to self
BLIND SELF Information about you that you don’t know but others do know
UNKNOWN SELF Information about you that neither you nor others know
The Johari window is a model for self-knowledge. Much of what we think and feel is shaped by inevitable blind spots in our self-awareness. They shape the way we feel about ourselves and others, how we parent, and our attitudes to self-care. And, crucially, they create areas of unconscious inattention which in professional life can lead to errors and failings in patient care.
“To keep repeating a baleful pattern without recognizing that we are caught in its loop is one of life’s greatest tragedies; to recognize it but feel helpless in breaking it is one of our greatest trials; to transcend the fear of uncertainty, which undergirds all such patterns of belief and behavior, is a supreme triumph.” Nicole Krauss for the Van Gogh Museum, Amsterdam (2015)
Over 100 years ago CG Jung began using artwork, sand play and narrative writing with his patients (Jung, 1973). Many therapists have used these same techniques as well as journaling and mandalas to document experiences and reflect on what they mean (Pennebaker, 1997; Mulcahy, 2013). Journaling plus applications of mandala analysis may lead to a better understanding of visualisation in psychology and promote their wider use and treatment (Billington, 2013). Ongoing experience with these tools also supports their value for developing positive communication skills in education, practice and leadership.
Working in this way calls on several different ways of thinking. One might for instance create a visual image or mental representation by thinking in words, or on the other hand because of feelings that trigger an associated picture in the mind. Or the picture may just appear as a whole, and the feelings and thoughts about them follow. Some of these responses could be directly related to what we read, see, hear, taste, feel. They could originate in a sensory input from some other external source, or they might be generated by an internal building process involving repetition and composite pieces. They may have a sensory input from an external source, or they may be generated by an internal building using repetition of composite pieces. Most people experience all three though one of them may be dominant. It is an everyday experience that music, art, dance, poetry can trigger emotional reactions, and research has demonstrated that the thought, mental activity or action is preceded by unconscious brain/body activity. This suggests that such responses begin at a level of unawareness before we have an awareness of our decision or choice. When in danger, such pre-cognitive preparation for conscious action would have protected our ancestors in the wild –evolution has embedded the fight or flight mechanism in our biology as a response to potential threat. In fact we are continually sensing and responding unconsciously to our external surrounding, and internal processes of which we are generally unaware constantly
“The mind begins to emerge as a self-designing system of representations, embodied physically in the brain.” Hofstadter and Dennett, The Mind’s Eye
The discovery process
The discovery process protocols rest on the premise that internal awareness and discovery can express themselves in an exterior creation, which can be observed, participated in and re-internalised. This makes everything we do grist for the mill of a process to uncover ‘self’. Communication with ourselves is cyclic: mandala art creates a physical representation of internal experience, which mandalas may communicate back to their creator. It is helpful to see the process as a circle that turns back on itself for understanding and awareness. Some mandalas speak to others, just as art speaks. Art that does not communicate is not art.
Humans interact with their environment. So while we are self-designing, we are also shaping what shapes us. Subsequently, what we have created will influence and shape us. Each of us is in a process of self-selection and simultaneously self-creation, in relation to our surroundings, how and where we live, what we choose to do, and with whom we choose to do it. This process is not limited to the external world, for we are also shaping our inner world of ‘mind’, which may find many ways of expressing itself in the body, even –as we now are discovering –at a cellular level through epigenetic switching. It seems that thoughts become things and then those things sing back to us.
“Compassion: sympathetic consciousness of others’ distress together with a desire to alleviate it.” Webster’s New Collegiate Dictionary
Mirror neurons and empathy
During the 1990s researchers at the Rizzolati lab in Italy, while tracing the brain functions of macaque monkeys, accidentally uncovered an unknown neuronal activity. The story is that the team went for lunch leaving the monkeys attached to the electrodes and tracing equipment. One monkey was watching a researcher having lunch while he prepared for the next experiment. Later the researchers saw that the part of the brain being triggered in the tracings was related to motor activity; it seemed the researcher’s eating movements had activated the monkey’s brain as if the monkey itself were eating. Through subsequent research the team developed the concept of mirror neurons (Rizzolatti et al, 1996).
Because of this biological capacity for mirroring, every encounter –whether watching people play football, dance, sing, create art, and even look at mandalas which others have created –includes an element (albeit embodied and unconscious) of empathic ‘feeling into’ the others experience. The same applies of course when we are in the presence of another’s distress, or rage, fear or suffering of whatever kind. These feelings are in a sense contagious and, though their impact is generally below conscious awareness, they nonetheless affect us. Inevitably to ignore, push away, or compartmentalise this mirrored suffering takes up some of our energy and attention. In professional life this avoidance arguably serves a purpose, and we may think the emotional distancing process works: which it will until the effort becomes too much –until there is overload. This as we know is especially the case with vicarious trauma and burnout (increasingly referred to now as moral injury) among emergency workers, first responders, law enforcement and healthcare workers, but also in any high stress occupation including faculty and administration in nursing education. My work in these fields has used reflective journaling and mandala-making to help mitigate some of these negative consequences, and for creating change. The process, however, has been applied with other professions in our inter-professional development programmes.
“The wound is the place where the light enters you.” Rumi
Self-compassionate care to mitigate burnout has a replicable pattern
• First in the response is recognising what is happening or has happened (slow down and use awareness skills)
• Second is noticing there are thoughts impacting the body causing emotional/physical responses (journaling about events and occurrences)
• Third is to consider the strategy in place for dealing with the thought and the physical response (considering options and reviewing self-responses to options)
• Fourth is doing something with it (test, evaluate, practice and change behaviour)
• Fifth is moment by moment awareness in a repeating cycle.
“Art is never necessary. It is merely indispensable.” Michael Kimmelman
Before you read this section, please do this exercise. Look at the mandalas on the following page.Observe and note your responses and thoughts about them.
The focus of reflective journaling and mandala making is to bring unaware information into awareness, then use that information for self-care, for improving interacti
ons with others and for reducing negative experiences and responses. These mandalas were made by a healthcare worker and a teacher, who have graciously allowed me to use their work. There are obvious differences and commonalities in the work. Remember: you are your own best teacher.
These mandalas represent how they look in a journal..
In just observing them you might notice some thoughts and feeling. You might think about how your own mirror neurons are working. You might also want to think about the part of the response is to
do with ‘your stuff’. Noticing what you bring to the exercise and the feelings thoughts and meanings you project on to it has parallels in our work with others. The ability to distinguish between what
is there in you and what is hereinside me, is crucial for good professional practice.
An empathetic connection may allow an awareness of what the other is thinking and experiencing; but to believe you know this may mean you are bringing too much of yourself into the process rather than not actually experiencing the other. This is an example of empathy as a form of defence. True empathy requires noticing more fully what another person is communicating about themselves, and being able to tell the difference between t heir experience and your own multi-leveled responses
“Every work of art is the child of its age and, in many cases, the mother of our emotions.” Wassily Kandinsky
The process of using mandalas in reflective journaling aims to increase cognitive flexibility, and develop participants’ resilience. There is no right or wrong way to do the mandala creation, and only the one who created it can say what their mandala is actually about. We always remind the participants to share only what they feel comfortable sharing at that time. There is always time to bring in further re
flections and connections. The role of the observer, supervisor, colleague, therapist, teacher, is only to witness. This is the basis of all mandala art therapy, whether with patients, groups, professional learning communities or our students and mentees. A facilitator can ask questions for clarity, and make suggestions, particularly when these are linked to reflective practice in a professional area. For example, in the third image below there is a mis-spelled word ‘peak’. However, remembering our comments about accidents, mistakes and errors being slips of information into conscious awareness, bringing them to the attention of the creator can provide food for thought. The images below were made by sam
e process, yet clearly this set represent expressions of self from set one.
As you work with your own self-care and the care of others, it is important to remember this whole effort is a working toward compassionate self-care and compassionate care for others.This is the basis of all mandala art therapy, whether used with patients, groups, professional learning communities or our students and mentees, or in working groups to clarify hard-to communicate dynamics or as a vehicle for interpersonal growth. Because it gives an entry point to share verbally it is also useful for those who find self-expression or self disclosure difficult.
“Just be with ourselves… Such a simple, gentle way calls first for a heart.” Karl Grass
In discovery process we view the symptoms and signs of burnout as healthy responses as our bodies and minds try to get our attention to make changes in our lives. This brings us back to journaling and mandala-making as a strategy for leading an individual to greater awareness. Doing so should be helpful in resolving difficulties and building skills for healthier functioning and interactions. What is known, and how we come to know, are important for successful communication since we cannot be aware of all there is within us. Nor can we be aware of ‘the other’ in any depth unless we actively engage in making the effort to know ourselves and be known. There are means of actively engaging with our ‘unconsidered self’: I have found journaling and mandala-making of great value because in patient-facing work the depth of our self-knowledge influences choices and decision-making, contributes to unintended consequences in relationship distress, parenting difficulties and work dissatisfaction.
With discovery process we have found positive outcomes related to reduced distress and psychological symptoms, improvement in work environments, and increased positive engagement with children, parents, partners, co-workers and those we are serving through our work. We are finding this process of self-empowerment combined with our development programme impacts positively on the closed and fearful self, reducing resistance, stagnation and ultimately burn-out. This new area of research and work calls for more exploration and study.
And so, to end with a twist on a proverb from popular culture: ‘when life hands you lemons, make lemonade… or mandalas’.
The implications for practice and research, including reflective practice, can be found in a series of recommendations adopted and presented in the Sigma Theta Tau International Nursing Honor Society’s paper Scholarship of Reflective Practice (2014). In working with students and colleagues, the functionality of reflective practice hinges on the ability to be open-minded to the developing awareness, while critically appraising one’s actions and their outcomes (Titchen et al, 2011). The work of reflective practice and journaling cannot be separated from lived experience and a critical thought process (Amble, 2012). This is requisite for improved decision-making related to actions taken for self and others (Mulcahy, 2013),
Amble N (2012) Reflection in action with care workers in emotion work. Action Research, 10(3) 260–275.
Billington T (2013) Promoting self-awareness through reflective practice. British Journal of Nursing, 22(1).
Browne I (1990) Psychological trauma, or unexperienced experience. Re-vision, 12(4) 21.
Jung CG (1973) (RFC Hull, trans) Mandala symbolism. Princeton, NJ: Princeton University Press.
Krauss N (2015) Letter to Vincent Van Gogh in When I Give, I Give Myself. Van Gogh Museum exhibition, May 2015–January 2016.
Mulcahy M (2013) Mandalas as a tool for transformation to enable human flourishing: the influence of Carl Jung. International Practice Development Journal, 3(2).
Pennebaker J (1997) Writing about emotional experiences as a therapeutic process. Psychological Science, 8(3) 162–166.
Rizzolatti G, Fadiga L, Gallese V, Fogassi L (1996) Premotor cortex and the recognition of motor actions. Cognitive Brain Research, 3, 131–141.
The Honor Society of Nursing Sigma Theta Tau International (2014) The scholarship of reflective practice. Available at: www.nursingsociety.org/docs/default-source/ positionpapers/resource_reflective.pdf?sfvrsn=4 (accessed 22 June 2020).
Titchen A, McCormack B, Wilson V, Solman A (2011) Human flourishing through body, creative imagination and reflection. International Practice Development Journal 1(1).
By Kathleen Quinn, Psychotherapist and integrative healthcare practitioner
My first year in college I began using poster board and paints to draw circles and fill them in. I used my hands like finger paints and created masses of circles. I did not name or have any other thought about the circles except I HAD to make them. Years later when I completed three master’s degrees in counseling and theology I would do retreats and part of what the participants did was make circles and talk about how they felt. When I discovered Carl Jung’s work in mandala making, I was at home. I understood what I was creating and why. I now work with students, faculty, patients and colleagues creating mandalas and using them for integrative psychotherapy. If anyone in interested in the history, philosophy, or what we do using mandala therapy as an integrative technique please go the website www.drkathleenquinn.com