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Buddhist Chaplaincy Speaker Series: Spiritual Care as Koan – Formation and Embodiment - Alice Cabotaje

The following talk was given by Alice Cabotaje at The Sati Center in Redwood City, CA on November 18, 2024. Please visit the website www.audiodharma.org for more information.

Buddhist Chaplaincy Speaker Series: Spiritual Care as Koan – Formation and Embodiment

Host: Welcome everyone to the Sati Center's Buddhist Chaplaincy Speaker Series. We are delighted to welcome the Reverend Alice Cabotaje.

Reverend Alice Cabotaje is the Director of Spiritual Care at Stanford Health Care. Alice is a Certified Educator from the Association for Clinical Pastoral Education (ACPE) and a Board Certified Chaplain through the Association of Professional Chaplains. Prior to Stanford Health Care, Alice was Director of Spiritual Care and Education at Massachusetts General Hospital in Boston. Before Mass General, she was at the University of California San Francisco Medical Center, where she served as a chaplain and underwent supervisory education to become an ACPE Certified Educator. She is an ordained minister with the Metropolitan Community Church and an authorized Zen teacher in the Rinzai Zen school, Empty Cloud lineage. She has a Master of Divinity from the Pacific School of Religion at the Graduate Theological Union in Berkeley and a Bachelor of Arts in Philosophy from the University of the Philippines. Prior to her move into healthcare leadership and chaplaincy, she was a financial journalist for 20 years and covered the economies and capital markets of Asia and North and South America.

We are delighted to have you with us today, Alice. I am going to pass it over to you.

Alice Cabotaje: Thank you, Jim, and also Vanessa, for this opportunity to be here with you. I am so delighted to see many of you joining today to listen and reflect on spiritual care as kōan¹—formation and embodiment.

Before I start a talk, I invite everyone to take a few minutes of silence. I will ring the bell three times and invite us to come to our bodies, to be where we are right now. Let's listen to the sound of the bell—the rising of the sound, the disappearing of the sound, and all the sounds surrounding us. As we listen, let us simply be here. There is nothing to achieve. Let's simply be here.

(Silence)

For those whose eyes are closed, I'd like to invite you to open your eyes.

Good morning, dear friends. I see friends here, colleagues, and fellow pilgrims on this path of service, this path of compassion, this path of awakening. It is both an honor and a joy to be here before you as we explore together the intersection of spiritual care and kōans—a fertile meeting ground of formation and embodiment in our work as Buddhist chaplains and as providers of spiritual care.

I once again invite you to settle in, to let body and heart-mind drop into this very moment, and to meet the words and silence of our time together not as information, but rather as a kōan in itself—a space where knowing and not knowing can dance, where wisdom and wonder can arise.

My talk has four parts. The first part is Kōan as a Path of Formation. Part two is Kōan as an Embodiment of Spiritual Care. Part three is Spiritual Care as Kōan: A Tool for Awakening. Part four will be all of us reflecting on this, receiving questions, and being in conversation.

Kōan as a Path of Formation

In the Zen tradition, a kōan is a question, a story, or a paradox meant to pull us out of our habitual ways of thinking. It is meant to break us out of dualistic thinking. It is used in Zen practice, especially in the Rinzai sect, to provoke a direct experience of our essential nature—to awaken us to ultimate reality.

Author Ruth Fuller Sasaki traced the origins of kōans to the early Tang Dynasty in China, where they emerged as part of the Chan tradition. Initially, kōans were records of interactions between Zen masters and their disciples—moments that encapsulated the spontaneous and direct transmission of awakening. Over time, these dialogues were formalized into tools for training and contemplation. A kōan is not resolved through logic, intellect, nor verbal explanation. A kōan is meant to be wrestled with, experienced, lived, and ultimately integrated and embodied in our everyday life in service to all.

Let us consider this kōan: "Dogo's Condolence Visit," Case Number 55 in the Hekiganroku² (The Blue Cliff Record).

The kōan goes: Zen Master Dogo and his student Zengen came to a house to express condolences. Zengen tapped on the coffin and said, "Is this life or is this death?" Dogo said, "I don't say life. I don't say death." Zengen said, "Why don't you?" Dogo said, "I won't say. I won't say." On the way back, Zengen said, "Master, please say it to me right away. If you don't, I shall hit you." Dogo said, "If you want to hit me, you can hit me, but I will never say." Thereupon, Zengen hit him.

Sometime later, Dogo passed away. Zengen then went to Dogo's successor, Sekiso, and told him what happened. Sekiso said, "I don't say life. I don't say death." Zengen said, "Why don't you?" Sekiso said, "I won't say. I won't say." With these words, Zengen came suddenly to an insight.

The question of life and death is central to our practice. In Zen monasteries and retreats, the retreatants at the close of every day chant the Evening Gatha, stating that life and death are of supreme importance, inviting all to strive to awaken to the true nature of life and death. The Evening Gatha says:

Let me respectfully remind you, Life and death are of supreme importance. Time swiftly passes by and opportunity is lost. Each of us should strive to awaken. Awaken. Take heed, do not squander your life.

For those of us who work in hospitals and hospices, we face the question and reality of life and death repeatedly, constantly. My Zen teacher, Greg Mayers, gave me this kōan when I started work as a hospice chaplain in 2008. I immersed myself in it for six months, and I was beginning to get frustrated because I just couldn't get through it. What is life? What is death?

One morning, a nurse called me to visit a patient who was dying. I sat with the patient, and as I sat there, I matched my breathing with their breathing. After 30 minutes of sitting with them, the kōan suddenly opened up. Wow. I was speechless for the whole day.

Formation as a chaplain is a kōan. For many, or some of us, when we enter this path of spiritual care, perhaps we thought, "I will learn to ease suffering, offer comfort, and be a presence of peace." Really noble intentions. And yet, what we may have discovered is that spiritual care is not neat, it is not linear, and certainly it is not comfortable. It is messy.

A dying patient says, "Why is this happening to me?" A grieving family asks, "Where is God in this?" A colleague snaps at us, exhausted by their own burdens.

What do we do? What do we say in these moments? These questions, this situation, become a kōan. As we sit with it, as we wrestle with it, as we immerse ourselves in it, we become the kōan. We are the question and the answer, the paradox and the breakthrough.

Returning to Dogo's condolence visit: Zengen begged Master Dogo and said, "Master, please say to me right away. If you don't, I shall hit you." Zengen was desperate to know the answer. And Dogo said, "I won't say. I won't say."

He didn't say "I can't say." He didn't say "I don't know." He didn't say "Go away." He didn't say "I forgot." He said, "I won't say." For one, he wanted Zengen to realize it himself. At the same time, what was Dogo pointing to? This kōan essentially asks us to look into our own birth and life, to come face to face with our own death and dying.

In kōan practice, the first step is often described as "not knowing." We approach the kōan with a beginner's mind, relinquishing preconceived notions. In spiritual care, this is the practice of dropping our certainties—our certainties about ourselves, our beliefs about others, and even suffering itself—to meet another's suffering. We are invited to surrender our need to fix, to rescue, to solve, or to have all the answers.

Formation begins not with mastery; it begins with humility, with openness, with curiosity. When a patient asks, "Why is this happening to me?" perhaps the most appropriate response is to sit with them in equanimity and then explore and embody the question with them.

Zen Master Dōgen³ said:

To study the Buddha Way is to study the self. To study the self is to forget the self. To forget the self is to be actualized by all things.

As chaplains, as those of us who provide spiritual care, our formation is not merely about learning the art and skill of spiritual care. It is not merely about integrating theories into our practice. It is not merely engaging in reflection drawing on our own religion, spiritual practice, philosophy, and worldview. Rather, it is a stripping away of our need for control. It is allowing the suffering we encounter to turn the light inward, illuminating our own shadows, our attachments, our fears.

Have you noticed how those we serve are often our greatest teachers? Their questions, their struggles, their silences—they are the kōan that shapes us, calling forth authenticity and truly being. Being with, moment by moment, in and in-between moments. Formation is about becoming the kōan.

Kōan as an Embodiment of Spiritual Care

Embodiment of a kōan is about living it. In Zen, we often say the true resolution of a kōan is not in words but in action. How does this apply to spiritual care?

As we know, in spiritual care there are no fixed answers. In the same way, no kōan has a fixed answer. The answer is you—the person that you become. When you walk into a hospital room, your very being speaks before a single word is uttered. Your embodied practice—your stillness, your openness, your humility, your grounded state—communicates everything that needs to be said.

In another kōan, "Ordinary Mind is the Way" (Case 19 in the Mumonkan or Gateless Gate): Jōshū earnestly asked his teacher Nansen, "What is the Way?" Nansen answered, "Ordinary mind is the Way." Jōshū asked, "Should I direct myself toward it or not?" Nansen said, "If you try to turn toward it, you go against it." Jōshū asked, "If I do not try to turn toward it, how can I know that it is the Way?" Nansen answered, "The Way does not belong to knowing or not knowing. Knowing is delusion. Not knowing is a blank consciousness. When you have really reached the true Way beyond all doubt, you will find it as vast and boundless as the great empty sky. How can it be talked about on a level of right and wrong?" At these words, Jōshū was suddenly enlightened.

What is "ordinary mind"? Ordinary mind is an undefiled mind. It is mirror-like, reflecting anything and everything that is placed before it, just as it is. No more, no less.

In spiritual care, there is an element of immediacy. When living out "ordinary mind," we do what is required here and now, with swiftness, with naturalness, and with our full attention. There is no argument, there is no rationalizing, there is no resistance to the present situation. There is no wishing for something else other than what is unfolding.

In spiritual care, "ordinary mind" also translates to being the fruit of one's practice. That is being aware, unpretentious, and profoundly attentive. It is not about performing; it is about being a vessel through which service flows, through which loving-kindness flows, through which compassion flows.

As many of us know, one of the challenges of spiritual care is bearing witness to immense suffering without being overwhelmed. In Zen, we practice equanimity not as detachment, rather as the ability to hold space for the full catastrophe of life while remaining rooted. When a patient lashes out in anger or fear, we meet them with compassion, and we try to meet them without taking their anger and fear personally. When we sit with someone who is dying, we stay present and we try not to cling to outcomes. This is the embodiment of the kōan. It requires both a tender heart and a steady and clear mind. It requires being with "only this, just this."

Returning to Dogo's condolence visit, this kōan also invites us to sit with all that is happening, especially with our feelings, which is vital in being a skillful chaplain. This kōan calls us to sit with our losses and our grief, which includes our sadness, our anger, our shock, our frustrations, our sense of isolation, our dashed hopes, our loneliness, our regrets, our longings, our memories, our fears, our pain. It also asks us to sit with our joy, our gladness, our celebration, and appreciation for life.

It encourages us to be with: Our sadness—only our sadness. Our joy—only our joy. Our anger—only our anger. Our gratitude—only our gratitude. Our shock—only our shock. Our awe—only our awe. Our frustration—only our frustration. Our delight—only our delight. Our sense of isolation—only our sense of isolation. Our pleasures—only our pleasures. Our dashed hopes—only our dashed hopes. Our success—only our success. Our loneliness—only our loneliness. Our regrets—only our regrets. Our longings—only our longings. Our fears—only our fears. Our pain—only our pain.

Japanese poet Saigyō⁴ wrote:

"Detached observer of blossoms finds himself in time intimate with them, so when they separate from the branch, it is he who falls deeply into grief."

As we sit with all the feelings that arise, we are invited to stop running away when a situation hurts. To stop sweetening things up. To stop smoothing things over. To stop wanting something different to what is happening here, right now.

Only this. Just this.

The beauty with "only this, just this" is that when we give it our time and full attention, something opens up that surprises us.

Spiritual Care as Kōan: A Tool for Awakening

Finally, I want us to consider this: Spiritual care is not merely a profession or a role. It is a spiritual practice, a path of awakening. Every interaction, every encounter we have, is an invitation to deepen our connection to the Dharma, to embody compassion, and to realize our essential nature.

When we sit with a patient who is dying, we too face our own impermanence. Japanese Zen Buddhist monk and poet Ikkyū Sōjun⁵ wrote:

"The moon is a house in which the mind is master. Look very closely: Only impermanence lasts. The floating world, too, will pass."

When we hold space for a family's grief, or for anyone who comes to us sad and grieving, we too hold space for the sorrow of all beings. When we offer kindness to a stranger, to someone, to a pet, to a situation, we offer boundless Bodhicitta⁶.

As I end this talk, I invite you to reflect on this: How do we serve others while awakening ourselves? How do we offer spiritual care without falling into dualism—without seeing us as the healer and them as the ones needing healing? Also, what kōan is shaping you right now? Is it a question, a relationship, a challenge, or a mystery?

Whatever it is, I encourage you to wrestle with it, to marinate in it fully, to let it teach you, and to let it awaken you.

May we, as chaplains, as providers of spiritual care, continue to embody the practice of being, the practice of compassion, the practice of full attention and awareness in all that we do. And may our lives become a living kōan, offering not answers, but rather offering an opening to that loving, liberating vastness we are all in.

Finally, let me ask you: Is this life, or is this death? For those of you who would like to work on this kōan, may you break through this kōan and experience true freedom and the boundlessness of all.

Q&A and Reflections

Jim: Well, thank you, Alice. That was a beautiful talk. Would it be okay now to invite questions and reflections from the folks here?

Alice: Yes, yes. And if you have your own reflections around this as well, I invite you to share it. This is one of the best ways we can learn—sharing, drawing from the wisdom of everyone.

Jim: I have a question here from Paul Fulmer, a staff chaplain at Stanford Health Care. He says: "Alice, you mentioned reflecting on a kōan over the course of six months during your time in hospice. What practices or actions did you take? How might we keep a kōan alive and active over an extended amount of time?"

Alice: Great question, Paul. In kōan study, it has to be a relentless thing. For me, every moment—while I'm walking ("Is this life or is this death?"), while I'm washing my clothes, while I'm washing dishes, while I'm sweeping the floor. Of course, not when I'm in conversation with others, but when I take a walk, when I take a shower. Until it opens up, until a breakthrough happens, it's something that I constantly am in, until I become the kōan. The kōan becomes me.

Sometimes with kōan study, it requires a level of frustration and desperation to break through. Sometimes it takes years. For others, it can just take a moment and suddenly it comes up. In my case, there are kōans that hook me, and there are kōans that, "Eh, okay." But there are kōans that affect me in a most profound way. So yes, it's literally always at the back of one's mind.

Jim: I also did kōan study with my teacher in the Zen tradition, and as you say, sometimes it takes a while to work with a particular kōan. You have to work with it during zazen, you're working with it off the cushion. It's a process. And then when the time is right, the presentation is enough to pass. There is a lot of time often to work with our kōan; the teacher doesn't necessarily expect an immediate response.

I would say that in healthcare, maybe you don't always have that degree of time. What came to me was the kōan where someone asked Master Yunmen (Ummon)⁷, "What was the lifetime teaching of the Buddha?" and he said, "An appropriate response." For me, that always has a sense of immediacy, timeliness, of being able to meet that moment fully. My experience of working with kōans often has the luxury of time, but in healthcare, that's not always the case—whether it's being with a patient or a bioethical issue that is emergent. I was just curious to hear your thoughts about those different time frames, or if there's something about the spirit of the kōan—of kind of sitting with that uncertainty and trusting that you can meet that moment—that is maybe more important.

Alice: Yes, especially when one practices trying to be aware, being here, being present. In Zen practice, one of the "sins" is hesitation. When I go to my teacher and present a kōan, the moment I hesitate and the thinking comes, it's like, "Okay, leave. Continue to work on your kōan."

In the same way in spiritual care—and that's especially for those who go through CPE (Clinical Pastoral Education) or chaplaincy training—one of the things is awareness of where we are at. It's a process of knowing our biases, our assumptions, everything that's going on. We're taught to be aware of what's happening in the room, to read the room, to sense what may be going on with the person. It's a sensitivity to everything that happens. As we continue to practice this, and use theories to make a spiritual care assessment, we learn more and more and get to the point where it becomes second nature.

When a situation arises, sometimes the appropriate response—and trusting what arises—may be to say "I don't know," or "Let me find out." Or it may be a word, it may be smiling, it may be a song. Sometimes we're not perfect; it may not be the "appropriate" response, and even being aware of that is appropriate in itself.

It's having more the spirit of embracing whatever comes up and trusting that somehow it works out. And if it does not, like in CPE, we ask ourselves to reflect: "Okay, how would I do it differently next time? What would be another or a more appropriate answer?" That would be, once again, responding in the immediacy. So it's no second-guessing and just trying to come forth.

Jim: And that action-reflection model is actually quite similar to working with a teacher in kōan study, where you maybe go in a number of times and your presentation doesn't cut it, and you go back out to work on it again. That parallel process is quite similar.

Alice: Exactly, that's the parallel process. And being willing—like in going through chaplaincy training—the willingness to be embarrassed, to not know, and trying again and again. That requires humility, surrender, letting go of many things, an unsheathing or taking off of our defenses. In the same way, in kōan study, that's the same thing: going to try each time, being thrown out of the room, being asked to leave, being told "No, it's not that." It develops a sense of persistence, dedication, and passion for the study. In the same way, I'm in spiritual care because I not only love it, I am passionate about it.

Jim: I have a question from Sam. Sam and I worked together; he was a CPE student at Mass General Hospital in the summer of 2019. Sam asks: "Would you please elaborate on what you mean by 'only this'? Often with patients and ourselves there are multiple feelings. Are you suggesting that we are present to this one by one?"

Alice: Great question, Sam. When multiple feelings come up, it's being able to sit with all of those—yes, and this "only." Even sitting with "all" becomes "only all these feelings." Only all of these things that come forth. Only that.

When I was talking about "only anger" or "only joy," it's more of one's personal practice. When you're feeling anything, and anger arises, "only"—being willing to not only acknowledge and recognize that, but being willing to just stay and sit with it. Then when it's joy, being willing to stay and sit with it. We don't rush through things.

In the same way, in spiritual care, when the person is complaining about certain things, we stay with that and not try to say, "Okay, can we move on to the next?" It's being able to be there, whether it's long or short. As you know, Sam, I use the word "tracking"—being able to track where the patient is at, and tracking as well where you're at as you engage during the encounter.

In Zen practice, this practice of "only this, just this" is a practice to invite oneself to be wholly here in the moment. Nothing else. Only this. And in being that, for me, it opens up to "all this" as well.

Jim: I have a question from Bruce: "Is this question I have been living for the last few years a kōan? 'What is this livening in me that is yearning to be revealed and lived?'"

Alice: Yes, Bruce. Yes. That constant search, that constant longing and yearning—"What is this?" I remember for me, the first call I had was when I asked myself at 14, "Who am I? What am I here for?" That was a kōan, and for decades I wrestled with that. Because Bruce, as you ask this question over and over in your waking time, in your prayer, this relentless asking or bringing that up somehow will bring some breakthrough. Breakthroughs happen in many ways, at different levels. So yes, it is a kōan.

Bruce: Thank you, Alice. It's a question I not only ask, but it arises in me. It's like a real living question. It's not something... it's a question that came to me. It becomes me.

Alice: Yes, a kōan is... yes. And hopefully as it becomes you and you become it, just see where it takes you. It opens up.

Bruce: Yes. This is a masterful talk, beautiful. Thank you.

Jim: Are there other questions or any reflections? Margaret has her hand up.

Margaret: Hi Alice. Alice is a co-sitter; we sit together with the Mercy Center East West group. Some years ago, I took this chaplaincy class and I served as a jail chaplain, which is very different from hospital chaplaincy. But in my over 15 years of service there, what I am looking back on is the line you said: "Impermanence is the only lasting thing."

I changed a lot from beginning to end. My first days in jail, I was very goal-oriented; I wanted people to learn the meditations I was teaching. By the end, I understood very clearly many of the things you're saying: just being there was what was needed and what served. Going every week for 15 years, I looked forward to it, and I was afraid of it because of how changed I became over those visits. There were things to be afraid of, things to be challenged by, and things to be thrilled about. The incarcerated people taught me my practice during those years. I'm not doing it now—I actually still miss it—but it is still teaching me. So this is a lifelong, as you said, passionate way of life, and I cannot think of anything that served me better than that.

Alice: Thank you, Margaret. I'd like to go back again to Sam's question about "only this." In terms of spiritual care, it also is a practice of being able to fully delve deeply into what we're feeling—not to run away, to truly get into it. As I share with students whom I've educated and supervised, I say that we can only go so far with a patient—with the depths of their anger, or their fears, or their frustrations, or their loneliness and longings, and also the heights of their joy—we can only do any of those things if we can do that with ourselves. We are not able to accompany them in the heights of what they feel or the depths of what they feel if we can't do that with ourselves.

Jim: Alice, if I may add another thought. I love when you brought up the kōan with Dogo and Zengen. Thinking about that in the context of chaplaincy, this idea of "I won't say." Even though Dogo is a teacher in that setup, he was kind of accompanying. They were almost like spiritual friends; they were walking together, they went to this funeral together. He even let him hit him! It was a very unusual dynamic.

The role of chaplain is as one that accompanies, not one that leads. In the same way, it can be very tempting in a situation where a patient may be wrestling with something to kind of give your own advice, to give your own perspective. There's that real sense of wanting to fix or wanting to get in there and do something. But instead, the kind of compassion of Dogo to hold back. As you said, he wanted Zengen to wrestle with this himself. In the same way with a patient, if we put too much of ourselves into the mix, we're kind of muddying the waters. We're not giving them the space to really work through what they need to work through. So I kind of appreciated the way that this relationship between Dogo and Zengen modeled the relationship of a chaplain accompanying someone who's working with these deep spiritual questions.

Alice: Well said, Jim. This brings to mind something that Dr. Alan Wolfelt has written on "companioning," and it encapsulates what you said. I'll send it to you if you don't have it.

Claire: Hello. Thank you so much, that was fantastic. I'm doing the course at the moment with Vanessa online. I've just been writing down lots of things. The "only this" that you were talking more about there when Sam asked, and this idea of equanimity. The word that was coming up for me—because it all sounds quite calm—is actually the fearlessness that is needed to stay in that. It really struck me what sort of courage it takes, in a way, to not interfere. That's the word that was coming. I'm a Soto Zen student, and the "not grasping and not pushing away"—how simple all these little phrases sound, but actually the ask of it. It was lovely listening to Margaret talk about her experiences and just thinking of the ask of that.

Alice: Thank you for sharing, Claire. Yes, because it really can get scary, especially when the stuff that doesn't look pretty comes up—the stuff that shows us our shadow, the stuff that brings up shame and rejection of ourselves. It takes courage.

One of the stories that reminds me about being willing to embrace all that I am, including the things that I'm ashamed of or that I reject, is this story by Milarepa⁸. Milarepa had an intense sitting practice; he lived in a cave. One day he went out to gather firewood, and when he got back, he saw all of these demons eating his food, reading his books, sitting on his cushion—being in his cave.

He looked at them and said, "Ah, wow. So what should I do?" So what he decided was he sat on his teaching cushion and he started teaching them the Dharma. The demons were like, "Yeah, yeah, yeah." Then he said, "Okay, eat my food, read my books, sleep on my bed. Stay as long as you want. I'm fine with it." And then they left. They got up and left.

But there was one who stayed behind. Milarepa looked at this demon and said, "Oh dear, this is a really, really tough one." Then later on, he approached the demon, opened this demon's mouth and said, "Eat me. Take me if that is what it needs. I am fine." He surrendered himself completely to that demon, and the demon disappeared.

Jim: Alice, we just hit the top of the hour. Thank you again for such an amazing presentation, really bringing the kōan tradition to life in the spiritual care context. It was quite remarkable. Next month we have Kevin Griffin joining us talking on the nature of suffering, addiction, and the Four Truths. Thank you.