Inside Compassion: Edge States, Contemplative Interventions, Neuroscience

On May 12, 2012, Zen Buddhist Roshi Joan Halifax gave a lecture about empathy and compassion at the Library of Congress. Dr. George Chrousos, an authority on the effects of stress on the body, provided a response. The lecture, "Inside Compassion: Edge States, Contemplative Interventions, Neuroscience" includes what Ms. Halifax has termed "edge states," or the challenges faced by clinicians and caregivers in care of those who are seriously ill. She touches on basic research in the areas of neuroscience and social psychology on mindfulness and compassion. And she covers six contemplative interventions that are useful for clinicians and caregivers, and talks about various types of compassion.

Dr. James Billington, Librarian of Congress: Good Afternoon. I'm [inaudible] Library of Congress and I'm—the program will be moderated and presided over by the head of our Kluge Center, Dr. Caroline Brown. But I just wanted to welcome you all here and thank you all for being here, above all thank one of our more engaging and popular fellows here at the Kluge Center recently. And I did want everyone to know that we're honored today by the visitor and this is John Kluge, Maria Kluge who's honored us with her presence and I just like you to take a bow and so we can all express appreciation. Please [inaudible].

[ Applause ]

And now with the great pleasure, we turn it over to Dr. Brown, Caroline Brown who will preside over introduce our speakers and get us all to the flying start and the great enterprise that Kluge has build us to and which of course, he's headquarters is right in there and I'm please to see so many members. Can you hear me? You haven't missed anything if you haven't accepted—accept Mrs. Kluge's presence. So Dr. Brown, take over. And once again, welcome to the Library of Congress and to the Kluge Center.

Dr. Caroline Brown: Welcome, we're delighted to have all of you here for what is going to be, I think, a most splendid interesting and deeply felt presentation. Our guest speaker, Dr. Joan Halifax, will be speaking on this subject "Inside Compassion: Edge States, Contemplative Interventions, Neuroscience," looking at the issues of empathy and compassion especially on the part of those carrying for the ill and dying. A little bit unusual for today's phenomenal presentation is she will be followed by a slightly brief presentation by another scholar at the Kluge Center, Dr. George Chrousos.

I had the pleasure of introducing them, I guess was early—sort of late march, not one of my most graceful introductions but I said, "George, you have to meet Joan. Joan you have to meet George. And I have to go to a meeting." And they introduced themselves and it's been a wonderful intellectual partnership since that time. I do wanna say just a word about the Kluge Center which as I think you know then was established by a very generous donation from John W. Kluge. With a wonderful vision that Mr. Kluge and the Library shared.

The vision really was that there should be a place for a scholarly place within the nation's capital with the leaders, nations leaders would have the opportunity to tap into the wisdom and knowledge of mature scholars so that their judgment and knowledge might provide fresh prospectives in government. Or as we'd like to say to bring together the world of affairs and the world of ideas, the thinkers and the doers coming together in enriching, and formal conversation. And that's been the highest vision of the Kluge Center that the librarian and John Kluge shared together in created the center from that.

In addition, the senior scholars, wonderful scholars would be part of a community that would include the most promising junior scholars, the rising generation who we hope maybe some 20, 25 years from now will be back as senior scholars. But to bring these two groups together with the expertise of the libraries, curators and areas specialist, other specialist for research in the reach collections of the library and our other resources. That was the founding vision.

In addition, I would just say the center also sponsors a number of intellectual activities such as this afternoon's presentation, lectures, symposia, small conferences, and you can sign up on the webpage for further information. Just quickly go the library's homepage, on the right-hand side scroll down to the Kluge Center, go to the Kluge page, and you'll be able to signup and know what's coming along.

Today's program, I think in some ways represents the very best of what a center would hope to achieve where you just have a sum which is much greater than the parts, two scholars coming together in a wonderful collaboration. I'm not going to go into a long introduction about them.

We provided bios on your chairs so that you could read in great depth. But let me just say a few words, Dr. Joan Halifax is the founding Abbot of Upaya Zen Center, in Santa Fe, a writer, thinker and a great teacher. I think I wanna emphasize that. I think many of you have experience that a great teacher who's worked with dying people and trained clinicians in how to do say has written several books on this issue. The most recent one being with dying cultivating compassion and fearlessness in the presence of death, a book that was personal resource for me in my own life in that experience.

Dr. George Chrousos is one of the world's prominent clinical investigators engaged in research on the interrelationships between the nervous and endocrines systems with the special focus on the physiology of stress. And I would note that next week, he will be traveling to Athens to receive the Bodossaki Prize which is some people called the Greek Nobel. I know that that Roshi Halifax and Dr. Chrousos had met at the Kluge Center, discovered the complementary nature of their own work, approaching common issues. Joan from her basis in Neuroscience and Buddhist thought, George from his knowledge of Endocrinological System and let just add a Greek—a deep knowledge of the Greek—the Greek classics. So it's just been a privilege to be a part of witnessing this wonderful relationship. Today, you'll—in the short time we have, you'll just get a short glimpse of the kind of mutual discovery in exploration that has been characteristic of their time here. So I think I've said more than enough. I would ask you at this point to welcome Joan and George.

[ Applause ]

Joan Halifax: So George and I had a very intense meeting, day before yesterday, and solved a number of problems. It was very interesting that I've been sitting on like a mother hen on an egg for the egg of compassion for two months and I'm very honored to have this opportunity to present with George and we wish we had several days. And we want to fly through this PowerPoint that I'm doing. It's going to be a very rapid because two-thirds of the way through is the egg that hatched. And so George, thank you for being so generous with your wisdom and your wonderful imagination and insight. The other thing we've been doing is a kind of philological exploration of the Greek terms for Buddhist states of mind. So that's been—We haven't quite arrived, that egg is yet to be hatched. Is that correct?

Yeah.

We're still in the process. But thank you George.

[ Pause ]

Jessie [...] thank you. Dr. Bellington, thank you. Caroline, thank you. And it's always a collaboration. I'm so grateful for these team members for being part of this exploration into compassion and also to my friends in the world of neuroscience who have added the immeasurably to this area. So I want to explore what I've been calling Edge States in caregiving, lymphatic distress, lymphatic concern, priming and optimizing compassion, neuroscience research and compassion, contemplative practices and types of compassion. And if I get just to the priming part, I'll be happy, although I would like to take you through the whole sequence.

Anne Harrington has written a very important book, A History of Mind-Body Medicine where she speaks about compassion not being something that is valued, in our world well understood and it's actually—we could say from the point of view of not working medicine. There is a great compassion deficit in medicine and causing suffering to caregivers. But there's also a compassion deficit in general. I would say being in Washington we're all sensitive to that. In fact, I said recently in a public talk, I wish we had vote for our politicians based on their compassion capacities.

As many of you know, I'm a long time Buddhist practitioner since 1965. And so I have to have a little tiny bit of Buddhism in here. "Would it be true," asked the cousin of the Buddha, "to say that cultivation, the cultivation of loving and kindness and compassion is part of our practice?" And the Buddha replied, "No, it would not be true to say that the cultivation of loving and kindness and compassion is part of our practice. It would be true to say that the cultivation of loving and kindness and compassion is all of our practice." So compassion, what do we mean by that? So the emotion one experiences when feeling concerned for another suffering. And the desire to enhance that individual's welfare. And it's made up basically from the point of view of, you know, most social psychologies of two components.

But today I was speaking with our group in the Max Planck Institute. They're very excited because have gone quite granular as you will see shortly. But basically, it's felt that the affect of feeling of caring for one who is suffering is part of compassion and then them motivation to actually relieve that suffering. As if about 10 years, there's been an increasing encounter between neuroscience and Buddhist meditation. And part of that exploration has been in the field of what happens, what are the neural substrates of compassion. So, one of the reaches fields in which to really look at compassion—and the military is one of those fields by the way, but also one [inaudible] care for dying. This photograph by the way is—it portrays a man who has just died and the arm of my students who has helped with that transition reaches toward the elderly patient. So what do we do in caring for dying?

We endeavored to alleviate the suffering and pain of those who are gravely ill. We try to work with the survivors and we also address the suffering of our colleagues or of caregivers, family and professional caregivers. But there are edge states which all caregivers face and I want to talk about this edge states very briefly. They're described a little bit more except for the first edge state that I—part of my work at the library interfered for me, so thank you very much for this protected time. And that is the edge state of pathological altruism. And this is altruism in excess where the individual who's caring is actually harmed physically or emotionally by the active caregiving and that gives rise to a number of other edge states. By the way, this particular point was made in the work of Michael Mcgrath, burnt-out which is now more often called vital exhaustion, refers to the experience of cumulative work demands.

Secondary trauma which is known primarily in the field and we feel it's [inaudible]. We're calling secondary trauma or vicarious trauma or empathic over arousal. We feel that compassion has been misunderstood in the western world of values, behaviors and science so that the term compassion fatigue is not a term that we would use ever in this context. And this secondary trauma arises because individuals are exposed to suffering and you can say this, you know, whether you're a clinician or in the military or in other areas of work like working with homeless people, et cetera. Where there's a prolonged exposure to suffering and where the response is stress related. George will go into this.

Moral distress in this area was opened up for me by my colleagues, Cynda Rushton at Hopkins. And this is when the caregiver knows what to do, whether it's a family caregiver or a professional caregiver and can't actualize it. The next is horizontal or vertical violence and this is disrespect that occurs between an individual and a peer or a group or between for example a physician and a nurse that devalues, disrespect that individual, basically abuses that individual. And I want to thank my students, John Janner [phonetic] who happens to be a nurse and also in our Chaplaincy program who brought this material forward to me.

And the last area I'm calling "structural violence," which refers to systemic violence. An example would be—which I encountered actually when I was at the University of Miami School of Medicine, thanks to [inaudible], teaching there and learned that they had actually change the policy where a gay couple were separated when the woman who had the stroke was put into the ICU, her partner was not allowed in, the woman who the stroke died, the partner was outraged and pushed the policy in the hospital to be opened to partnerships of the same sex, you know, that kind of issue. And I have to say working in the field of death and dying, since I've been in this field since 1970, I'm almost 70, so I—you know, I can sort of remember that number fortunately. There are many, many issues including the denial of death, clinicians who try to keep their patients alive at any cause and actually I'm gonna not go into details.

It's hard to hold back but honest around pain, suffering and death, inability to discuss interventions or death with patients and families, inability to actually communicate about stresses in work, workaholism, self neglect, perfectionism, guilt for avoiding or abandoning patients and the tendency to engage in what is called negative-cognitive appraisal. And that basically means that you have a frame of reference that is completely depressive or a negative and how you actually are perceiving your circumstances. And this then gives rise also to a whole area, I called the "six futilities." Futility with patient demands, institutional demands, errors in communication and treatment, feelings of inadequacy, the sense of the work that you're doing where there is a family caregiver, or as a physician really not benefiting the patient, and then the actual perception of suffering. So this so-called compassion fatigue and you'll find if you Google it, mostly this domain of stress where we're perceiving the suffering of other is called "compassion fatigue." We're calling it secondary trauma or vicarious trauma or empathic over arousal or empathic distress.

In caregivers, whether we're speaking about family caregivers or professional caregivers, we see secondary trauma at a level somewhere between 40 and 80 percent. I'm sure many of you have taken care of your dying relatives. You know what it's like. In the other work, 76 percent of medical resident respondents reported symptoms of work burnt-out and that includes the experience of very high depersonalization and emotional exhaustion. And half the residents who were interviewed feel burnt-out and suffer. Medical residents suffer from depressive symptoms. So you get the feeling that you want to go a little upstream in medical eduction because this is—has grave effects not only on the well being of clinicians but also on the well being of the actual medical system itself.

It's very costly, the economic consequences of clinicians falling ill is not to be underestimated. So burnt-out is shown to predict mood disorders and poor general health and physicians and of course increased in patient dissatisfaction, increase in medical errors and suboptimal practices, medical practice. And this is a really scary step. Male physicians are 1.41 times more likely to commit suicide than the average male and female physicians 2.7 more likely to commit suicide. So this is really a population that we can speak of as being at risk.

So the actual symptoms if you will of secondary trauma are very close to what we know is posttraumatic stress syndrome. It can seriously impact the health of caregivers and it produces things like nightmares, sleepiness or sleeping too much, addictive behaviors, avoiding situations of suffering and so forth. And through Mcgrath's work and others, we see that this kind of distress is based on an excess of altruism combined with it—we'll see later, an inability to really self-regulate.

So this is called pathological altruism. And then we see in Chrousos work more than any other factors including the patient's disability and the time spent caregiving, it's the perceived suffering, it's the felt suffering of the patient that leads to depressive symptoms. So let's just move into empathy for a minute and thank you George. George is smiling because we work on this day before yesterday together. It is a step in a process. And, you know, I say a process, I'm not saying it's a chain of—this happens and this happens. It's not an algorithm per say, it's a step and a process of emotional and somatic responses leading towards feeling of emphatic concern and compassion in the best of circumstances. But there is an important distinction between empathy and compassion. And that distinction, maybe George you would like to say something to that but let's be brief.

[ Laughter ]

Dr. George Chrousos: You did a beautiful job.

Joan Halifax: Okay, so empathy and I just—you know, I was just on the Skype call meeting with Tania Singer this morning and, you know, talking about this. Empathy is that—what George and I is we shifted the language. We say that empathy is feeling inside, it's really having that feeling inside of yourself but inside of the person who's suffering, so that that distinction between self and other is not present. You're feeling what the other person is suffering, but you haven't made a critical distinction which you do in compassion and we'll get to that distinction in just a minute. But compassion is a feeling along side and I change the wording George, I hope you don't mind. Feeling along side the sufferer's affect of state and very importantly aspiring to relieve it.

That is critical because the premotor cortex is active, activated in states of compassion but not in states of empathy. So I wanna turn briefly to the work of Daniel Batson who is one of the—the kind of key people in this field. His work at 1987 and he still going strong, I just did something in Zurich with him recently. Batson basically said, "There are two emotions that basically motivate an individual health to help others." One he is terming—he terms empathic concern, and this is other-focused, very important, not self-focused. Other-focused—And the other-focused congruent emotion produce when suffering is witnessed. But there are feelings of tenderness and compassion that accompany this experience.

Now, okay, personal distress is the second pathway or possibility that arises. And this personal distress that is we feel very uncomfortable, we're in the state of empathic over arousal. We experience personal distress and we wanna help relieve the other person suffering, but it's actually focused on ourselves. What we're trying to relieve more than anything is our own sense of discomfort at being in the presence of suffering. And this is prompted by, as I said, the need to relieve ones own uncomfortable feelings.

Now what we've learned is really critical about compassion and we're gonna get more granular in the next few slides. But what is really critical in the experience of compassion which is not actualized in empathy but empathy is an important part of compassion, but is that you're able to actually make a distinction between yourself and the person who suffer. This activation of a situation of stress, as George will explain, is really necessary for individuals. You have to be somewhat stressed in order to feel compassion. But you—at the same time, either it's a top-down process or a bottom-up process, you have to be able to actually distinguish self from other and to be able to regulate your emotion—emotional arousal. So I wanna go to one of my favorite researcher, Nancy Isenberg.

I did a modification of her algorithm. The problem with an algorithm is that it looks like it's sequential and I'm positing that actually compassion is an emergent feature inside of a complex dynamical system. But Nancy has some very important dimensions that I wanna share. She's saying that an individual who's going to actualize compassion or going to personal distress has to experience some degree of affective or emotional attunement. There also has to be cognitive attunement and that is the individual is actually able to look at through the eyes of the other person and see kind of how they see the world. And there also had has to be the medium of memory. If you had been a person without any experience of suffering which means that you have some probably autism related disorder where you don't perceive your own suffering, you're not sensitive to it, it's very difficult to actually perceive the suffering of others.

These streams, these three streams come together and initiate an arousal level which George will speak about, which produces a kind of tipping point. And the tipping point either goes into a positive expression or a dysfunctional one. If it is dysfunctional, the experiencer, the caregiver, it goes through the medium of personal distress. And that personal distress, if you look at Isenberg's algorithm basically has two possibilities. One of those possibilities is the—to actually alleviate the person suffering but base on the need for you to alleviate your own suffering because you just can't handle being around this person.

Let just give an example, the patient who has really advance cancer who is suffering from intractable pain. Nothing seems to be able to touch that pain. It's really at the core of the body and so the patient asks for a palliative sedation. But actually the patient really wants to not be sedated. But the caregivers are sort of manipulating the patient into a decision of palliative sedation because the caregivers really can't handle, taking care of someone who's obviously requiring so much care and it's so challenging.

So that would be what is called selfish prosocial behavior. The other pathway and still this relates to your question that we were exploring the other night and this is all fear-based behaviors. What happens in clinical situations is that like caregiver and also, you know, a family member, same, is experiencing over arousal, moves into the experience of personal distress and then there are three basic expressions that we have observed as very common among professional caregivers, also among family members and the first is moral outrage.

And moral outrage is of course the fight dimension that Cannon talked about, Walter Cannon. It is that feeling that the right things have not been done for the patient or for the family member. The second is the flight impulse and this is occurring more and more, reported more and more in the medical literature and that is that patients are avoided or even abandoned and a year and a half ago, when I was doing teaching at Hopkins, Dr. Rushton and I worked in the CICU with their team and the whole ICU was sort of team, the nurse team, was moving between moral outrage and what we call freeze, but had actually abandoned the patient along the way so they've gone through all three of this expression.

The third piece is—Walter Cannon didn't mention it but it is the experience of freeze. It's just when the clinician goes numb, doesn't feel anything. And this is for your Phil. Thank you, [inaudible] of our wonderful conversation. So what do we do to engender empathic concern and compassion? Tania Singer with whom I spoke this morning, we had a Skype meeting that was great. And what Tania Singer, who's a neuroscientist, she's head of the Max Planck Institute at Leipzig.

What she observed is that individuals who are suffering from offsets and related disorder called alexithymia who have a very low capacity or no capacity to read their interoceptive processes which means they really can't know what's happening to them viscerally, when they're hungry, when they wanna go to the bathroom and sexual feelings are present and so on. At the same time parallel with that, alexic people were suffering with alexithymia have little to no empathy. They have not—they don't have the capacity to really feel into how another person feels. And the fact they can't—they're own somatic sensitivities really not present.

So this is what's very fascinating and Tania and I really pushed on this piece because we feel it's very important because clinicians, in the way clinicians are trained, it's very low embodiment training as many of you know even though it's a high embodied practice. So I made a simple algorithm based on this conversation with Tania that it is really important that clinician stay in touch with their body. And it thinks Tuzy [phonetic], would agree with this completely and that the same neuro networks are active, activated in interoceptivity as in empathy. And that—so what we see is interoceptivity gives rise to empathy. This combined with positive regard and inside distinction between self and other primes compassion.

So what have I been doing for the past two months? Some of these I knew, some of these I learned, thanks to the protected time here. Thanks to the conversation with George, also Phil, and other people, Sharon who's my students, who is just at [inaudible] and who's a fellow here. It's been really exciting having her here. To have protected time too really think about things has produced this list so to speak and this list is based on a couple of things. It's based on many years of meditation practice. I know the feeling in the body from direct experience. But it also is based on more than 25 years of interacting with neuroscientist, of looking out what is really important in terms of, you know, what gets active, what neural substrates get active in attention and if we had all day, we would do the attention research. We would do the open presence research in neuroscience and social psychology and so on.

I cut all the slides. Sorry. I have it on another PowerPoint though. They didn't go into the trash. But this is a very granular look. And this what I'm taking actually to Berlin in July where we're meeting with the lead people who are doing this neuroscience research on compassion and really looking to develop a protocol which we can use in across cultures and also in various professions and in eduction that would help individuals be more compassionate. And I have to say, I'd like to see the compassion protocol right in the middle of our educational system, if I can just, you know, say that out loud in here right now and in the halls of congress too but—[laughter].

So let's—let me just touch in. The first access but this is non-sequential, this is co-arising, is what is—what I'm calling the AEB Access, that is the Attentional and Emotional Balance Access that you need to have attentional balance in order to actually perceive suffering. If you don't have attentional balance, if you're just like this all the time, you will not perceive suffering accurately. Also, with attention on your own visceral processes, that actually primes empathy.

The same neural network that is active when individuals are in states of compassion is active in the interoceptive experience. And so it's really critical that individuals actually bring their attention to their own physical processes like attending to the breath or the heartbeat. Emotional balance, very critical and that is we cultivate what is called pro-sociality as distinct from anti-sociality which means that basically we have positive regard for others and we're engaged actively not just in positive regard but it's engaged positive regard where kind. And that we are actualizing empathy which is affect of attunement.

The second access in this—you know, as I say are integrated. This is a vision of co-arising is what I'm calling the II access. And the first that I has to do with intention. That is very important in our work for example that physicians want to relieve suffering, they're not just out there to make money. Politicians want to actualize policies that are wholesome not just for their state but not—and not just for American but really wholesome for the world and so on and so forth. That you have a pro-social motivation to transformed suffering. The second I relates to insight and there are several areas that are very critical. One is that one has self awareness.

That one is really aware of one's own mental continuum and somatic continuum and we need that insight in order to actually recognize when we're up regulated so we can down regulate. We also need to have the ability to do what's called prospective taking which means "can we really look out the eyes of the other? Can we see how they see? See their view?" The next area is the capacity and I mentioned this earlier to distinguish self and other. And the fourth area is the insight about the impermanent that no matter how much pain this person is in, at some point it's going to change or end.

The truth of impermanent prevails and my kind of host, whose house I'm staying at is watching the stock market today. I was preparing for my talk and he said, "oh, I just—you know, it went down, down, down." And then he came back and said, "Oh, it's up, up, up." So I said, the truth of impermanents. Another insight is that no matter how difficult or so-called dispositive an individual is, they wanna be free of suffering and maybe their way of being dispositive is unwholesome but they wanna be free of suffering.

The third access is called the GR access and that is we are grounded. We have to be really embodied in our work. And the second part of that is that the pre—sorry, the premotor cortex in compassion is active so there's a readiness to actually mobilize ourselves to relieve suffering. And then there's sort of sum of the parts is wisdom. And George and I had great discussions about this and that is that at the same time that we're deeply dedicated to ending suffering, by the same token, if there's attachment to outcome, we will experience futility. So we have to hold these two valances simultaneously.

And that's my little lotus. And George and I had so much fun making it. I'm not gonna go through it, but it has to do with co-arising, that all of these features inter are. They're interdependent, they're priming each other, they're regulating each other, and they give rise to compassion and wisdom at the center of the lotus. And I will say that, I just—George it was—one of the most fun exercises I've ever done really, working on this cartoon with you.

So—Okay, I'm gonna do a little bit on neuroscience. So I just wanna acknowledge the role of the Mind and Life Institute in this, Francisco Varela and I conceived this in 1983 I think it was, it came into being through Adam Engle and Francisco's collaboration in 1987. And these were dialogues primarily between neuroscientist and His Holiness the Dalai Lama with regards to neuroscience. And you know, there are—what meditation is about. And the three main meditation practices that have been studied are focused attention where you take your attentional body if you will and you focus it very narrowly on one thing.

Open presence which is receptive, panoramic, nonjudgmental, inclusive, reflective qualities was very wide, attentional-base, and compassion. These are the three main domains of practice that have been studied. And I'm quoting from a work that was done some years ago by Richie Davidson. Actually there's much more. But Richie's work summarizes all the work that's come after. And what he seen—what he saw in these advance Zen practitioners, is that there is—these Zen practitioners by the way had 10,000 or more hours of meditation. So they're the kind of Olympians of meditation practice.

And that when they perceive an experience of suffering, what happens is that their heart rate increases but at the same time, their—actually they have enhanced brain activity. And there's also activation of the insular cortex. And this is an area of the brain that is associated with love and disgust and empathy and feelings of relationality. But interestingly enough, and this is Tania Singers work, it's also associated with our capacity to process uncertainty. That's really critical. I mean if there's anything that needs to be addressed in medicine, it has to do with the truth of impermanents, or the fact that although it's very prescriptive, prescribed, evidence-based discipline, the truth is that there is a tremendous amount of uncertainty. Another area of the brain that is activated is the temporal parietal junction.

And that is a key area for making the distinction between self and other and in perceiving mental and emotional—mental and emotional states of others. George and I were talking about this. The prefrontal cortex is active but particularly the left prefrontal cortex, which is associated with positive emotions. And then there's the activation of the premotor cortex which is very distinct. In other words, the feeling of someone in compassion is that they're at the ready, and also, the somatosensory cortex which is associated with interoceptivity. Now this slide is too many words on it, it's because gamma is not well understood.

But in any case, there was a high prevalence of gamma on the advance practitioners during the experience of meditation. And gamma has been loosely associated with the following things and its an area that is in, really in development, you know, with all over the web of science found a number of articles but still it is a kind of frontier area but it's an area associated to conscious perception, with focused attention and working memory with meditation and with experiences of insight. Also this rolling gamma way that 40 hertz per second is very interesting because what we see is that creates a kind of medium for neural synchrony, links up all of this—the different areas of the brain.

And I just want to briefly talk and I hope George will touch into this. Charles for his own work on immune response, again, he worked with a pretty big population just understand that all of these research, it's basic, not clinical. We're in the sort of beginning phases of research so you cannot draw conclusions for example and [inaudible] Cliff Saron, whose paper was included in this but we had to drop because of time but the production of telomerase, other research on immune enhancement or—and so forth. But Chuck's [phonetic] studies are quite interesting because he did with a fairly large population, 61 undergraduates with 6-week meditation training. So these are meditation [inaudible] people, which is really great. Six-week training and the control group are basically, you know, doing a kind of health education course and what Chuck [inaudible] discovered is that there's a reduction of inflammatory and negative mood of response.

So these are the four areas that I want to just summarize which you've seen already in the sort of a Venn diagram, attentional balance, emotional balance, cognitive control, and immune function. And this has—thanks to the library, I had a sort of sketch of this, six months ago, but it is definitely built up in details in the past two months. Another really important feature that we have to know is many of us feel like, "Oh, gosh I'm ADD or I'm depressive, I can't learn." But what the neuroscientists have found out is that actually, our brains are very plastic. We can train ourselves.

We call this mental training and in fact most of us who work in this field as [inaudible] teachers, I don't use usually the word meditation when I'm training clinicians. I use the word clinical word more likely, reflective practice. And I'm just gonna mentioned briefly, these are the six interventions, contemplative interventions that we actually train clinicians in, focused attention, cultivate in the investigative faculty, presence in pain and suffering, the cultivation of prosocial mental qualities, the subjective familiarization with the psychophysical aspects of sickness, dying and death and our open presence. And by the way, we could do days just on that.

So the question is, are there different types of compassion? And yes, there are.

There are two major types. One is called referential or biased compassion, that is—there is compassion with an actual object. There's a person before you or a person in your imagination. And the first subcategories that there's a compassion, experience that is really based on biology. It's biologically-based. And that is, for example, the experience of instinctual compassion that a mother and infant, or a father and infant field, or unripened compassion which for example would be compassion that somewhat compromised but there's a feasible bond say, an unwanted child or even sexual bond with a partner where, you know, the caregivers angry at the partner but sill there's resonance.

Attached compassion comes about through the in group, the family, or sexual bond and there's a lot of research being done regarding altruism and compassion right now in the relation to in group. The next area is compassion through identification. And that is if you suffered like this person has, you will tend to feel compassion more. But it also can mean that you can be over aroused if you have it actually regulated your response.

The next big domain is called "reasoned compassion." And this is compassion that is ethically-based. One realizes that compassion is a moral imperative or conceptually-based compassion, understanding that all beings want to be happy and that we're interdependent. But the richest compassion and the most liberated if you will is known as non-referential, unbiased, or universal compassion.

And that is compassion that is without an object but where the experience, there's always at the ready to meet whatever suffering arises. I can't believe we're almost done. So I just wanna finish with this quote from their Dalai Lama which is very meaningful to me and I actually be with him tomorrow morning in another venue, up in [inaudible]. But love and compassion are not luxuries. They are necessities in order for human beings to survive. And I think that is the case. So thank you very, very much.

[ Applause ]

Dr. George Chrousos: This was a very extensive beautiful presentation and it's a very hard act to follow. But I will try to follow by referring to what Joan has already said. Okay, before I say anything else, I'm also grateful for being here to the librarian, to Mrs. Kluge for giving me the opportunity to live this amazing period of intellectual activity in contemplation and learning and enrichment. What is stress?
The etymology is very old and old in the European root and you will find today in Greek strado which means, you know, struggle; and in Latin [inaudible] which means to press tight or—so in other words, this root, STR means something harsh, something bad is happening to somebody.

Now, in my reading, things started quite early with Pythagoras when he saw the harmony of the world. He saw the balance, the harmony of the cosmos. And what he said was that everything in the world is in a marvelous equilibrium or harmony or balance. And this balance is constantly disturb by disturbing forces and is brought back by counteracting, reestablishing forces. So despite everything that's happening, it stay somewhere in the middle and survives. The disturbing forces, it can cause thresholds which can be physical or emotion. And the counteracting, reestablishing forces, you can call the adaptive response. So whether there is something bad has happened, our body has an adaptive response that starts and brings balance back.

Now, homeostasis is a new term. It was coined by Walter Cannon in the late 19th Century and it means state to state, it's another Greek term. Now, this term existed earlier in antiquity where Alcmaeon, who was a student of Pythagoras actually from Croton in Southern Italy, called this balance isonomia which means the same thing but the term didn't catch and it had to be reinvented. So in a few words stress is the state of hurting or perceived threat in homeostasis. In other words, if we feel that we're not in homeostasis, we're not in homeostasis. And here is a list of, you know, how this cause have developed from the harmony of Pythagoras, to isonomia of Alcmaeon, to Empedocles who talked about matter consist of essential elements and qualities and opposition or alliance to one another. Hippocrates who calls harmonious balance of the elements and qualities of life as health and this harmony is disease and that's exactly what it is. And then Epicurus who suggested that ataraxia, which means imperturbability of mind, and aponia means lack of pain, absence of pain as the superior pleasures of human beings.

He also spoke about eustathia or eustacia which means good balance. Claude Bernard [inaudible] described the milieu interieur which is kept in a relevant homeostasis inside our bodies. Walter Cannon who also described the "fight or flight" response as you heard. Later on, the freeze response was added. And in fact, when we faint that's what happens. Faint and is a freeze response. It's also called "play dead" because it can be adaptive. And finally, Hans Seyle talked about the distress versus new stress, another bad stress which is good stress and you're talking about diseases or adaption. And actually today, we believe that more than 50 percent of human pathology, the so-called chronic noncommunicative disorders which plagued humanity are stress related. Now in our body, we have several homeostatic systems that maintain this balance.

And of course for us humans, the most important is that prefrontal and frontal lobe, that's lobus, [inaudible]. But then we have also the amygdala which the fear and anger center. We have the mesocortical limbic system, MCLS, which is the reward and punishment center. And then the stress system, we have a specific system in our brain and body that's activated whenever we're stress and helps us come back to normal. [Inaudible] the cardiorespiratory, the metabolic immune, fatigue and pain, wake from a sleep, the clock system that gives us the circadian rhythm. So in other words, all of these complex systems work in alliance or opposition to each other to produce this amazing balance that we have called "homeostasis." Now, this is another curve that works for most homeostatic systems. In other words things that are good somewhere in the middle.

If you arouse well, you feel well, you do well, you perform well. If you're hyperaroused, that's not good. If you're hypoaroused, that's not good. So this is the so-called "Inverse U-shaped curve." And all of the systems are trying to keep us somewhere in the middle. So not too much, not too little. Then this is a famous law of physics called "Hooke's law" and it's very simple. So don't look at the curve. Just think of a metal rod that you press in the middle and advanced, the more you press the more advanced. So what Hooke said in the middle of the 16th Century, was that up to certain point, the relations between the amount of weight you put and the bending gives you a straight line and that straight line that you see there. It's called eustress or homeostasis because that all goes back where it was before.

So that's what we want. Whenever we're stressed, we wanna go back to where we're before. Now there is a tipping point beyond which in physics called the "yield point" beyond which the rod changes and it doesn't come back to where it was before, to the normal state. And of course there is a fraction point, beyond which the rod breaks and that's death. Now interestingly, there is curve in living beings, in life can change. You can change it and move it to the left and upward or to the right and downward. And to right is a resilience, improved resilience. To the left, you make more frailty, you become more frail. So that's the beauty of human beings that can change themselves to become more resilient or allow themselves to become more frail. I guess all of us want to be more resilient. It can be done.

Now let's say we have a major stress wherein a baseline, healthy homeostasis which is defined by our genetics and by our constitution that is genetic et cetera, and something bad is happening to us. That means we go down into distress. But then the stress system, all of the system that I mentioned will bring us right back. Well we have three possibilities. One is to come back exactly to where we were before, so that's baseline homeostasis, eustasis. We can never come back and that's a problem with many of the stressful situations like you have when—with [inaudible] compassion, where compassion is not the way it should be. Then you have deteriorated homeostasis which one could call cacostasis [phonetic], which is bad homeostasis. And what is this? Well it can be depression or depressive feelings, it can be burnout, and it can be PTSD, posttraumatic stress disorder. In these states we have changes that are hard to overcome and to come back to where you were before.

On the other hand, there's another state, another possibility that we become stronger, more resilient after the stress. So in other words, you—it's the stressor was a practice for your body and brain to make you better. So these are three possibilities that can happen. Now in situations such as that require compassion, you have at least two people that are very stress. One is the patient, he went through a major stressor, let's say, diagnosed of cancer, chemotherapy, and so forth, that person may never come back to where he was before. So he goes into cacostasis and the better he can tolerate it, the better it is.

And that's what you're trying to do as a caretaker. On the other hand, the person who provides the care can go in three directions again. He can make, remain the same through this. Be affected negatively in going to cacostasis or be affected positively and actually did better than what you would have been in the absence of caring for the individual. So here's a long list of human stressors and go to the yellow one that says care taking and empathy, care taking is one of the most stressful things that you can do. In other words, we're seeing pediatrics patients of—parents of children with autism. This people [inaudible] for a few years, they age very rapidly. Why? Because stress damages them, they are in permanent cacostasis and they need help and can be help. That's true of embody who takes care of sick people. And then empathy as mentioned before, if you're not able to separate it from yourself, empathy is not compassion and affects you.

Why? Because human beings are societies. We're not one person. We're many people that communicate with each other. Now we talk about resonance and we have mirror neurons in our brain and what's defective in children with autism actually is those mirror neurons. They can't communicate because they don't have those neurons. And to some extent this is true for people with psychopathy. That's why psychopathy is emotional defect. So this interaction between human beings has been called resonants. But it should be called consonance actually because resonants means, again; "re" means again; "con" means together. And now we're talking about cognitive and emotional epidemiology. Let's say what happens last year with the vaccines, right? The entire world, the humanity was talking about vaccines and was affected.

Some people were for, against them, and so forth. That's emotional epidemiology. Now the stress systems in our brain are really a few nuclei, a few areas in the brain. One of them was in hypothalamus, it's called the [inaudible] center and the other is in the brainstem in the back and that's the center for arousal and the center for the autonomic or sympathetic nervous system. And these two systems, for a long time were studied separately. People studying in one, we're not talking to the people studying the other. And then we found out about 25 or 30 years ago that the two actually communicate, they are constant communication with each other. So they go together. And sorry for this slide, but I'll just summarize in a few words. Whenever the stress system is activated, it activated some other centers in the brain.

So you're stress but the same time you activate the reward system because if you're not rewarded, you will not do anything, you abandon the situation. You won't do anything. But because you activate the reward system, you're optimistic that you're gonna deal with the stress, so that—that's one thing that happens. The second thing that happens is you activate the amygdala which means you activate fear and you activate anger. So it depends whether you're gonna flight or fight or in some most situations, the best thing to do is just freeze and fall down and hope that the aggressor does not attack you.

Now, there is another center for the hippocampus which is important in which provides negative inhibitory [inaudible]. So if for some reason your system doesn't work well and you have a hyperactive stress system, which means also a hypoactive hippocampus, doesn't provide control; a hypoactive mesocortical limbic system, a reward system; and a hyperactive amygdala, then you have the typical case of the chronically stress individual.

And if you're chronically stressed, you develop several problems. They can be problems with the central nervous system, so it can get adjustments and maladjustment disorder, anxiety, depression, personality problems, addiction, psychosomatic problems, that's from the brain. On the other hand from the body, you can get, if you're a child, growth retardation, don't grow very well. If you're an adult you get the so-called metabolic syndrome, which kills most of the adults, which leads to cardiovascular disease and also you get osteoporosis. Why do all these things happen? Because the homeostatic mediators that are there to help us, because they are secreted for a long periods of time and not properly controlled, they have a negative effect. Now remember, when you feel well, that means your mesocortical limbic system toned, the reward system is tone, the [inaudible], the stress system tone is down. It makes a lot of sense.

If you feel well, stress is down. If you don't feel well, stress is up. And that's what this like source. So we have to try always to feel well, mostly thinking in all of these is important. It works. Now, what are those peripheral mediators that create all these problems, the ones that help us? So it's CRH, the corticotropin-releasing hormone in the brain, catecholamines in the brain, cortisol in the periphery—catecholamine is in the periphery. Another hormone called [inaudible] which is immune hormone, that's also activated by stress and inflammation is affected. When we're stress chronically, our inflammatory sponsor is down. Our immune system is down.

It's easier for us to get infected. Also, don't look at this, just for me to remember. If you're stress, the reproductive system is inhibited. And we know why, that the hormones of the stress system normally inhibit the reproductive hormones. If you're stressed, the growth hormones are inhibited. So you don't grow, why? Because you wanna conserve energy, the same thing with thyroid, the thyroid system is suppressed. Again, you conserve energy. In the immune system, that's also suppressed. That mean to say, you see a positive red line there from estradiol to CRH. Yeah. Women have a more powerful stress system and immune system. They're better than man on that. But because of that advantage, those who have disadvantage, they get more stress related psychiatric disorders and more with the immune disorders. That's because their systems work so much better.

And here is a mechanism where you can start from the brain depending on a genetic variation, developmental history, how—as a child, if you're exposed to stress [inaudible] et cetera, the current—concurrent stress, the nutrition we're getting, the age you are, you can influence your stress hormones and if your stress hormones are elevated for a prolonged periods of time which has happens in chronic stress, then you start collecting visceral fact. You collect fact inside the abdomen. You lose muscle. You lose bone, that's osteoporosis. And the end result is endothelial inflammation, endothelial dysfunction, that's the blood vessels inflamed, atherosclerosis and cardiovascular disease.

All of this, what you see in the slide, for example, sickness syndrome, cholecystic ovary syndrome, cardiovascular disease, osteoporosis, sleep apnea, these are all stress related disorders. And, you know, they're extremely common. There is an area, the beautiful book by Steven Hall called "Wisdom: From Philosophy to Neuroscience," just published. And he—at the end he gives his conclusion that the ingredients of wisdom are fearless aggregation of knowledge, emotional regulation, dealing with uncertainty, moral judgment, sense of fairness, other centeredness, you have altruism, and principle compassion. That's how he mentioned this.

Now as a person who was born in Greece and raised in the Greek language, that's the way I understand it. From the same root, you have empathy, so feeling inside. Sympathy, "sym" together, with; and "apa," not feeling. And alexithymia actually is apathy. Now in Latin it's compassion. Basically it means sympathy, it's exactly the same word as sympathy—compassion. However, it has changed and now compassion is actually principle empathy. Now, what are the ingredients of wisdom after reading that book and after talking many hours with Joan and thinking, you have to have proper cognitive function which is called agnosia.

You have to have proper emotional regulation which is [inaudible], where there's a thing include, it includes interoception, dealing with uncertainty, patience, ability for delayed gratification, emotional consonance and empathy, and moral reasoning. These are all part of that. Then you have to have proper behavior, eupraxia, you're doing the correct deeds, which means you have to have courage, humility, compassion, and altruism, or other centeredness. And these have to be principle.

So in my opinion, compassion is really part of wisdom and it's very hard to ask from a child to be compassionate if—that child is not born to compassionate because some people are genetically born to be wise. Most of us are not. We have struggle for it and learn and it takes a long time and now we knew that the older you get, the wiser you get which—maybe.

[Laughter]

Just the experience is enough. Just understanding, you know, and feeling is enough. And I was looking for this term that Joan was looking for, how can we call this emotional training? We train our brain to sustain resilience, right? Emotional resilience and regulation. Well, the human mind has fall in great nous, N-O-U-S. So you have eugnosia which means knowledge, proper thinking and moral judgment, you have euthymia, you have eupraxia, and they're all related to each other as you can see. So how can you call the emotional training and [inaudible]? I would call it neuropedia.

[ Inaudible Remark ]

[Inaudible], it's neuropedia. Great. And — Wonderful. This is an exchange of email we had with Joan, can you see that Joan?

I'm sorry. Sorry, I ended up with two words, neuropedia and neuromorphosis, which means the same thing, basically. But I prefer neuropedia. Now, Aristotle in his eulogy to Plato, 4th Century BC, he said—for Plato. He said, he [inaudible] with his deeds and the method of his logic that for somebody to be happy, one has to be good. And basically, what does he mean by that. If you're wise and you wanna feel well, you do good deeds because it's in our [inaudible], bilateral, bidirectional interaction. We do good deeds, you feel well. You feel well, you have an expensive mood, you do good things, more [inaudible].

And let me go now to John Mill a 19th century English Philosopher who said this and I think its very important, "Those only are happy, who have their minds fixed on some object other than their own happiness; on the happiness of others, on the improvement of mankind, even on some art or pursuit, followed not as a means, but as itself and ideal end. Aiming thus at something else, they find happiness by the way." And I think John purposely mean, that's the way we operate. That's how we feel happy. Now Friedrich Wilhelm Nietzsche in the 19th Century had said, "Philosophy has not advanced one step after Epicurus and frequently is 1,000 steps behind.

Epicure as I said before suggested that the purpose of philosophy was to help attain the happy, tranquil life characterize by ataraxia, peace and freedom from fear; and aponia, the absence of pain, and by living a self-sufficient life surrounded by friends. But from other [inaudible], before that's not enough. Epicurus himself—Epicurus was happy because he was trying to transmit this idea to the world and he did. There was—in antiquity, there were hundreds of thousands of Epicureans that then were totally eliminated by the brothers of Christianity.

Now the [inaudible] in which we face the pursuit of dying is without doubt the most not worthy action of human life. That's Michel de Montaigne, 1533 to 1592. And I thought I would mention that for Joan. And I will finish with a letter written by Epicurus to his friend, Idomeneus on the day that he died. It says, "I have written this letter to you on a happy day to me, which is also the last day of my life."

"For I have been attacked by a painful inability to urinate, [inaudible], and also dysentery, so violent that nothing can be added to the violence of my sufferings. But the cheerfulness of my mind, which comes from the recollection of all my philosophical contemplation, counterbalances all these afflictions. And I beg you to take care of the children of Metrodorus, in a manner worthy of the devotion shown by the young man to me, and to philosophy." [Inaudible] and amending, the qualities which the Greek stages being present in every wise man were logistical, that's not eugnosia, thumetikon [phonetic], euthymia, Epithumetikon [phonetic], stress control, behavior control, and diaraticon [phonetic] vision. In corresponding in Latin, not exactly actually to the four cardinal virtues of prudence, fortitude, [inaudible]. Thank you very much.

[ Applause ]

So Caroline, Dr. Brown said we have time for questions.

[ Noise ]

Any questions? Yes, Tim.

[ Inaudible Remarks ]

[ Noise ]

Several of the examples you—noted about the test on the skilled meditators of [inaudible] more hours but you've also have one referring to where even though the [inaudible] meditation could have notable effect, so these some [inaudible] way, some advice for those of us who are modest in those skills, [inaudible]?

Yes Tim. It is the basic research on primarily to Zen practitioners were kind of Olympians if you will of meditation practice has allowed for Richie Davidson and other neuroscientist to map out the areas of the brain that light up in various meditation states. So that was—that's very important work for mapping. But now many research projects are happening with the individuals who are meditation naive but put—are put through a training program.

And Davidson even has a training program of compassion that's on the internet that is showing results. So there is definitely a dose effect. You get higher effects, the more you practice. But you get significant effects with actually very, you know, small interventions if I can use that kind of language. So I think one of the most important people in this field really has been Jon Kabat-Zinn. He developed a protocol called the "Mindfulness-Based Stress Reduction" and that has now been probably the most research meditation protocol in the world. Researcher is happening all over the world on it.

Two years ago I just—you know, I did a scan on—or last year, on how many research projects were funded by the National Institute of Health that—were mindfulness related. There were almost 130 of those so—that year. So this is—I mean what's important is and I think what George is pointing to which is really critical, most of us just feel a little futile. We're born this way. We're messed up. There's kind of no hope. But what is the neuroscientist have learned and also people like Rusty Gage at Salk Institute with regards to the production of new neurons, you know, through the hippocampus when you're in unstressed situation and get adequate exercise throughout your life span is this principle that you just call neuroplasticity, that you can train yourself and increase the areas of the brain that are associate with these prosocial emotions through practice. So go for it.

[Laughter]

It was on CNN today. I have to tell you, I saw Chuck [inaudible], you know, a little video on CNN, anybody else see that? Anyway, talking about lawyers, you know, training lawyers in meditation to reduce their stress, yeah. Thank you, Tim.

You were mentioning the 10,000 figure and I think the [inaudible] variants here on the other night I think we had [inaudible] reading with Mr. Merwin [phonetic] in the same number of 10,000 came up for the required number of hours to become an accomplished writer [inaudible]. I wonder if there's something magical about that formula. But my second question, my serious one is, you know, technology and pre-technology, a lot of the traditions you're talking about are what we consider pre-scientific in the western sense and yet we're engage in perhaps validating some of that. What do you think is the colonel of the positive addition your research is making to ancient wisdom?

You know, I've been in this field for 40 years, over 40 years endeavoring to try, you know, [inaudible] been a learning curve since 1970. And medicine is evidence-based. And clinicians are in general extraordinarily involved, engaged and dedicate people. They don't wanna mess around floppy stuff. You know, they want something that you know where they know that they're gonna be possible effects. Now 2,500 years, you know, contempt—using the mind as a laboratory would seemed like you know, a convincing history. But it isn't for people in the western world. People in the western world, you know, it's kind of the Kansas thing. You've got to kind of prove it to [inaudible] at Kansas, whatever it is, show me. Missouri.

Missouri, thank you.

[Laughter]

Who is from Kansas? Oh, yeah. So it's the Missouri thing, show me. They wanna know it works and it also it has to do with the allocation of time. Many people in today will feel that they don't have time. They're, you know, dopamine addicted. George and I have talked about this. Can you be addicted to your own endogenous chemicals? Yes you can. So you know, you're hanging on your iPhone, your Blackberry, your iPad, your computer, your PC or, you know, Mac, you're surrounded by technology that's constantly grabbing your attention and you're producing this chemical which is basically, you know, related to the reward system. And this is, you know, when Tania and I were at [inaudible] in—you know, I was—all the religiously [inaudible] briefly, it was really fascinating. She looked around and she said everybody here is addicted to dopamine. I came back, you know, up here and I talk to George, it's—you know, in that seeking reward addiction. So, you know, we have to learn how to downregulate. We have to really take care of ourselves. If we stay upregulated, we're gonna go right to what George is talking about, pass the tipping point in the fracture point. Yes.

I was wondering if you can comment on the power [inaudible] beauty on compassion and maybe stress reduction. And not just, you know, somebody helping other percuss the environment or the beauty of architecture or art perhaps can have in helping us to deal with difficultly.

The answer is yes. Anything that makes us feel well—there have been studies now where they use aroma therapy and they measure cortisol. And cortisol which is an index of stress system activity goes down. So things like massage and things like that, they do work. Of course they're limited, you know, for the time that they are exposed to them. But they do work.

[ Inaudible Remarks ]

[ Laughter ]

It will work though, right? But you have to continue, in other words—

[ Inaudible Remark ]

Yeah. Alright, unlimited.

[ Laughter ]

[ Inaudible Remarks ]

Our friend was asking about the freezing process. No, it's not on—

[ Simultaneous Talking ]

I can take this if you want.

Something that was intriguing me very much is the freezing process and people are going to overdrive stress related and very familiar with animals going into this, but they defreeze. What would that look like in the human? When is the defreezing start or the unfreezing? When do I come back to normal after—

Oh, they come to normal soon. It's a normal response that apparently has been of some benefit to us. That's why we have retrained it.

[ Inaudible Remark ]

Right. So basically what happens is—normally when you're stressed, the symbiotic system is activated and the parasympathetic system withdraws. In the freezing reactions the parasympathetic is excessive and blocks everything. So your blood pressure drops and you fall down. That's fainting and that's the mechanism of fainting. In many animals, it's a key stress response because for example a lion won't eat a dead animal.

So one of the mechanisms of animals to be safe from lions is to just lie down and pretend they're dead. That's [inaudible] call freeze responsible or play dead response.

[ Inaudible Remark ]

Yeah.

I want to thank you. I want to thank you for your talk today because you've explained something. You've synthesize something for me in my experience of bereavement and I want to synthesize something to combine what you just said. I found out that at the moment I lost my mother, she died in my arms, and I couldn't understand what I was missing since it was a very happy death, it was very peaceful, she was fine, she wasn't suffering, and I had let her go, but I couldn't understand what I was missing. Was I missing here? I saw her as an autonomous being on her own self somewhere in the universe and I was satisfied and still I was missing her.

I finally understood it. I missed the authentic self that I was when I was with her. The empathy and the compassion were so real, I was so aware of it. I even said to my friends, I know I love this person because I can wipe her butt and I don't mind doing it. And that's what I had prayed for. I cannot take care of this person unless I love and that's what I missed. I miss my authentic self and I'm still looking for it now and I hope I'm given another chance to empathize and to be compassionate. Thank you.

Thank you so much. There are question over there. Hi [inaudible].

I was wondering with the access of technology today and this addiction to dopamine. What that possible impact is and what the future looks like on humanity or the modern society?

[Inaudible] is a friend of mine and has a long life ahead of her, George what do you think?

Yes, it is problem for many people and it's in a small percent of this pathologic. There are children, adolescents that stay at home all the time. They'd even forget to eat. That's very pathologic. The answer is moderation. You know, we live it. We cannot live now without these technological advances but we have to exert some moderation.

What George also said earlier in the talk was that we need dopamine otherwise we're just never gonna get up and do anything. So but then there's a point where it becomes excessive.

It's the curve that I showed you. You fall on one curve, that's not right. You have to come back to what's appropriate, proper range.

Well thank you for [inaudible]. We have to finish our talk. I just want to again thank the librarian for the extraordinary opportunity to have two months in which to think and also to study and to have resources at the library accessible to me in the way they have been. And Caroline, it is just been wonderful to have the opportunity to be with you and also to meet people like George, so I could be really be enriched and Tuzy, thank you. And I wanna thank my host here in Washington. He was gonna sell his house but he didn't and I had a wonderful place to live for the past two months so thank you so much for restraining yourself. And we're gonna have a short reception, is that right? So I can say hi to quite a few good friends and I have to disappear.

So thank on the speakers too.

[ Applause ]

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is the Founding Abbot of Upaya Zen Center in Santa Fe, New Mexico, and director of the Project on Being with Dying.