Process Oriented Coma Work, (or simply coma work) refers to a body of theory and practice for psychotherapeutic work with patients in comatose, vegetative, and other highly withdrawn states of consciousness. It was developed by psychotherapist Arnold Mindell and is an extension of Process Oriented Psychology („process work”) It is based on observations by Arnold and Amy Mindell (1989, 1998) and others (Owen 2006, 2007) that patients who appear non-communicative according to the usual neuropsychiatric diagnostic criteria (Posner 2007) still experience the world around them and are capable of communicating using subtle, often barely detectable nonverbal signals.

Patients in comatose states have traditionally been considered by mainstream medicine to be victims of pathological processes that curtail normal cognitive and communicative functioning. Modern research suggest that patients may display “islands” of consciousness in even persistent vegetative states. Nevertheless, the range of comatose and vegetative states described by medicine are thought to be without intrinsic meaning, and the experiences of their victims without significance.

Since by definition, the patient is incapable of understanding, thinking about, or communicating about his or her own condition, this view precludes the participation of patients in their own care. Decisions of whether or not to maintain life support must be based on consensus of medical opinion, input from the patient’s family, and any pre-coma statements of the patient in the form of living wills, advance directives and the like.

Coma work, because it focuses on and amplifies whatever residual ability the patient has to perceive, think about and communicate about their own condition, makes patients active participants in their own care, as well as in decisions about maintaining or ending their lives.’

Amy Mindell (1998) reports on the Mindells’ first case which was to form the foundation for their subsequent development of coma work. In 1986, they worked with a man named “Peter” who was dying of leukemia. Arnold Mindell (1989) describes this case in his book, “Coma: Key to Awakening” . The Mindells applied the methods of process work to Peter in varying stages of his illness, right up to his comatose state just before death. Their experiences formed the foundation of the methodology of coma work.

Coma work begins with the attitude that the comatose patient is capable of perceiving and relating to outer and inner experience, no matter how minimally. The coma worker therefore tries to discover what communication channels are open to the patient, and then to use these channels to relate to the patient’s experience. Channels of communication may be identified by noticing small, sometimes minute signals in the form of movement, eye movement, facial expressions, and vocalization by the patient. The coma worker then attempts to interact with the patient by interacting with and amplifying these signals.

During the interaction, the coma worker is guided by feedback from the patient. For instance, if the coma worker joins the patient in vocalizations, perhaps adding a bit of extra modulation, the patient may respond by changing his or her own vocalization. In addition, the coma worker may attempt to set up a „binary” communication link, inviting the patient to use available movement, like the movement of an eyelid or a finger, to answer „yes” or „no” to questions.

One common, although often unattainable goal, is to have the patient awaken from the coma. Although this has been known to happen as a consequence of coma work interventions, it is not the ultimate goal of the work. Additional goals are to help the patient communicate in whatever way is open to them, as well as to facilitate the patient’s participation in decisions regarding his or her care and ultimately, maintenance of life.

Amy Mindell distinguishes between two ranges of interventions: those usable by family and friends of the patient, and a more complete set of interventions to be used by the trained coma worker.

Coma work has been used with patients in comatose and persistent vegetative states. It is particularly useful in working with patients near death, since it permits patients to make decisions about, for example, the tradeoff between the amount of narcotic medication they receive against the clouding of consciousness they may experience as a result of these drugs.

Disputes regularly arise around the proper way to treat patients who have been rendered unresponsive – in comnatose or vegetative states – through injury or illness. When medical examination reveals apparently irreversible brain damage, emotional, family, and medical opinions may come into stark conflict. Occasionally, such cases break through to public awareness, as was the case with Terri Schiavo. Schiavo had been in a persistent vegetative state since 1990. Her husband and her family engaged in a long battle over whether to remove her feeding tube, which would result in her death. Her husband prevailed in 2005, leading to Schiavo’s death in March 2005.

A key factor in the legal battles was the inability to discern Schiavo’s preference – to continue living or to be allowed to die.

Recently doctors in England and Belgium (Owen et al., 2006, 2007) found signs of awareness in a brain damaged woman who was in a so-called vegetative state and 'outwardly unresponsive’. When doctors asked the patient to imagine playing tennis they saw peaks of activity in the premotor cortex part of the brain that mimicked responses of healthy volunteers. The same thing occurred when they asked her to imagine walking through her home. These studies and others using functional imaging techniques have documented islands of awareness in patients who showed no outer signs of consciousness. They demonstrate that there may be more going on in terms of patients’ self-awareness than are evident from routine clinical examinations. One conclusion is that a person may be aware even in the absence of obvious outer signs of this awareness.

Coma Books

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Coma: Key to Awakening

Arnold Mindell

1989

Arnold Mindell’s work with comatose patients offers a new direction in psychotherapy and in the study of near-death experiences. He argues that people in such states are not merely vegetables but human beings in an altered state of consciousness that may be an important experience for them: some report experiences of insight, ecstasy, and self-knowledge.

Offering verbatim bedside reports, theoretical discussion, and practical exercises; the author demonstrates his techniques for communicating with the comatose person based on process-oriented psychology.

In showing that the comatose person is able to communicate with others, the author argues that such patients can often make conscious, rational decisions; thus adding a new dimension to ethical and legal debates about near-death conditions.

Mindell, A. (1989). Coma: key to awakening (1st ed.). Boston Shambhala: [New York].

Coma: The Dreambody near Death

Arnold Mindell

1994

Arnold Mindell’s work with comatose patients offers a new direction in psychotherapy and in the study of near-death experiences. He argues that people in such states are not merely vegetables, but human beings in an altered state of consciousness that may be an important experience for them: some report experiences of insight, ecstasy and self-knowledge. Offering verbatim bedside reports, theoretical discussion and practical exercises, the author demonstrates his techniques for communicating with the comatose person based on his own process-orientated psychology. In showing that the comatose person is able to communicate with others, the author argues that such patients can often make conscious, rational decisions, thus adding a new dimension to ethical and legal debates about near-death conditions.

Mindell, A. (1994). Coma: the dreambody near death. London: Arkana.

Metaskills: The Spiritual Art of Therapy

Amy Mindell

1995

Why is some therapy effective and some disappointing? Amy Mindell says it has to do with the subtle atmosphere created by therapists’ unconscious feelings and attitudes. By tapping into their deepest beliefs about spirit, nature, and human development (metaskills), they can become more effective healers and spiritual teachers.

Through years of researching Arnold Mindell’s work with individuals, couples, and groups, Amy Mindell has identified a number of feeling attitudes which she amplifies here through analogies to Eastern traditions, the teachings of Don Juan, and/or modern physics. She approaches the question of learning metaskills: Is it possible? How is it done? (She postulates that the therapist, not unlike the client, is on a path of spiritual development.) And she explains how the concept could revolutionize the vast field of psychotherapy. The book has numerous verbatim transcripts, as well as detailed theoretical and poetic explanations.

In addition to offering helping professionals an inspiring new approach to working with people, this book will also valuable to anyone interested in discovering the unconscious attitudes that can lead to a deeper self-knowledge and satisfaction in relationships.

Mindell, A. (1995). Metaskills: The Spiritual Art of Therapy. Tempe, AZ: New Falcon Publications.

Coma: A Healing Journey

Amy Mindell

1999

In this step-by-step guide, Mindell shows family and helpers how to understand the subtle signal of the comatose person and set up a communication system that can facilitate expression of wishes regarding life and health-care.

In this immensely hopeful, helpful and readable book Mindell gives the reader factual information and reframes the term coma as an „altered state of consciousness” that can be worked with and learned from. — ForeWord Magazine Steven Holl February 1999

Mindell’s revolutionary guide paves the way for an exciting journey through the depths of human experience. It renders a diagnosis of coma anything but a dead-end road. — Linda J. Thorlakson Independent Publisher January 1999

Amy Mindell, P. D. (1999). Coma: A Healing Journey. Portland: Lao Tse Press.

Coma and Remote State Directive

Stan Tomandl

2006

The Coma and Remote State Directive is a legal document; an advance directive, also known as a living will. The intention of this document is to implement your wishes if you are ever concerned with communication and decision making duirng confusion, delirium, stupor, coma, vegitative state, depression, catatonia, dementia, and other remote states of altered consciousness. This document helps ensure that you receive verbal and nonverbal support for your awareness of spiritual, physical, emotional, and cognitive experiences; and that you are facilitated in making your own decisions while you are in remote states of consciousness. We advise you to inform your durable power of attorney for healthcare, family, friends, guardians, spiritual advisors, therapists, lawyers, physicians, healthcare facilities, and others about your wishes set forth in this document.

Tomandl, S. (2006). Coma and Remote State Directive. Phoenix, OR: Interactive Media.

An Alzheimer’s Surprise Party: Unveiling the Mystery, Inner Experience, and Gifts of Dementia

Stan Tomandl & Tom Richards

2006

Revolutionary and grounded in practical application, this book is filled with surprising research results that offer possibilities and comfort to millions of patients, families, and caregivers. The information and tools provided are both timely and essential, and could help transform the way people interpret and respond to patients with Alzheimers and other dementias.

NEW 2009 EDITION ALZHEIMER’S ASSOCIATION RECOMMENDED RESOURCE

An Alzheimer’s Surprise Party investigates the widely held belief that dementia is only a „mindless pathology”. Instead, the authors discover an essential, soulful, spiritual process that can be facilitated right from Alzheimer’s onset. This book provides pioneering and innovative research on the Alzheimer’s pandemic, and serves as an intimate, intense, compelling beacon, shining light on the disease’s potential for deeper meaning and spiritual healing.

I strongly recommend this as an original method of understanding and dealing with people in Alzheimer’s and other dementias. DR. ARNOLD MINDELL, PhD, founder of Process Oriented Psychology

This book is revolutionary in providing hope and meaning for patients, relatives, friends, caregivers and professionals in the management of Alzheimer’s and other dementias. DR. ROSEMARY SHINKWIN, MD, MRCPsych

Tomandl, S., & Richards, T. (2009). An Alzheimer’s Surprise Party: Unveiling the Mystery, Inner Experience, and Gifts of Dementia. Phoenix, OR: Interactive Media.

Inside Coma: A New View of Awareness, Healing, and Hope

Pierre Morin & Gary Reiss

2010

A woman who is thought to have no consciousness is able to play tennis in her mind in a way that is measurable. Another person, who is given no chance of recovery, suddenly speaks after 20 years. People in comas fill hospital beds worldwide—and there is more reason for hope about their chances for recovery than ever.

Drs. Morin and Reiss share their unique experience of working with people in coma. Their book is exciting to read, full of valuable information and an important contribution to the growing field of process-oriented coma work. With their powerful mix of theory, client stories of remarkable journeys, and easy-to-follow exercises, the reader is taken into the world inside coma. It helps professionals and caregivers relate with people in coma, and with their own internal states. We highly recommend it. —Drs. Amy and Arnold Mindell, authors of Coma, A Healing Journey, and Coma, Key to Awakening

Morin, P., PhD., M.D., & Reiss, G., Ph.D. (2010). Inside Coma: A New View of Awareness, Healing, and Hope. Santa Barbara: Praeger