Insights and Exercises In Personal Forgiveness (IEPF), a meditative mindfulness tool by Doug Duffee MD, Mdiv, FACP. Faculty Attending Physician, Parkview Medical Center Internal Medicine Residency Program, Pueblo Colorado, June 2019.
IEPF
Introduction:
Welcome to our mindfulness tool entitled Insights and Exercises in Personal Forgiveness (IEPF)! This tool strives to encourage personal discovery and growth as a vehicle toward building a platform for wellness inside the stresses and strains of clinical patient care activities. The ever changing and intensifying demands placed on health care workers by the medical system is a source of burgeoning stressors. While the field of medical mindfulness is maturing toward larger acceptance and application, the methods used to facilitate its implementation are many. Each tool personally and properly applied can play a role in this multifaceted process. While not every tool is for everybody, we have tried to make this tool accessible to Health Care Providers open to exploring questions of worldview as it applies to personal forgiveness and guilt release.
Our tool (the “IEPF”), seeks to find its niche in this process as a “facilitated self help tool”. Designed as a brief daily encounter implemented over 4 weeks, we hope you find its approach time efficient, simple, practical and effective. By reflecting on a culturally neutral but philosophically provocative ancient Semitic poem called Psalm 19 during a 5 minute daily time of meditative mindfulness we hope to introduce and apply two important wellness principles:
1. The physical and emotional strength it takes to be a Health Care Provider comes from embracing participation in a “bigger than self” issue of personal importance.
2. Identifying reasonable responsibilities and accepting one’s best efforts as good allows “self-forgiveness” to bring peace to event outcomes and subsequently to our professional and personal lives.
The Issue:
Consider these events encountered during a Hematology rotation during my Internal Medicine residency program. After a busy day and evening, I entered my call night (and morning). About 2 am a Heme ICU nurse called with an update on a cross cover patient on the service. This acute leukemic who had recently received induction chemotherapy was febrile, hypotensive, delirious and had bright red stools. Their ANC and platelets were near zero and their hemoglobin was rapidly trending downward. Oh, and they had chest pain too. I was being called to emergently resuscitate and formulate a diagnosis and treatment plan for this septic, GI bleeding patient in DIC most likely with dynamic ST changes on EKG. As I walked from my call room and entered the ICU with its health care team vision statement banner on the wall proclaiming the goal “to be the best health care providers in the world”, I felt the weight of high expectations. Being totally exhausted and totally isolated a thought crossed my mind. “Who is going to die tonight, me or this patient?” My next thought was directed to my worldview. “God you had better be real because I need your strength right now.” The strength came, the patient wobbled toward stability and one of my resident colleagues on rounds the next morning snidely observed that the patient “needed more attention than received overnight”.
A World Vision report on the aftermath of the Rwandan genocide describes how the hostilities of 1994 slowly yielded to faith and forgiveness. (https://www.worldvision.org/disaster-relief-news-stories/rwanda-20-years-later).
In hosting a recent international student retreat at our Colorado cabin, I met a group of Rwandan students who gave testimony to the power of forgiveness in their personal and national lives. The Rwandan genocidal atrocities, I learned, were driven by a history of social conflict that came to be symbolized by a physical distinction between the Tutsi and Hutu peoples. When this physical distinction was unclear, the conflict was then based on name recognition of family associations. As I learned the names of these Rwandan students, they described their last names now as descriptive of their personality and not of their genealogy. This was to emphasize, they explained, that there were no longer genetic or familial based distinctions among them that could lead to reigniting of genocidal revenge. They had let go of past hurts and they sang their hearts out as the entire group shared spiritual folk songs in multiple languages.
Letting go of personal attacks are a challenge to all who care for patients inside our health care system. Finding the physical and mental strength to respond, finding emotional strength to care and building relational support amongst colleagues are ever present stressors. Indeed, we can even add the growing administrative challenges of quality measuring, coding and documenting our experience to the ever diluted primary goal of therapeutically relating to patients. So lets dive in…
The IEPF
1. Psalm 19, translated with grammatical annotations by the Principle Investigator to help facilitate illustration and application (see appendix 1)
Verse 1. To the One who excels(1), a Psalm belonging to David(2).
Verse 2. The heavens are declaring(3) the glory of God and from the work(4) of His hand(5) the expanse(6) is making [Him] known(7).
Verse 3. Day to day it [the expanse] is gushing forth speech(8) and night to night it shows knowledge.
Verse 4. [but there is] no speech(9), [and there are] no words(10) because no voice has been heard.
Verse 5. In all the earth the end [of human effort] is going out(11) and to the end of the world [their effort] from them, but the sun is above their tent.
Verse 6. And God is like the bridegroom going out(12) from His canopy, cheerful like a warrior to run(13) a path.
Verse 7. From the heavens is His egress and His course extends to the heavens terminator and nothing is out of His heat.
Verse 8. The law of the Lord is complete, restoring(14) the soul, the testimony of the Lord builds up(15) making wise broadly.
Verse 9. The mandates of the Lord are straight rejoicing the heart(16). The commandment of the Lord is pure enlightening the eyes.
Verse 10. The fear of the Lord is clean, standing to the [end of] the age. The judgments(17) of the Lord are sure making right when taken together in total(18).
Verse 11. [His judgments] are delighting(19) more than gold, more than much fine gold and more sweet than honey, even liquid honey of the comb.
Verse 12. Indeed your servant is warned by them [and] to keep [them] is great reward.
Verse 13. Errors(20), who discerns [their own]?(21) From hidden ones, forgive me!(22)
Verse 14. Indeed from presumptuous errors(23), protect your servant, do not let them rule over me. Then I am complete(24) and I am clean(25) from much transgression.
Verse 15. Let it come as a delight the sayings from my mouth and meditations of my heart before Your face Lord, my rock and my redeemer.
2. The curriculum
Psalm 19: Insights and Exercises in Personal Forgiveness
Goals of Exercise: Expanding on the two important wellness principles shared in the introduction we hope to facilitate: 1. A discovery that embracing participation in a “bigger than self” issue of personal importance is one key to nurturing the physical and emotional strength it takes to be a Health Care Provider from verses 1-7. 2. A Development towards a positive attitudinal shift in the feelings, actions and beliefs about the self through release of unhealthy aspects of perfectionism as encountered in verses 8-13. 3. A release from the delayed experience of resentment, blame, bitterness, hostility, hatred, anger and fear that may be fostered through ruminating on certain events or transgressors through the illustration of self-forgiveness found in verses 14-15.
Instructions: Spend 5 minutes on each day in sequence considering and acting on principles derived from Psalm 19 translated and annotated as attached.
Day 1 Healthy Perfectionism
Consider: Read Psalm 19 verse 1. It begins by addressing literally “the one who excels”. In context this often is applied to talented musicians but is also applicable to Health Care Providers, the clinical care “talent”. Consider your preparation for work as a Health Care Provider; training, practice, maintaining certification, performance evaluations and critiques. The demand “to excel” placed on us by others and that we place on ourselves can foster a self-critical and perfectionist spirit. While this can motivate us to achieve beyond what we thought was possible, it has the potential to cause anxiety, sleep disruption and loneliness when we feel that we have fallen short. This is especially true if we feel that we are the only one who has “fallen short” among a cohort of colleagues, often coinciding with a patient care complication.
Act: List 3 character traits resulting from demands and expectations placed upon you that have positively and 3 you feel that have negatively impacted you.
Positive: ________________, ___________________, ______________________________
Negative: _______________, ___________________, ______________________________
Resolve to affirm the positive and consider ways to let go of the negative as we proceed.
Day 2 Healthy Perfectionism
Consider: Re-read verse 1 and consider who King David (the author of this psalm) was…a leader who struggled with expectations and demands placed on him by an entire nation.
Act: Review the 3 positive and negative characteristics from yesterday. Do you see any of those characteristics in David’s life as implied by the full text of Psalm 19? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Resolve to be open to receiving forgiveness and instituting healthy change in the areas of negative impact.
Day 3 Combating Loneliness
Consider: Read verse 2 and the associated translation notes. What do you think the Psalmist wants us to know so importantly that he “declares” it. How does being reminded that there is a God who is an intentional designer give us teleological perspective for purposeful living? How does being reminded that there is a God who is the “first cause” give us cosmological perspective that we are part of a bigger plan?
______________________________________________________________________________________________________________________________________
Act: Find a space that allows you to take in and consider God’s beauty in creation and spend time there this week.
Day 4 Combating Loneliness
Consider: Re-read verse 2 and consider the argument from design and causation for the existence of God. Two ideas are supported by these truths…Purpose and Presence. If these ideas are accepted, then we are never existentially alone or purposeless. This can be the beginning of moving from loneliness to relationship.
Act: Find time for an activity this week that you enjoy and that gives you a sense of release or distance from professional activities. For example a bike ride, a hike, watching a fun movie, play an instrument you may not have played for a while or start/develop a hobby. Try to do this regularly if you can.
Day 5 What is Prayer?
Consider: Read verse 3 and the associated translation notes. Have you ever felt that God was trying to get your attention? How? Does the fact that “the expanse is gushing forth speech” make you wonder why you may not have “heard” it? ______________________________________________________________________________________________________________________________________
Act: Praying is simply a form of meditation that seeks relationship by talking conversationally to God in an “inner voice”. This is sometimes difficult for the same reason that hearing God’s creation “speak” to us is difficult. We are so busy and preoccupied that we do not slow down enough to communicate or listen. Take 3 minutes of complete and uninterrupted quietness and pray by asking God to show Himself to you in a new way today.
Day 6 What is Prayer?
Consider: Re-read verse 3 and reconsider your prayer from yesterday. Did God show Himself to you or give you an insight into something? If so, write it down._________________________________________________________________________________________________________________________________
Act: Try to begin a daily habit of spending a few quiet moments in prayer and meditation and write any insights and activities in a “prayer journal”.
Day 7 Exquisite Anatomy
Consider: Read verse 4 and the associated translation notes. The fact that there is no audible rational proclamation from God does not mean that He does not “speak”. In this instance His speaking (also called revelation) is by the display of His creative work and shows that actions truly can speak louder than words.
Act: Review the anatomy of the eye and the physiology of the heart. Focus on the rods and cones and the depolarization process and the cardiac conduction system that can operate autonomously by idioventricular rhythmic compensation during av nodal block. Look at a normal echo and the parasternal long axis view of the heart and notice the coordination of contraction and relaxation of the myocardium and the opening and closing of the heart valves, all in synchrony. Does this design speak to you of a designer? ___________________________________
Day 8 Exquisite Anatomy
Consider: Read Psalm 139. It is a very personal passage of Semitic poetry and serves as a reminder to each of us of our created individuality. How does knowing that you are “fearfully and wonderfully made” affect how you view yourself?
________________________________________________________________________________________________________________________________________________
Act: Psalm 139 begins and ends with the Psalmist asking for God to search him, his heart and his motives. Why is it valuable for us to have someone speak truth into our lives? How can this soften a defensive or aggressive personality shell? Why might this be valuable?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Day 9 Work Motivation
Consider: Read verse 5 and the associated translation notes. As the Psalmist comments on the Sisyphean nature of all work, do you ever have the sense that your hard work goes unnoticed, unappreciated or is never ending? How is the sun a metaphor for our work being noticed by the creator?
Act: Try turning our motivation for work productivity from people or self focused to God focused. Does this change in focus give a new perspective on the motivation and meaning of our efforts? Set 3 goals for work motivation that show the ”bigger than self” higher calling for what you do (eg ministering a comforting presence to a lonely patient as a reason to be at the bedside). Write those goals in your prayer journal.
Day 10 Work Motivation
Consider: Read Psalm 144:11-15 which shows the fruit of different kinds of labor involving family, farming and ranching. How does God bless the labor of those seeking His help?________________
Act: As your work “goes out”, do you ever feel you have given all that you can give and that intrinsic mental, emotional and/or physical resources are being drained? How can one replenish those resources? List 3 actions you can plan to take in order to regain strength. (eg time off for rest and unplugging, exercise)
Day 11 Work Motivation
Consider: Read verse 6 with translation notes. In re-iterating the “going out” (same word as in verse 5) now as God’s effort, note the contrast between the scorching sun affecting man’s effort and the cheerful energy of God’s effort. Do you find that work is like working under the sun (monitored, energy draining) or invigorating (like a warrior running a path)?
Act: What steps can we take to re-invigorate (or maintain invigoration) the energy, passion and joy in work.
1. Evaluate your commitment
2. Define boundaries to that commitment
3. Find an area of focused interest inside the work activity and develop/master it.
Day 12 Work Motivation
Consider: Continuing with verse 6, what principles characterize God’s activity?
-bridegroom + canopy = relationship
-running warrior = strong and physically fit
Act: Consider your work support system. Do you have one? How should it function? If not, look for team resources to join or build one. Are you staying physically fit? Resolve to walk at least 20 minutes three times per week apart/away from work.
Day 13 Work Motivation
Consider: Read verse 7. What is implied by the reminder that God’s egress is heaven and nothing is “out of His heat”? If this verse is implying that God is all present and all powerful, does this give us a context for our work?
Act: Try to find an aspect of work that is bigger than self that you can be a part of or volunteer in. Consider a committee or outreach mission that exercises your sense of bigger purpose.
Day 14 Review
Consider: Verses 1-7 complete the first section of Psalm 19. These verses suggest to us that God’s existence, purposeful design and presence can fuel and give context to work actions and activities.
Act: Remember to try and keep a daily prayer/meditation journal
Day 15 Surrender
Consider: Read verse 8 with translation notes. The Psalmist now moves from the presence of the cosmological mover to instructions for life from that same cosmological mover. Speech now turns from demonstrative revelatory actions to historical-grammatical communication of precepts to us that were written down for consideration.
Act: How can we surrender ourselves to hear and receive these words, embracing the claims that they are good for us? Consider areas of pride that may need to be set aside. Read Proverbs 3 and find 3 promises and 3 precepts that describe the Lord’s instructions.
Promises:__________________, _____________________, _____________
Precepts:___________________, _____________________,______________
Day 16 Surrender
Consider: Why is it that embracing God’s truth/law brings restoration? Surrender removes struggle and wise living prevents conflict. Think back to a struggle or conflict in your life. Do any of the words from Proverbs 3 apply to that situation?
Act: Take the 3 promises and precepts from Proverbs 3 that you considered yesterday and apply them in your life over the next week.
Day 17 Integrity
Consider: Read verse 9 with translation notes. This verse emphasizes the moral component of God’s guidance. As you seek to find and do what is spoken of as “right”, joy and insight result.
Act: Think of an area where your integrity was put to the test, for example, not being truthful with a coworker or not being fully transparent with a patient communication or complication. Re-read Proverbs 3:3-4. What is the benefit of “not letting truth and kindness leave you”? ________________________________________________________________________________________________________________________________________________
Day 18 Integrity with Confession
Consider: Re- read verse 9 and then read Psalm 119:26-27. As we “tell of our ways” in relationship with God and He reveals an understanding of His precepts, the interplay between surrender and growth becomes apparent. It also illustrates that private confession of a heavy heart to God brings enlightenment and release of the “heaviness”. Here in Psalm 19 the release of heaviness is illustrated by a burgeoning joyful heart and enlightened eyes.
Act: Consider an event where your response/action has caused personal remorse. Express that sense of remorse internally or out loud to God and listen to what he might teach you.
Event________________________________________________
How expressed? ____________________________________________________________
How did it make you feel? ____________________________________________________________
Day 19 Confronting fear
Consider: Read verse 10 with translation notes. Fear and anxiety are common feelings especially in our society where competition, commitment and striving are paramount. Expectations, financial commitments, contingent relationships and the concern that they may falter can create internal fear and anxiety.
Act: What is the difference between healthy and unhealthy fear?__________________________________________________________________
Make a list of 3 benefits of healthy fear: ________________, ________________
______________________.
Make a list of 3 dangers of unhealthy fear: _______________, _______________
______________________.
Day 20 Confronting fear
Consider: In keeping with learning to differentiate between healthy and unhealthy fear, consider if you have used unhealthy fear to motivate certain behaviors.__________________________________________________________
Act: Think of 3 lifestyle changes to reduce unhealthy fear (eg build a debt management plan, decrease extraneous time commitments and increase family focus) or increase healthy fear (seeing God as omniscient and sovereign motivates one to seek His words and wisdom and apply to personal and family life). ___________, ___________________________________
Day 21 Finding resources
Consider: Read verses 11-12 with translation note. God’s judgments and guidance are to be desired and applied. Thus far God’s guidance has been called law, testimony, mandate, commandment and judgment. When properly applied they result in restoration, wisdom, joy, enlightenment, and purity. These verses are the reaffirmation that guidance accepted brings positive life change.
Act: Sometimes we need to be reminded that certain things are good for us. Identity areas in your life that need restoration (eg a relationship or an altruistic activity). Once identified, try to begin anew.
Day 22 Finding resources
Consider: Where do we find more specific statements of God’s guidance? This is why there is such strong emphasis in verses 1-4 regarding the possibility of God’s “speech” being made known. This happens as we encounter Him in nature or read His revelation in scripture. We can learn more of God through the written words that His prophets, who also encountered Him, wrote down in scripture.
Act: Find a resource for guidance in God’s words. Psalm chapter 1 is a good starting example. Read it.
Day 23 Errors of Omission
Consider: Read verse 13 and associated translation notes. We have now reached the penultimate section of Psalm 19. In light of God’s revelation and statements of benefit, the Psalmist’s heart softens and he is able to take an introspective look at the areas in his life where he may fallen short. He is at a turning point, now able to gain insight into his actions, activities and behaviors. He does this in 2 ways. He realizes that one’s “errors” can be hidden or “of omission”. This then prompts him to ask for insight and protection into trouble spots in his life of which he is not aware.
Act: Ask God to reveal any personal blind spots and to build an attitude of change and renewal. Accept this step of release as a way to start fresh.
Day 24 Errors of Omission
Consider: Knowing, realizing and understanding that we are not perfect allows us to release the past and move ahead with sensitivity for growth.
Act: List 3 areas in your life that upon deeper consideration may be/have been blind spots. Resolve to rectify those situations. ______________________,
____________________________, ________________________________
Day 25 Freedom and Forgiveness
Consider: Read verse 14 with translation notes. Now the Psalmist turns from unrecognized shortcomings to ”presumptuous [behavioral] errors” of which he may be fully aware. He asks for protection from them and asks that they not become addictions or bad habits (“do not let them rule over me”). Do you have any bad and/or addictive habits from which you need release?
Act: Identify one area of behavior which is “ingrained” in your personality but from which you want freedom. Consider things like anger, criticism, drugs, alcohol, pornography, food etc. Pray that they “not be allowed to rule over you”. Ask God for protection and forgiveness from these previous events. Write down your resolution and consider sharing it with a mentor or close friend for support and accountability. ________________________________________________________________________
Day 26 Freedom and Forgiveness
Consider: Read verse 14 again. As we become free from previous behavior patterns (freedom = protection from pursuing and not being ruled by those patterns), “cleanness” results. Being clean means experiencing release from the repetitive activity pattern and gaining a fresh start without guilt or remorse. It also implies the strength to move forward without that old pattern. If the event is not repetitive but rather an isolated event that continues to affect you, the confession as described above also results in “cleanness”. This may involve things like interpersonal professional conflict, medical or diagnostic errors that resulted in a death, self criticism or family estrangement. Whatever it may be, this verse is the climax of Psalm 19 and promises that with resolution comes “completeness”.
Act: Breath in deeply and think internally of the troubling activity in one word. Slowly let that deep breath out and sigh the word “release”. If you feel you need to take concrete steps to seek reconciliation, ask your mentor for counsel.
Day 27 The Change of Heart
Consider: Read verse 15. Notice the full circle which the Psalmist has travelled, going from “learning to hear God speak” to “speaking as pleasing back to God”. This signifies renewal of relationship.
Act: Consider continuing in a pattern of daily meditation and journaling in a new area of discovery.
Day 28 The Change of Heart
Consider: In light of these verses and the examples given, can you institute an ongoing behavior pattern in your life that looks for restoration and then appropriates restoration through concrete activities.
Act: An example of the above behavior pattern may be daily meditation and prayer focusing on an external teaching idea and then finding ways to practically apply what you have learned. It also may involve joining a church fellowship.
Appendix 1
1. “The one who excels” is used here without reference to a musical instrument. In other Psalms it is translated “choir director” in association with “on a musical instrument”. Health care providers can be driven to excel and tend toward a perfectionist bent. For all its good, this can sometimes lead to unhealthy self-criticism. So this Psalm can be applied to us as health care providers.
2. The preposition attached to the name “David”, literally means to or for David. Traditionally this preposition has been translated as “belonging to” and the authorship of this Psalm is attributed to King David of Ancient Israel ca. 1000 BCE. This allows enough “cultural distance” for Psalm 19’s principles to be more universal in nature.
3. Declaring is a Piel participle. The force of the Piel stem in the Hebrew language is emphatic, emphasizing that the “declaring!” is with much force.
4. This work is the same noun used in Genesis 1:31 and 2:2 and is indicative of God’s creative work. From the macro evidence of the heavens to the micro evidence of creation (down to the detail of the heart and eyes which show up later in the Psalm), God’s teleological purpose, like a fine watchmaker, is seen in nature.
5. Hand is a collective singular here, God is our creator.
6. This noun, “expanse” is the same word used in Genesis 1 as the expanse between waters to waters. The wideness of creation is making God known.
7. “Making [Him] known is a Hiphil participle. In the Hebrew language the Hiphil stem is causative, thus the heavens, the work and the expanse are “causing” a revelation of the reality of God to those who “listen”. And as we will find out in the upcoming verses, what is heard are words with no sound and actions that “speak” of the reality of God. This is His revelation to us of His existence. There is something bigger than us in this universe.
8. Speech as in revelatory activity.
9. Two different words for “word” here (the first of which is the same word as speech in verse 3) reemphasize the experiential and not explanatory nature of these revelatory events (experiencing the heavens, work and expanse).
10. Plural
11. Compare Psalm 144:14, “going out” in labor like activity.
12. Same word as 11.
13. Literally ”swift to run”
14. Compare here and Ruth 4:14 where “restore” is in the Hiphil (causative) stem and is seen as “causing to restore life”. In contrast to the revelatory words which are not words but are actions in the initial verses, the revelatory words which are words in verses 8-10 (law, testimony, mandates, commandments and judgments) are revealed and then written and recorded words of God which “restore” us. As we seek precepts to inform change inside of self-forgiveness, the promise is that God’s precepts are life-giving.
15. “Builds up” is in the Niphal stem in the Hebrew language and here carries its “reflexive” voice, namely that these precepts “build US up”.
16. “Rejoicing” is in the Piel stem and again is emphatic. It is also joined by a Maqqeph to the word “heart” to give it a rhyming and emphatic rhythm for extra emphasis; “mishmakay-lave” (transliterated). Literally the molecular workings of the heart as a work of God’s hand and figuratively as the sensory center for spiritual feelings and life, the “rejoicing heart”, the “mishmakay-lave” finds new joy as it embraces precepts for change inside of self-forgiveness.
17. Compare Psalm 25:9 and Psalm 119:62 where judgments are seen as “guiding instructions” the results of which we can be “thankful for”.
18. Adverb implying “when taken together in the totality of their guidance”
19. “Delighting” is in the Niphal stem and in this use is applied as a passive, “are to be desired”
20. This word for “Errors” is used only once in the OT (ie is a “hapax legomenon”) and implies errors of omission, those events that we may not realize we have done wrong but in our “excelling perfectionism” know they exist. This verse asks for us to be able to discern them so we can identify, contemplate then seek forgiveness and change.
21. Compare Psalm 92:6 where these errors “are not perceived or understood”. Thus the call to perceive and understand so forgiveness can happen.
22. “Forgive me” is a Piel (emphatic) imperative, a strong cry from within. Compare Psalm 19:14 where in the Niphal (reflexive use) stem emphasizing “I myself am clean”. What a freeing feeling to feel clean of, clear from and able to move on from errors.
23. “Presumptuous errors” are sins of commission, those sins where a big mistake was made and from these the Psalmist asks for protection.
24. “Complete” as in a finished work.
25. See 22.