Feb 22, 2021
I’ve been with many patients as they die; here’s why non-verbal communication is so important
We are living in shocking times. The COVID-19 pandemic has taken a horrific toll on human life. Millions of health-care providers are needed every single day, to be present with someone who is suddenly dying. These unselfish souls, around the globe, are pushing past exhaustion, straining to be truly present with someone who has lost their strength and maybe even their desire to communicate. They are beyond brave, and their job is terrifying — numbingly so.
How do you prepare for this heart-wrenching job?
Maybe you’ve already been there, where the patient’s fear is palpable. I felt that fear when I was working as a massage therapist with war veterans, trying to ease their pain, both physical and psychological, as they approached death.
When I started, I lacked confidence to offer the kind of compassionate connection I felt they needed. Then I came across the work of Dr. Daniel N. Stern, who was a prominent American psychiatrist. Stern’s research into the earliest forms of communication between a mother and her infant suggested to me a reservoir of tools that could help.
Now, during this unprecedented time of suffering, I want to share what I’ve learned about being with those facing death.
Humans are the most dependent creatures on earth
For the first several years of life, humans need constant supervision, care, and nurturing. In Stern’s most notable book, The Interpersonal World of the Infant (1985), he explains that we are born into a lush matrix where life is experienced as intensities, shapes, patterns of time, and what he calls vitality affects, or our “sense of aliveness.” As unencumbered infants, without verbal skills or the need for words or other symbols, we live, as Stern writes, only in the moment.
What we need most is to connect
Our lives depend on it. Our earliest caregivers show us how our minds connect to others in direct ways. Before we put our lives into words, we experience everything with our bodies through our senses.
During my 15 years working with veterans, I noticed that their ability and motivation to communicate verbally faded as their health declined, particularly in the last few months of palliative care. As their world shrunk to the size of a room with a bed, they seemed to experience life in a similar way to an infant, where the immediate moment was all that mattered.
As the veterans and I approached their death together, we abandoned words; they left as they had arrived, unconcerned with symbol or meaning. I believe that, at the end of life, our final task may be very similar to the infant’s — to connect as fully as possible in Stern’s same rich matrix of the present moment.
How do you be what you’re needed to be?
Many of what Stern calls “ways-of-being-with” infants can help us find comfortable “ways-of-being-with” people as they face their death. Remembering the non-verbal relating of our earliest care can guide us.
With less concern for the past or the future, a dying person may simply want to be seen — to stay connected.
Stern describes our “sense of aliveness” as being felt in surges, rushes, fadings, or burstings that rise and fall. Unlike Darwinian emotions such as anger, sadness, or happiness, which fluctuate with our moods, our “sense of aliveness” is always with us, whether we are experiencing an emotion or not.
As we grow, we develop more communication skills that help us relate our complicated bodily experiences to others symbolically. Gradually language, our main use of symbols, becomes our dominant mode of communicating. But we never lose our earliest way of knowing and connecting.
In The Present Moment (2004), Stern talks about the reasons we connect: to orient ourselves in relation to others; to share experiences; and to define and redefine ourselves. These reasons to connect still apply at the end of life. With less concern for the past or the future, a dying person may simply want to be seen — to stay connected — or redefine themselves through the eyes and touch of another.
Speak with your eyes
Gazing is the first type of social interaction in which we are able to exercise free will. Even as infants, we have the choice to either look or look away. Gifted with normal sight we can stare intently at someone, gaze lazily at them, look away, or simply close our eyes, blocking them out completely.
We choose to connect or reject through our eyes. We know that infants use staring to connect, and we excuse their boldness. As adults, we don’t need to use gaze in that way; in fact, unless we are loving intimates, we consider staring to be rude. As Stern puts it, “Nonlovers (in this culture) ... cannot tolerate the mounting intensity of a silent mutual gaze for more than 7 to 9 seconds without fighting, making love, or turning away” (2004, p. 109).
Gaze is also the final frontier of self-motivated activity. Our first mode of engaging may also be our last — all we’re capable of doing. The stare of a dying person is intimidating, like the brazen stare of a baby.
Even though it can be extremely uncomfortable, keep in mind that the dying have as many choices to not connect with their eyes as infants do. Their stare could be a way of hanging on, or of easing pain. Understanding this may make it easier to tolerate the intensity of this deep gaze — if you choose to meet it.
Tune in to what you already know
Our ability to support someone on a non-verbal level depends partly on our ability to resonate with what they are experiencing and feeling. Neurological studies confirm that we already have what we need to do this.
When we watch someone do something, we map an equivalent representation of the action onto our brain. We get a sense of participating, as if we were actually doing the activity ourselves. Amazingly, we can share in similar feelings, and even muscle sensations, simply by watching.
Without speaking, you can share emotional states through a gaze, a touch, a moan, or a breath.
We are also able to resonate rhythmically with others, allowing us to anticipate their actions and giving us the ability to move in sync with them. This tuning-in contributes to our ability to be empathic and is at the root of human connection.
A hand hug, even through a glove, is worth a thousand words
In The Interpersonal World of the Infant (1985), Stern cites research that clearly supports our ability to provide touch to a dying person that will closely match their emotional experience. Without speaking, you can share emotional states through a gaze, a touch, a moan, or a breath.
You can already do this without thought. With thought and conscious intention, your effectiveness in providing comfort, connection, and a gentler easing out of life can be even greater.
Self-care — putting on the brakes
Being the accomplished “resonators” that we are, we need a mechanism that allows us to stop, so that we are not overwhelmed. Luckily, we have “brakes” to help us select what to let in and what to keep out, to stop our muscles from being activated, and to temper our resonance. Just knowing you have brakes can help you manage your fears.
Several years ago I had the privilege of working with a lovely man I had known for many years. I visited him one evening when he was very near death. I entered his hospital room and found him lying in bed wearing an oxygen mask, fighting desperately for each breath.
I felt his panic through our eyes. I took his shaking hand gently in mine. Sitting very close to his face and holding his gaze, I whispered to him that he didn’t need to try so hard. After breathing together for a few minutes, his fear began to subside. I placed one hand over his heart and the other on his forehead.
We continued to stare at each other as I slowly began singing his favourite Shirley Temple song: “On the gooood ship Lollipop, it’s a sweeeet trip to the candy shop...” I gently stroked his forehead to the same tempo. Soon his breathing calmed — met my pace — and the desperation faded from his eyes. He reached up and removed his oxygen mask. In that moment, connected to me, he seemed both fully alive and ready to let go.
If you trust what you know, and trust that your boundaries and brakes are strong enough, you may find it easier to provide final connections. If you believe that in the end, connection is everything, then you are already equipped to help others make their connections out of life as meaningful as those they formed when they came in.
Stern, Daniel N. (1985). The interpersonal world of the infant: A view from psychoanalysis and development. New York: Basic Books.
Stern, Daniel N. (2004). The present moment in psychotherapy and everyday life. New York: W.W. Norton.