Written by Barbara Elliott, republished w/ permission from the Greenbrier Valley Quarterly

3 happy pilgrimsImagine getting a call out of the blue offering you an opportunity to undertake the number one adventure on your bucket list. Would you hesitate?

Lewisburg psychotherapist Hanno Kirk and his wife, Jo Weisbrod, a mental health counselor, certainly did not. They were stunned in the summer of 2015 when a professional colleague of Hanno’s called with just such an offer: Did they want to travel to Dharamsala, India, home of the Dalai Lama and headquarters of the Central Tibetan Administration (the Tibetan government in exile), to attend a training session taught by the Dalai Lama?

They did, and the journey proved to be a profoundly spiritual experience for the couple, who have been practicing Buddhist meditation for many years. Even better, thanks to a totally unexpected private meeting with the Dalai Lama, the trip also opened doors to a scientific exchange that has the potential to profoundly affect others as well.

Both Hanno and Jo were attracted to Buddhism early on because it provides a system of thoughts and principles that coexist with other religions. In fact, Hanno jokingly calls himself a BuddheoPresbyterian, because for years he has sung in the choir at the Old Stone Presbyterian Church on Sunday mornings, and he and Jo are part of a small group who gather in Lewisburg for silent Buddhist meditation on Sunday afternoons.

“The Dalai Lama insists that it is not a religion. It is a set of ethical principles, and if you can logically conclude that they work for you, you can follow them,” Hanno explained. He finds it appealing that the Dalai Lama encourages his followers to keep exploring and does not wish to be worshipped, only venerated.

Hanno’s work in the field of neurofeedback was the catalyst that set the two delighted pilgrims on the road to Dharamsala. He has described the therapy as “basically nudging the brain to learn how to self-regulate itself.” He uses the technique, which involves extensive questioning to determine what issues are influencing a client’s behavior to determine what area of the person’s brain is over-aroused, under-aroused or unstable. He then connects electrodes to different areas of the client’s scalp and introduces a variety of stimuli such as music, videos, and even games and uses a computer to essentially “listen to the brain” to get feedback on how the brain is reacting.

Although neurofeedback therapy has not been wholly embraced by Western medicine, Hanno and other practitioners find it very effective in treating a wide range of patients, including veterans suffering from Post-Traumatic Stress Disorder, children and adolescents with Attention Deficit/Hyperactivity Disorder, and people with autism. The therapy has the effect of calming the mind that Hanno finds to be a natural fit with the healing effects of Buddhist meditation. For that reason, he thought the Dalai Lama, known for his keen interest in neuroscience, would enjoy reading a new book that Hanno edited and contributed to called Restoring the Brain: Neurofeedback as an Integrative Approach to Health.

It was through an online community of fellow practitioners that Hanno had come to know Minh Chau Le. Minh, a Vietnamese woman who extended the invitation, gave him the chance to put the book into His Holiness’s hands. She invited Jo and Hanno to join her as part of her delegation to the Southeast Asian Teaching Event in Dharamsala last September.

When Hanno approached Jo with a “very funny look on his face” to tell her of the invitation, Jo was stunned. “My whole world just turned around,” she said.

The training was held in the Dalai Lama’s temple, where around 800 delegates, primarily from Southeast Asia, congregated. They had to arrive at the temple at 6:30 a.m. each day to undergo an extensive security check before they could enter the hall.

“Security was extremely tight, which was alright because of the threats to his life,” Jo said. If you brought a bottle of water, you had to open it and drink from it to make sure it wasn’t something you were going to throw on him.” Hanno added that they even checked his pens to make sure they didn’t contain poison darts.

Fortunately for the Americans, simultaneous translation into English was available through FM receivers during the sessions, although there were few English-speaking attendees. Even so, a few concepts got lost in the translation.

“There was a lot of discussion about egg crates,” Jo laughed. “I was puzzled until the third day when it finally struck me they were saying ‘aggregates.’”

In addition to attending the training, Minh also planned for the couple to visit the Men Tsee Kahang Clinic of Tibetan Medicine, where last year a delegation of Neurofeedback instructors provided training for five doctors and then donated neurofeedback equipment. Their thought was that Tibetan monks who had been traumatized by their treatment at the hands of the Chinese could benefit from the therapy.

“Our expectations were only to attend the retreat and talk to the doctors. That was as far as my hopes went. We had no idea of interacting with His Holiness,” Hanno said.

The first hint that this visit was going to exceed their expectations came when they discovered that Minh had obtained VIP passes so that they could sit on the stage just feet away from the teaching throne where the Dalai Lama sat as he conducted the training.

A bigger surprise came during a break on the first day. Jo had left the stage when Hanno found himself standing only about eight feet away from the Dalai Lama.

“He was on his throne, looking kind of bored. And he looked at me, and I looked at him, and we both smiled and then he waved me over and asked who I was. I told him who I was and that I was there for the teaching. But I also said I had this book on neurofeedback and I knew of his interest in neuroscience, and I wanted to tell him how it could apply to Tibetan medicine. And I explained about the five Tibetan medical doctors who had been trained last year. He was very interested, and I told him I would like a chance to talk to him more about this,” Hanno recalled.

That encounter was already much more that he had dared hope for. Little did he realize that an even more important meeting lay ahead. At 6:30 the following Sunday the couple was aroused by a phone call asking if they could be at the security check by 8 a.m. His Holiness wanted to speak with them privately. The timing was perfect, because in the interval since Hanno’s conversation with him on the previous day, he had discovered another topic to discuss.

During the visit to the Men Tsee Kahang Clinic, Mihn and her colleagues had been distressed to learn that despite the donated equipment and training, the Tibetan doctors had only used neurofeedback to treat a about 20 patients in the year since the Vietnamese delegation’s last visit.

“The doctors explained that they were so busy and overworked that they felt guilty taking 35 to 45 minutes for a neurofeedback session when they could see four or five patients in that time,” Hanno said, adding that their extremely small offices and frequent electrical outages did not lend themselves to conducting the therapy.

To his surprise, the doctors also reported that they saw very few cases of PTSD, and they theorized that because the Tibetan monks embrace the Buddhist belief that suffering is an important aspect of life, and they deal with it very effectively through meditation, they are not as prone to the disorder. The doctors did agree that neurofeedback would be helpful in treating patients with asthma, migraines, autism, traumatic brain injury, and other conditions, but the time and space problems were prohibitive.

The visitors proposed a solution that would bring non-doctors, such as nurses and social workers, to the United States for training in how to conduct the therapy, and to move the neurofeedback sessions to a separate location. Now, all they needed were resources to make that possible. It occurred to them that the Dalai Lama might be able to help.

During their 20-minute private meeting with the Dalai Lama, Hanno, Jo and Minh had an opportunity to make their case. Thankfully, His Holiness spoke English fluently, and his assistants helped out if he had difficulty with a word.

“He could see almost immediately how neurofeedback could be an adjunct to traditional Tibetan medicine,” Hanno said. “I explained that there is a common goal between Buddhism and neurofeedback, and that is to calm and balance the mind. When you have calmed and balanced the mind, then you can focus on other things such as developing compassion, love, and caring for others.”

When Hanno went on to explain that the therapy can be effective within a relatively short period of time—major changes can be seen with some patients after only 20 sessions—His Holiness revealed a delightful sense of humor. He suggested that they might want to share the technique with the United Nations and try it out on Putin, Assad, and that “troublesome little boy from North Korea.” He also asked whether Hanno was saying that neurofeedback could accomplish in a week what it took Tibetan monks 50 years to do. Everyone got a good laugh from that one.

The visitors then explained the situation at the clinic and the need to train new practitioners. “He thought for a nanosecond, and then he said, ‘This is a mission. I want to do this.’ Then he turned to one of his secretaries and said, ‘I can do this, I can do this.’” Jo recalled.

At the conclusion of their session, His Holiness blessed the three guests and gave each one a small golden Buddha, something he rarely does, Hanno was told. He then presented them with white silk ceremonial scarves, or khatas, that he had blessed, and took each person’s hands and put them to his forehead.

“We floated out of there,” Jo said.

The trip was transformational for the couple, who think of themselves as pilgrims because they are not experts but merely seekers on their own path. They are still absorbing the enormity of the experience, the lessons learned, and the potential good that could come of their encounter with His Holiness, now that the clinic doctors know of the Dalai Lama’s interest in supporting their work.

As they were leaving the Dalai Lama’s office after he had offered his blessings, Minh asked Hanno and Jo if they knew what the blessings meant. “He passed the blessing onto you,” she explained. “Now it is up to you to pass it along to others.”

Jo and Hanno will give a presentation on their experience with the Dalai Lama at the Shepherd’s Center in Lewisburg early in Spring 2016.

Interview by David Van Nuys, Ph.D. on End of Life Issues

David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I’m a clinical psychologist and your host.

On today’s show, we’ll be talking with Dr. Hanno Kirk about end-of-life issues. Hanno W. Kirk, LICSW, Ph.D., was born in Germany and immigrated to the United States when he was 13 and grew up in Los Angeles. With a B.A. in international relations and an M.A. in political science and a Ph.D. in pacific studies, he went on to earn a masters in social work from the University of Texas. For the past 33 years he has worked clinically as well as an educator in oncology, home health, and hospice settings.

Dr. Kirk pioneered a federally funded training program on meeting the essential needs of residents of long-term care facilities for nurses and staff. At the University of Texas Health Science Center, he developed the Life Enrichment Program for Older Persons, which he later directed under the Dallas Council of Churches. He taught pastoral care for older persons at the Perkins School of Theology, and care giving and end-of-life issues for the physician assistant program at Mountain State University in West Virginia.

Dr. Kirk is principal author of the 2002 book, Psychosocial and Behavioral Aspects of Medicine. Currently, Dr. Kirk is in private practice in Lewisburg, West Virginia. In addition to geriatrics, he specializes in using neurofeedback for children with behavioral or developmental disorders, including autism spectrum disorders. Now, here’s the interview.

Dr. Hanno Kirk, welcome to Wise Counsel.

Hanno Kirk: Thank you.

David: I got your name from Dr. Mark Dombeck, who’s one of the principles at Mentalhelp.net, which hosts this series. And Mark took a workshop with you on end-of-life care decisions and was quite impressed and suggested that you’d make a good guest. So –

Hanno Kirk: Well, thank you.

David: That’s how we got here. So let’s start out with a bit about your background. Now, I see that you got a B.A. in international relations and an M.A. in political science and a Ph.D. in pacific studies. So how did you end up getting a masters in social work and getting into doing therapy?

Hanno Kirk: Well, I spent about seven years in Washington politics, part of it as a army captain introducing computer assisted simulations into the curriculum of the Industrial College of the Armed Forces, which is now the National Defense University, and then being a visiting fellow at the State Department or in the Arms Controls and Disarmament Agency, and then after that working on Capitol Hill for three years, and then working 16 months as a liaison between the Nixon White House and Congress on international economics and trade legislation. So after I got totally disgusted with the pressure and the paranoia in the Nixon White House, I left Washington altogether and did a complete career change.

David: Sounds like it. I mean none of that sounds like it’s leading towards social work.

Hanno Kirk: No. No, not yet. Well, initially, actually, I joined the Arica Institute. I took a three month training in sort of mystical practices and then taught 40-day intensive trainings around the country in eight different cities. And then, after that, basically had to reintegrate into the normal work life, and one of the interests I had was in counseling and in end-of-life care. And a colleague of mine and I developed a program of attending to the essential psychological needs of nursing home residents. We had read an article that only about 30 or 40% of nursing home residents had had a visit within the last year from outside.

David: Wow. Now, it feels like you skipped over a little bit here. I’m still trying to get –

Hanno Kirk: Oh, I haven’t gotten to the social work stuff yet.

David: Oh, you haven’t? Oh, you got interested in end of life before you –

Hanno Kirk: Yeah, right, before I got an interest in it.

David: Okay, okay. Then I shouldn’t interrupt. Go ahead.

Hanno Kirk: And so one of the things that happened then was that we also formed a – developed a life enrichment program for older persons, and that was initially in the Gerontology Services Administration at the Southwest Medical School. And then I moved that into the Dallas Council of Churches, and we had it in churches. And that was sort of a program for vulnerable, elderly persons to prevent them from going into nursing homes, basically, so they could maintain their own independence.

When that program ended, that’s when I found myself at a hiatus, and I decided that point that I needed to get some additional education, and so that’s when I went for a masters in social work. I was in Texas at the time.

David: Well, what a fascinating background. As I was going through your bio, I saw, in fact, that you had been a psycho-spiritual development trainer for Claudio Naranjo’s Arica Institute that you mentioned.

Hanno Kirk: Right.

David: And back in the ’70s, Claudio Naranjo was sort of the Eckhart Tolle – I’m not sure how you pronounce his name – of that period. And I wondered, well, what’s been the impact of your Arica experience on your life and your work?

Hanno Kirk: Well, I think I learned from that just a great reverence for the sacred, and that’s one of the reasons why I went on to develop this particular seminar, which really has to do, at the end, about creating sacred space at the end of life.

David: So we better have you define what you mean by the sacred.

Hanno Kirk: Well, I think what we are looking at here is more of how people can approach the end of life instead of with fear, somehow with confidence. That it is a passing over, that it is a change from leaving the mortal remains of the body into another dimension. And as Elizabeth Kübler-Ross has termed it, death is the final stage of growth. And if you graduate well, then you arrive on the other side with not being confused and not maybe in pain – not in psychic pain.

David: Have you always held that set of belief and expectation? Or was that the result of a religious upbringing for you, or your experience in the psycho-spiritual training? Where did that confidence come from for you?

Hanno Kirk: It’s funny, I somehow seem to have had that always, but I had a very profound spiritual experience at age seven, where I was lying on my back in a field and sunshine, spring, and a lark was singing above me. And all of a sudden, everything changed as if I were wrapped in the hands of God, and just everything took on this incredible, light kind of a image of just simply being in this wonderful surrounding of being loved and completely taken care of. And so from that, I’ve always had the confidence that there’s something more than just living on this earth, you know?

David: Yes.

Hanno Kirk: And I had a repeat of that experience when I was age 33, and it was similarly profound. I was driving from Washington, D.C., to Atlanta and had stayed up all night packing, and in the middle of the trip – which was about a seven or eight hour trip – I got so tired that I almost fell asleep. And I said, “Oh, God, I need some energy.” And whoosh, it was just like a sudden bang – not a bang – but I was suddenly again enveloped in this divine energy as I call it, and seemed to be floating through this golden haze and totally energized. When I got to Atlanta, my fellow workers got contact highs just touching me for the next two days.

David: Wow. Was that before or after your Arica training and experience?

Hanno Kirk: That was during the Arica experience.

David: During, yeah. Well, how lucky you are to be blessed by these experiences, I think, and it’s interesting the way that they have manifested, then, in your working I guess with the dying, but I don’t know how much work you’ve done with the dying, or if your work has been more with people who are caring for the dying.

Hanno Kirk: I’ve done more work with people who are caring for the dying. I’ve had brief contacts with people like Elizabeth Kübler-Ross and observed her while she was working with someone. And just the very simple questions she asked and how people opened up to her was just an eye opener for me.

David: In what way? I think you’re the only person I’ve ever spoken to who worked directly with her.

Hanno Kirk: Well, I didn’t work directly with her. I was just privileged to sort of attend one of her sessions. This was part of my social work internship. So we went bedside to someone who was dying, and she was basically helping them overcome their fear and just opening them up, and all she said, “So, how is it? Tell me about it.” And I just thought that was such a simple way of getting someone to open up and to talk about the doubts and about their fears and about everything, you know. Because we find so many people are caught up in this fighting, fighting to the end, battling the disease. They don’t allow themselves the time to actually come to terms with what the reality is of what is happening in their body and the fact that the body is shutting down.

David: I understand you recently lost your own mother, and so this all very fresh for you in a personal way, and my wife and I gave hospice care to her mother in our home last year, so it’s also relatively fresh for me.

Hanno Kirk: Yes, I think when it’s your own parent to whom this is happening, it always becomes very quickly very relevant. And you know one of the problems in our American society is that we have what you call medicalized death, which means that 80% of people now die in hospitals, whereas 50 years ago, 80% of people died in their homes, surrounded by their family.

David: And what a difference.

Hanno Kirk: A huge difference. And what it means, to a large extent, is that relatively few people, especially younger people, have any direct experience with dying or with a dying relative or a person, because it’s happening out of sight, behind curtains. It’s sanitized, and it’s not talked about, which has led people to sort of avoid making plans and having advanced directives, or in families even being able to talk about it.

David: Yes, I contrast our experience with a place like, say, India, where I guess it’s not unusual to see dead people in the streets and cremations going on all the time and so on. And here you can lead your whole life without ever encountering hardly any scenes of death at all.

Hanno Kirk: Right. And we even try to shield our children from it. In the workshops that I give, I find that many participants were, as children, were kept away from funerals even, or from going to the hospital to visit their dying grandfather or their dying parent even, because they wanted to shield them. And children do very well when it is explained to them.

I remember when my mother-in-law died. Our son at that time was about two-and-a-half, almost three, and my father-in-law did not want him to come to any of the funeral ceremonies. And so we ignored him and took him anyway, and of course this was very appropriate as far as we were concerned. And when we got to the graveside funeral service, Diamond was sort of walking around in tight circles around my wife and myself, and at one stage he came up to me in this very loud state whisper, asked, “Daddy, has Grandma gone on to get a new body yet?” And that was his understanding as we communicated it to him, that her body had worn out and that she could no longer stay in that body and that she would go on and maybe get a new body. So I think we can explain to children about death according to their developmental level, and it is very important that we not exclude them.

David: Yes. In your workshops, you focus a lot on ethical issues and defining ethical issues: for example, life extension versus quality of life and so on. Maybe you could take us through some of those ethical issues and what considerations are there; because most of us probably are – even if we haven’t defined ourselves as a “caregiver,” most of us at some point, probably more quickly than we think, are going to find ourselves in that position.

Hanno Kirk: Yes, I think one of the problems with the medical system is that it has a bias for automatically prolonging life. There seems to be an assumed duty to prolong life at all cost. And that is part of what we face, and it is made possible by these unprecedented techniques for life extension now. We can replace any organ in the body, I mean from kidneys to lungs to even bowel transplants, liver transplants, pancreas transplants. Thirty, forty years ago, if an older person broke their hips, that was a one way ticket to the nursing home, and nowadays no big deal; we just replace the hip.

And that’s not the issue so much. The issue is when the body is in a what we call a terminal decline situation or terminal drop condition. That’s the condition when, one after another, the organs start to shut down. And at that point, what do you do in terms of prolonging life? Because at that point, prolonging life is oftentimes done at the cost of quality of life. We have the high-tech equipment to do it, but we don’t always – well, rarely are patients made aware of, for example, the post-surgical complications or post-surgery pain. In cancer care, for example, some of the chemotherapy treatments are so aggressive that they attack the system to the point where people are constantly throwing up or have constant diarrhea, may develop blisters on their hands and on their feet, and be in constant pain. Now, the question is, how appropriate is that for a stage four cancer patient?

David: Right, right.

Hanno Kirk: You know most stage four cancer patients die while undergoing treatment. I mean hospice is vastly underutilized in our society, and oncologists are oftentimes the ones who have the hardest time letting go of their patients and sending them on to hospice care.

David: I have to say our own experience with the hospice organization was really quite wonderful. It was so good to have these people come into our home, and our mother-in-law was here, and we were going to take care of her. And at the time, it wasn’t at all clear to me that – you know, I wasn’t sure if she was dying, but they were able to come in and say, yes, the process has begun, and it’s going to take about X number of days, and, darned, if they weren’t right on.

Hanno Kirk: Um-hmm, yeah.

David: So it was just very comforting to kind of know what the road map was and to have the sense that they were there to answer our questions and to come in if there were times when we needed a nurse. So they were very helpful. Where are you on the issue of – speaking of ethical issues – right-to-die sorts of issues?

Hanno Kirk: Yeah, well, the right to die is born out of the desire to be in control at the end of life. I think it’s more of a psychological reassurance to have that available than for people to actually do it. We have found, for example, with the 11 years in which the Oregon law has been on the books, less than 500 people have availed themselves of the option.

Now, one of the things that happens is that people faced with the possibility of going out of control – there are three things people don’t want to do: they don’t want to die alone; they don’t want to die out of control; and they don’t want to die in pain. And of those three, the dying in pain and the dying out of control are the ones that people fear and feel that maybe I won’t be able to bear it, and if it gets that bad, I want to have the option to take action to end it.

David: Right, right. I’d sign up for that.

Hanno Kirk: Right. And actually in fact what happens is that most people, their tolerance for pain or their tolerance for being out of control, as we say – you know, the out of control means losing your dignity, too. It has to do with where you can’t do anything else for yourself any more. That’s really the hard part. And when people get into that position, they often fear that I don’t want to be a burden to anyone else, and I don’t think I can stand having people dig my fecal matter out of my anus, and having to do everything for me including feeding me and so forth and so on.

David: Right.

Hanno Kirk: And what in fact happens is that, usually, the process of losing control is so gradual, that most people actually can cope with it. And that’s why relatively few people actually go through with it. So while a lot more people have actually applied for death with dignity assisted suicide in Oregon, a very small minority have actually availed themselves of it.

David: You know, what you’re saying reminds me of – I was with a colleague of mine, a wise colleague, and we were visiting another one of our colleagues who had Parkinson’s disease and was on the decline and was in a nursing home. And she said something – my colleague who was accompanying me on this journey, and I was feeling apprehensive about our friend who was finding himself in this situation. And what my colleague said to me that I found very comforting, and I wonder if you would agree, it was something to the effect that, as a person declines, their consciousness tends to narrow in such a way that they’re not, say, missing some of things that we think we would be missing if we were in that position. In other words, they’re not missing going on bicycle rides or some of the other things that they’re –

Hanno Kirk: Oh, I think, yeah, I think that’s right. At the same time, they still have the same need for being touched, for being affirmed, and being looked at as persons, because part of the medicalization of death is the dehumanization. A patient is seen as his pathology, as his illness, in the hospital oftentimes.

David: Yes, oh, yeah, definitely.

Hanno Kirk: And that’s why I totally agree with you. Hospice is such a humane and caring alternative. That’s why I bemoan the fact that, on the average, most people only spend 5 to 14 days in hospice. They’re often turned over to hospice when it is a ratification of the realization, oh, okay, this person’s really dying; when finally people have sort of given up on their false hope for a miraculous cure, and the person’s already in that terminal decline stage. That doesn’t give the family or the patient time to do anticipatory grieving.

David: Yes, yes. I just think that’s a really important point.

Hanno Kirk: The sad part, really, is that the medical mindset is, by the third year of medical school, medical students become fascinated with the disease process. Everything is the puzzle of the disease process, solving how to overcome this pathology. And there’s ego involvement in this. And so for many doctors it becomes really difficult to see the patient not for what he or she is, but only in terms of the puzzle of the disease. And of course that ignores the humanity of the patient.

So you have a real difference in goals between the oncologist or the physician who is trying to pull this person through another crisis, and the family who may get caught up in that and stay in that, yes, we got to do another course of chemotherapy, or, yes, we got to do this and that in order to hang on to the hope that this person could recover.

David: Well, they must be struggling with their own sense of guilt, too. I mean they must have very – the family, I would guess would be struggling with the sort of divided feelings: on the one hand, wow, this continuing care is really expensive and can we afford it; and then, oh, but I can’t let that be part of my decision making. It seems like there’d be a lot of complex, conflicting factors.

Hanno Kirk: Oh, yeah. The family issues are huge. When you’re looking at, for example – in the ideal, the family becomes a support and an advocate for the patient with the medical system, who looks out for the patient to make sure they don’t get mis-medicated and so forth. I mean we have over 100,000 people a year in hospitals dying of medical mistakes, you know. That’s huge, and what the family persons can do or the family can do is, on a rotating basis, have someone bedside in the hospital, let’s say – if the person is in the hospital – to make sure that nothing is done wrong.

David: You have to have the right person. I know in my own family experience – you know, I’m kind of meek and mild, but my wife is fierce. My daughter is fierce, and they will speak up and challenge authority, where I might just say, “Oh well, this is the doctor. Doctor knows best.” So you got to pick the right family members to stick up for the patient.

Hanno Kirk: Yeah, that is really the crux right there. Up until very recently – and especially this older generation has the attitude doctor knows best; he’s God and he’s the expert. And so it’s very hard for them to contradict a doctor and to refuse his offer of surgery that he’s holding out as a hope: “Well, we could try another surgery,” and so on. And yet the doctor usually does not inform them, one, what are the odds here of this being really helpful or by how much would it prolong life; but not ever mentioning, even if it prolonged life, by how much reduced quality of life you have to cope with.

That’s the real difficulty because people who undergo surgery at that advanced age, if they’re under anesthesia, that has an effect on the brain that may produce confusion, dementia, for maybe up to six months; by which time, if the body is going down anyway, they may be dead. So they may not have the last six months in which they are able to be in their right mind. That’s where some of the ethical issues come in, you know?

David: Yes.

Hanno Kirk: And the same thing happens with CPR. One of the real difficulties with the use of CPR is the difficulty in predicting death. There was a study done by the Robert Wood Johnson Foundation which found that in the uncertainty of predictions, one week before death most patients were given 50/50 odds of living another two months. And even the day before death, the median patient was given a one in four odds of living two months. So, given that kind of uncertainty, it’s not unreasonable for people to say that the odds are not hopeless and to think that a really vigorous intervention will pull the patient through another crisis. It’s usually only afterwards that it’s seen as a waste. And when you look at the CPR survival rates – these were established by Alvin Moss from the Institute of Medical Bioethics at West Virginia University. He said people over 60, only 14% survive more than 48 hours, and of those, only six months later only 5% of those people are still alive.

David: Now, when you say CPR, you’re talking about I come into a room and there’s Granddad lying on the floor and so I start pounding on his chest and breathing into his lungs. Is that what we’re talking about?

Hanno Kirk: Right. That’s what we’re talking about, or even electrical stimulation.

David: Okay, so you’re talking the coming in with the paddles in the hospital room.

Hanno Kirk: Right. And of course from TV hospital shows, we see that these people immediately come out, they smile and “ah” – they’re glad they’re alive. But CPR is designed for healthy persons with a healthy heart whose heart has accidentally stopped either through electrocution, through drowning, a blow to the chest, or maybe atrial fibrillation. This happened to my younger son; they had to restart his heart. But he had a healthy system to support that heart.

But if the whole system is already in decline, the reason the heart stopped most likely was that it wasn’t getting support from the rest of the system. And at that point, trying to restart a heart is just futile, and yet most people have no knowledge of that.

David: Right. Now, under economic policy issues, one of the things you discuss are the pros and cons of rationing. And I’m not sure what you mean. Rationing what?

Hanno Kirk: Well, it’s sort of the third rail of health care right now. I mean something like 80% of health care goes on the last six months of life – of medical care, of Medicare expenditures goes on the last six months of life. It’s a huge amount, and a lot of that has to do with the fact that people practice defensive medicine because there are no advance directives in place.

In places like for example Gundersen Lutheran Hospital up in La Crosse, Wisconsin, they started an effort to get the whole community to create advance directives. They have in that community a 92% compliance rate with advanced directives, versus about 22% in the rest of the country. What they have found is that their end-of-life costs have gone down dramatically, because most people who are knowledgeable about what to expect at the end of life and create advanced directives don’t want to have themselves artificially prolonged or kept alive. And so then that dramatically reduces the costs of medical care.

And that’s not rationing. That’s just doing some other things. Rationing we already have in terms of what insurances will pay for.

David: Yeah. So there’s a real sort of public policy issue, then, is somehow promoting public awareness and advocacy for advanced directives? Something my wife and I have just done. We recently consulted a lawyer and got our trust set up and all, and that was part of it. And there is a certain – what’s the right word? – satisfaction or comfort, I guess, is knowing that you’ve got that squared away.

Hanno Kirk: Yeah, and part of that is, notice, when did you do it? After someone in your family just died.

David: That’s true, yes.

Hanno Kirk: And sometimes it takes that in the family for the rest of the family to sort of think to come to grips with that, because, as I said, we have this total avoidance of talking about death. Normally what happens when a parent wants to talk with their adult children about making final arrangements as they might call it, or advanced directives, they’re often shut up. They say, “Oh, don’t talk about that. Oh, don’t be morbid. You’ll live – you’re doing fine. What are you doing? Are you planning to die?” You know? And they’re discouraged, so the discussion oftentimes never takes place, which then means that there’s a lot of agonizing if there’s a stroke or if there’s a sudden decline in health, and the children are not informed what the wishes of their parents were. And so, of course, then they opt – then, as you say, out of guilt, you want to have everything done in order to keep them alive. And that’s what makes it expensive.

David: So what would be your advice to our listeners about the factors that they should keep in mind or the things that they should do if they are currently or when they find themselves in this position of being a caregiver for someone who’s about to die or who’s seriously ill, etc?

Hanno Kirk: Well, for one, I would make sure that hopefully, while the person is still competent, to fill out some advance directive so that the caregiver also knows what the wishes are. My mother was very clear that she never wanted to go back to the hospital again. She wanted to die at home. Well, when we explained that to her hired caregivers, they kind of thought that that was wrong because didn’t we want the best for our mother? And so we had to have my mother explain it to them that this was her wish, not that we were trying to save money by not putting her into the hospital any more.

David: Yeah.

Hanno Kirk: So there’s a lot of things that can be clarified just by people talking about it, and that the whole family needs to be in on a meeting like that, so that there’s not that child from out of town who isn’t aware of what’s been going on who comes in and wants everything done.

David: Okay, that sounds like great advice. What else?

Hanno Kirk: Well, the other part that I talk about is helping the patient basically coming to that awareness that end of life is coming close and that now would be the time for reaching closure and for saying the things that the family needs and wants to say to each other; and having that time as a time of growth and anticipatory grieving for each other. I mean that whole issue of creating sacred space, and that’s basically creating sacred space is when you shift from curative efforts to comfort care; when the patient’s illness is no longer the primary focus, but you now – the family pays attention to creating what I call a peaceful zone of rest and comfort and inner healing.

A lot of people at that stage go through that Erikson stage of Integrity versus Despair, where they worry about what they have done in their lives and whether they’ve done the right thing and so on – but being able to help them through that. And one of ways that I talk about that family members can really help is to encourage a life review process for the dying person by listening, attending, and supporting. If the patient is lucid enough, for example, maybe having grandchildren coming in, getting them involved and asking the grandparent, “Tell me about your growing up. Tell me about when… Tell me how you got through the Depression. Tell me… “And that is a wonderful way in which the person then can feel appreciated and also come to grips with their Integrity versus Despair issues. Does that make sense?

David: Yes, it does. Now what about the potentially negative side of that? I know some people would advocate that the children or other relatives speak their resentments, and I’m just wondering is that really a good idea. It might be good for them, but is it good for the dying patient? Is it kind of beating somebody up when they’re down?

Hanno Kirk: Yeah, that’s a really hard issue, one that needs to be addressed very carefully. And at that point, maybe bringing in another person, like a minister or a chaplain – all hospices have chaplains – and sort of mediating that so that it doesn’t become a… It is very difficult when adult children carry these large resentments about either abuse or neglect, and how to deal with that at the end of life is very difficult.

I had a patient, a client yesterday, who told me how she basically told her father how he had molested her and her twin sister, just before he died. Well, he flew into a rage. Well, obviously, he wasn’t ready to admit or to repent, and that was – but for the adult daughter and her sister, this is what they felt they had to do in order to let them forgive him, even though he didn’t seem ready to own up to what he had done.

But that’s a really hard question, and I have no easy answers for that.

David: Yes. I’m sort of thinking maybe they need to work that out in their own therapy. And it probably depends upon what stage that the dying person is in, whether or not they’re in a position where they’ve got enough of their defenses and so on that they can deal with it and there could be some back and forth kind of negotiation of the issues.

Hanno Kirk: Right.

David: I’m just thinking about it off the top of my own head here. As we sort of close down here, is there a book, maybe, that you like to recommend to people?

Hanno Kirk: Well, there are several books. One is Stephen Levine –

David: Oh, yes.

Hanno Kirk: Which is an old book. It’s called Who Dies: an Investigation of Conscious Living and Conscious Dying. There is a book by Sherwin Nuland, and that is – let me see here. Well, there’s another one called Last Rights – that’s R-I-G-H-T-S – which is by Steven Kiernan. And the Nuland book, basically, is How We Die: Reflections on Life’s Final Chapter. You talked earlier about how it was good to know what the signposts are.

David: Yes.

Hanno Kirk: And that’s what Sherwin Nuland does in this book. This is sort of a detailed examination of the physiological changes of the body as it begins to shut down. And he actually won a National Book Award for that. It is so well written and he’s so good at this. And it also examines the emotional impact of those changes on the patient, as well as the caregiver and the medical team. And I sort of consider it essential reading on terminal care.

David: Well, those sound like wonderful recommendations. Dr. Hanno Kirk, I want to thank you for being my guest today on Wise Counsel.

Hanno Kirk: Okay, thank you, and let me put one quick plug in. If they also want to attend one of my seminars, they can go cmieducation.org, and you’ll find a schedule there of my talks around the country over the next nine or ten months. Okay?

David: Okay, I’m glad you squeezed that in. My colleague, Dr. Mark Dombeck, rated you as one of the best presenters that he’s ever heard, and I’m sure he’s heard quite a few. So I want to put that out for our listeners, and again, I do thank you.

Hanno Kirk: Thank you very much. It was a pleasure.

David: Well, most of us tend to avoid thinking about the end of life. It’s nevertheless an issue that sooner or later we all must confront. As you heard Dr. Kirk say in this interview, we live in a death phobic culture. I hope you found this interview on care giving and end-of-life issues useful, and I do recommend you visit Dr. Kirk’s website to see if he might be giving a workshop in your area. I hear he’s a dynamite presenter.

You’ve been listening to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net. If you found today’s show interesting, we encourage you to visit Mentalhelp.net, where you can add a comment or question to this show’s web page, view other shows in the series, or simply page through the site, which is full of interesting mental health and wellness content. Access the show’s page and show archive information via the podcast box on the Mentalhelp.net home page.If you like Wise Counsel, you might also like ShrinkRapRadio, my other interview podcast series, which is available online at www.shrinkrapradio.com. Until next time, this is Dr. David Van Nuys, and you’ve been listening to Wise Counsel.

Restoring the Brain: Neurofeedback as an Integrative Approach

Restoring the Brain: Neurofeedback as an Integrative Approach describes the history and process by which neurofeedback has become an effective tool for treating many mental and behavioral health conditions. It explains how new brain research and improvements in imaging technology allow for a new conceptualization of the brain. It also discusses how biomedical factors can degrade brain functioning and cause a wide range of symptoms of mental disorders. The book is written in an accessible style for easy understanding and application to diagnosis and treatment.

The book shares the clinical experiences of practitioners working with specific symptom constellations generally categorized by a DSM diagnostic label. It examines the brain as a dynamic, regulated communications system and discusses how much of mental dysfunction can be understood as acquired brain behavior that can be redirected with the help of EEG-based neurofeedback. It describes principles and practices of integrating neurofeedback that make redirection possible.

Recent discoveries on the neuroelectrical properties of the brain illuminate the possibilities of combining innovative neurotherapy techniques with integrative medicine to achieve optimal brain function. This book’s case studies of clinical applications highlight neurofeedback’s effectiveness in treating autism, ADHD, and trauma, particularly PTSD. Integrative approaches are the future of health care and neurofeedback will play an increasingly significant role. Restoring the Brain: Neurofeedback as an Integrative Approach is an essential reference for all mental health professionals and those with an interest in the use and practice of neurofeedback.


  • Shares the experiences of experts and practitioners who explain, in accessible language, new findings on brain functioning and its potential for improvement
  • Describes how viewing the brain as a dynamically regulated communications system has led to efforts to influence brain functioning through the practice of neurofeedback
  • Presents the use of neurofeedback as a non-invasive, non-pharmacological supplement to traditional medical or mental health treatment
  • Includes case studies of clinical work that integrate neurofeedback
  • Demonstrates how and why neurofeedback works as part of an integrative approach to overall health


The effect of PTSD on the brain, and what Neurofeedback can do.

I want to explain the impact of  PTSD on causing disregulation in brain functioning and how Neurofeedback can be used to train the brain to restore itself to self regulation and resiliency.

Various standard psychotherapeutic techniques have been used to treat the symptoms of Post Traumatic Stress Disorder (PTSD), often with minimal success. We first found this to be true of Vietnam veterans, but it is of particular concern now as we can expect that one third of the 1.6 million soldiers returning from the war zones in Iraq and Afghanistan will have serious symptoms of combat stress or PTSD.

To stay alive in a very dangerous environment, soldiers learn to be hypervigilant, to suppress emotions (no time in battle), and not to talk about doubts and emotions. In situations where the soldier and his unit have to face life threatening situations day after day, there is no time to acknowledge the physical or emotional impact of shock from explosions or the trauma of seeing ghastly injuries and death among your buddies. However, these events are recorded in memory deep in the brain stem. At the same time, to keep functioning, the soldier may suppress the traumatic event from conscious consideration or reflection.

The essential feature of PTSD that results from shock or event trauma is that the traumatic memory involves the mind and the body as a unitary entity. The event is encoded as a body memory as well as an explicit historical memory. This means that event memory is coupled to state memory, i.e. memory of the physiological state at the time.

Such coupling is commonplace, but is usually associated with emotionally meaningful events. In happy situations (first experience of a kiss, sex) the explicit memory may be linked to a pleasant body-feeling memory. In a trauma situation, the valence of all such memory is heightened, and the memory is encoded as a unitary experience involving both sensory and visceral systems. More importantly the impact of such intense trauma experience is that it becomes one-shot learning, whereby the body-mind then alters its response to threat from that time forward.

It remains in a threat posture at some level, and this exacts a cost in terms of our normal regulatory function. When the brain is in a state of hypervigilance, any action that resembles a threat can lead to a primitive survival response coming from deep within the brainstem.  The brain responding from fight-flight alarm response is effectively hijacked.  We then lose top-down cortical (rational) control because subcortical and brainstem-related mechanisms have taken charge. The more often the brain is triggered, the more difficult it becomes to re-install the original more subtle, more complex, and more integrated cortical control over our critical regulatory functions.

This is why addressing this as a problem of the mind (as in cognitive behavioral therapy) is often inadequate. Talking to the cortex has limited influence as long as the brainstem is in emergency mode. That primitive part of the brain driven by its own  internal mechanisms is not paying much attention to the cortex. And when such methods (EMDR, desensitization, etc.) do succeed, it is only because the physiological response was also changed during the process. After all, the brain’s self-recovery processes can be mobilized in a variety of ways.

We can, however, also take advantage of the opportunity to retrain our physiological response directly, bypassing the suffering and ailing mind. In Neurofeedback the real target in recovery from PTSD is our physiology.  We are indeed focusing on calming the over aroused and unstable limbic areas, as well as the emotional control centers of the brain.  It should not surprise us that this strategy actually works most of the time. Clinical experience with hundreds of returning combat Marines at Camp Pendleton has proven that with Neurofeedback the brain can train itself to return to its normal self regulatory function. During the sessions, the brain observes itself as it responds to visual, auditory, and kinesthetic feedback in a continuous loop. As the traumatized brain  responds to the reward and inhibit cues it gets via video images, it learns to calm (or defuse) its learned alarm response. The detailed symptom tracking done in the Camp Pendleton study, showed dramatic reductions of PTSD symptoms within 10 to 20 sessions of  Neurofeedback. More importantly as the brain reorganizes itself, it settles into stable and efficient functioning that affects both cognitive processing, physical well being,  as well as emotional control. The added benefit is that the brain having learned to calm itself, has also acquired resiliency to future stress. This is why the program at Camp Pendleton for returning soldiers is called Combat Stress Reset.


Siegfried Othmer, Remediation of PTSD Symptoms Using Neurofeedback Training with Active Duty Service Members and Veterans. (Awaiting publication.) This is an analysis of the results of the study done initially with 400 combat Marines at Camp Pendleton in 2010. Results have now been tabulated for 500 Marines.