Articles

Apollo 11, The Overview Effect and the Psychology of Awe and Self-Transcendence: Considerations for the Human Dimension in Healthcare

Gordon E. MacKinnon, PhD Professor and Chair, Department of Psychology and Behavioral Sciences Rochester University 800 West Avon Rd. Rochester Hills, Michigan 48307 Email: [email protected]

Author Note The opinions expressed herein are those of the author alone and do not represent those of the institutions he serves. The author has no conflicts of interest. The photographs in the article are in the public domain. The photograph to the left and the first three to follow are from NASA.

Abstract When landed on the moon in the summer of 1969 and Neil Armstrong stepped onto the surface, he spoke the iconic words, “That’s one small step for (a) man, one giant leap for mankind” (Hansen, 2018, p. 493). This was a watershed moment for Americans amid a country in turmoil. The Apollo project was announced by President John F. Kennedy only three weeks after the first American was launched into space. This created a new perspective of our planet in which White (2014) coined “The Overview Effect.” In essence, it describes a shift in cognitive awareness of our planet having been seen by astronauts, cosmonauts and taikonauts [Chinese astronauts] from space. The is experienced as a tiny entity in an overwhelming and vast universe. The experience often has a transforming perspective for astronauts of our planet and humanity’s place in the universe. This article explores the experience of The Overview Effect and the subsequent psychological experiences of awe and transcendence. The science of awe and self-transcendence explores powerful emotional experiences that have transformational qualities that promote health and well-being and can reorient one’s life in ways that bring about new goals and values that enrich the individual (Keltner and Haidt, 2003). The self is diminished, creating the potential for the ego to be set aside to attend to the social collective in prosocial ways. Experiences of awe and transcendence on earth are explored in this article as constructs that can be experienced in contemporary society and lead to transformative involvement in the lives of others. Awe and transcendence can refocus our attention on the human dimension in healthcare and promote a healing paradigm using the concepts of mindfulness, awe, compassion, and gratitude--and how these positively affect patients and practitioners. Keywords: overview effect, awe, self-transcendence, mindfulness, healthcare

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Introduction That’s one small step for (a) man, one giant leap for mankind. Astronaut Neil Armstrong

These iconic words, spoken by Neil Armstrong when he became the first human to step onto the moon on July 20, 1969, were transforming and historical. As the lunar module landed, Armstrong proclaimed, “Houston, Tranquility Base here. The Eagle has landed” (Hansen, 2018, p. 478). The television images of an astronaut stepping onto the surface of the moon transfixed the nation and the world. The experience of this moment provided Americans an opportunity to contemplate their place in the world, an experience of others and themselves in different and transforming ways. Reflecting on the event of witnessing, in real-time, the moon landing on television in that summer of 1969 allowed the sharing of an experience that was overwhelming and awe-inspiring in its scope and one that made a profound impact on our nation, thereby providing meaning beyond what we had previously known.

American history is full of moments that could be considered transforming. Such moments renew our spirit, challenge our sense of self, change our conscious trajectory as a country, and profoundly affect us as individuals in our social and collective experience. Fifty years ago, Americans found themselves in the midst of major social upheavals. The 1969 Apollo moon landing came while the nation was still reeling from tumultuous 1968 events such as the assassinations of Robert Kennedy and Martin Luther King, Jr., anti-Vietnam War protests, riots in major cities throughout the United States, and the crisis of the poor, etc. In the midst of all this, Americans found themselves in a country divided but also subsequently united through the Apollo 11 mission to the moon--the pinnacle of the U. S. space program (Chaiken, 2009).

Three astronauts entered their Apollo capsule in the early morning of July 16, 1969, and were launched from a Saturn V rocket into space. The astronauts were: Neil Armstrong, Commander; Edwin “Buzz” E. Aldrin, Jr., Lunar Module Pilot; and Michael Collins, Command Module Pilot. They were facing the unknown by going where others had not gone before. In fact, the mission itself seemed so impossible that William Safire wrote a speech for President Richard Nixon in the event that a tragedy occurred and the astronauts were lost (Safire, 1969). Although Armstrong thought they had a 90% chance of returning to earth, the landing on the moon in the lunar module he calculated at 50% (Chaiken, 2009). In the shadow of this historic undertaking were some 400,000 dedicated, skilled scientists and engineers, fulfilling a goal that was boldly articulated, planned, and executed with precision on an immense scale (Thimmesh, 2015).

The Apollo Project originated with an earlier address by President John F. Kennedy to a joint session of Congress on May 25, 1961, in which he declared, “I believe that this nation should commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him safely to the earth” (National Aeronautics and Space Administration, 2004). This declaration was profound in its scope of launching astronauts into space because manned had scarcely begun at that time. Alan Shepard became the first American in space. His historic 15-minute sub-orbital flight aboard the Mercury-Redstone “Freedom 7” capsule, was seen by millions of Americans on May 5, 1961, only three weeks before President Kennedy’s declaration.

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Reflecting on the fiftieth anniversary of the Apollo 11 moon landing provides an opportunity for those who witnessed and experienced watching it live on television and offering a new perspective for a generation of observers that can re-live the transforming effect of that momentous accomplishment in contemporary context. This reflection on the fiftieth anniversary brings to a new generation the accomplishments of the space program and allows for the exploration of the meanings of that program--and how these meanings impact us as a society and as individuals. This reflection calls us to ask of ourselves very serious and important questions. What can we learn from the astronauts’ unique view from space looking down at earth? What changes in our lives does their experience make manifestly possible, resulting from overwhelming new stimulating thought? And how can all this alter one’s perspectives and one’s very self to promote today the development of needed prosocial and positive behavior?

Danali Music Festival 2012

Astronaut Buzz Aldrin Looks Back at Tranquility Base

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The Overview Effect The effects of space travel are profound and the subject of many studies. Positive emotional experiences and responses to spaceflight have been studied using interviews with astronauts and their own written accounts of being in space (White, 2014; Ihle, Ritsher, and Kanas, 2006; Yaden, et. al., 2016). The benefits of having traveled into space include advances in technology, increased knowledge of the planet Earth, experiences of awe and personal transcendence, spiritual renewal, new perceptions of Earth, and a stronger appreciation for the beauty and fragility of our planet. As Suedfeld and Weiszbeck have underscored: The recent scientific literature is replete with studies of how the conditions of spaceflight- isolation, confinement, novel problems (e.g., living in micro-gravity, working in a spacesuit), remoteness from accustomed people and environments, discomfort, lack of privacy, social and physical stimulus monotony, dependence on life-support technology, etc.-affect the interaction among crewmembers and between them and ground personnel. Some of the core researchers in this area have devoted considerable effort to elucidating such issues, with special attention to multicultural (usually bicultural) crew (2004, p. C6).

The distinctive experience of space flight was only 10 years old when Apollo 11 headed for the moon. However, the lunar landing was to become the ultimate triumph for the U.S. space program. Although American astronauts had first seen their home planet in its entirety during the Apollo 8 mission that flew around the moon, the moon’s surface offered a special vantage point. The moon provided a completely different perspective for the astronauts and subsequently introduced this particular awareness into our human perceptual experience. White (2014) described this as the “Overview Effect.”

…a cognitive shift in awareness reported by some astronauts and cosmonauts during spaceflight, often while viewing Earth from orbit, in transit between the Earth and the moon, or from the lunar surface. It refers to the experience of seeing firsthand the reality that the Earth is in space, a tiny, fragile ball of life, ‘hanging in the void,’ shielded and nourished by a paper-thin atmosphere. The experience often transforms astronauts’ perspective on the planet and humanity’s place in the universe. Some common aspects of it are a feeling of awe for the planet, a profound understanding of the interconnection of all life, and a renewed sense of responsibility for taking care of the environment” (2014, p. 2).

This unique “overview” perception of the earth (and, arguably, renewal of a national consciousness of ourselves) was initiated by the Apollo 8 flight in 1968 when astronaut snapped a photograph, now known as “,” of the earth emerging over the lunar surface (Yaden, et. al., 2016). Anders is famously quoted saying, “We came all this way to explore the Moon, and the most important thing is that we discovered the Earth” (Museumofflight. org, 2008). This photograph is often Earthrise

34 Volume V, No. 2 Journal of Health and Human Experience Articles cited as launching and inspiring the environmentalist movement in the United States (Lazier, 1990). Chaiken (2007) cites, “But it wasn’t just earth’s small size that impressed the astronauts; it was the fact that our planet was so clearly alive and, in that way, apparently alone in the universe. In contrast to the bleak and lifeless moonscape, earth represented, in the words of Apollo 8 command module pilot Jim Lovell, ‘a grand oasis in the big vastness of space.’ ” (p. 54).

Subsequent to that is the first photograph taken of the whole earth attributed to the crew (Eugene Cernan, Harrison Schmitt, and Ronald Evans) known as “” (Petsko, 2011). The view of earth from this perspective created new perceptions and meanings about our planet as a cohesive whole, without borders, without conflict, and shrouded in beautiful color. The research of Yaden and colleagues (2016) explored the overview effect by reviewing the excerpts of astronauts from around the world. Their findings characterize astronauts’ reported experiences with the following themes: 1) The experience of appreciation and the perception of beauty; 2) An unexpected and even overwhelming emotion; and, 3) an increased sense of connection to other people and the Earth as a whole. Collins (2019), Apollo 11 Command Module Pilot, described this experience in his writings, I think the view from 100,000 miles could be invaluable in getting people together to work out joint solutions, by causing them to realize that the planet we share unites us in a way far more basic and far more important than differences in skin color or religion or economic system. The pity of it is that so far the view from 100,000 miles has been the exclusive property of a handful of test pilots, rather than the world leaders who need this new perspective, or the poets who might communicate it to them (p. 470). Blue Marble

This incredible view of Earth as described by Apollo 11 astronauts, illustrates White’s (2014) conception of the perceptual experience of viewing Earth from space and, for the first time, viewing it from the moon. Neil Armstrong, Commander of Apollo 11, described the experience as, "It suddenly struck me that that tiny pea, pretty and blue, was the Earth. I put up my thumb and shut one eye, and my thumb blotted out the planet Earth. I didn't feel like a giant. I felt very, very small" (MacRae, 2012). Michael Collins, the Command Module pilot for Apollo 11 reported, “Seeing the Earth from a distance has changed my perception.” (Collins, 2019, p. 470). Additionally, he expressed the experience of vastness (the overview effect) and the potential transformation as a result of transcendence: I really believe that if the political leaders of the world could see their planet from a distance of, let’s say, 100,000 miles, their outlook could be fundamentally changed. That all- important border would be invisible, that noisy argument suddenly silenced. The tiny globe would continue to turn, serenely ignoring its subdivisions, presenting a unified façade that would cry out for unified understanding, for homogeneous treatment (Collins, 2019, p. 470).

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Buzz Aldrin, Lunar Module Pilot for Apollo 11, described his own experience as found in the following: I looked high above the dome of the landing module. Earth hung in the black sky, a disk cut in half by the day-night terminator. It was mostly blue, with swirling white clouds, and I could make out a brown landmass. A wisp of color on the black velvet of space--a living Earth, floating like a space flower over the dead moon. Glancing down at my boots, I realized that the soil Neil and I had stomped through had been here longer than any of those brown continents. Earth was a dynamic planet of tectonic plates, churning oceans and a changing atmosphere. The moon was dead, a relic of the early solar system. Looking back from the dust of the moon enabled me, and millions of others around the world, to truly see Earth as a finite oasis of life in the universe, an organism capable of death, an organism that requires our stewardship (Aldrin, 2005, p. 21).

Astronauts, cosmonauts, and taikonauts make up a relatively small group who have seen the earth from space in this overview effect. Over the course of six Apollo missions to land on the lunar surface, only 12 astronauts actually walked on the moon while six were in lunar orbit aboard their respective command modules. The concept of this “Overview Effect” has created a profound and life-changing experience for astronauts. This perspective has also been described as sometimes having a transcendent quality, an altered state of consciousness that has stemmed from the “overwhelming emotion and feelings of identification with humankind and the planet as a whole” (Yaden, et. al. 2016, p. 1; White, 2014). Subsequent astronauts have echoed similar experiences of seeing Earth from space.

Alan Shepard, the first American astronaut to travel in space aboard the Mercury “Freedom 7” capsule in 1961 (Commander of Apollo 14 and fifth man to walk on the surface of the moon), reflected on the overview effect: “If somebody had said before the flight, “Are you going to get carried away looking at the earth from the moon?” I would have said, “No, no way.” But yet when I first looked back at the earth, standing on the moon, I cried. (Nardo, 2014, p. 46).

Astronaut Russell Schweickart (Lunar Command Module Pilot for Apollo 9) described his experience stating that, The Earth is so small and so fragile and such a precious little spot in that universe that you can block it out with your thumb, and you realize on that small spot, that little blue and white thing, is everything that means anything to you--all of history and music and poetry and art and death and birth and love, tears, joy, games, all of it on that little spot out there that you can cover with your thumb. And you realize from that perspective that you’ve changed, that there’s something new there, that the relationship is no longer what it was (White, 2014, p. 36-37).

Gene Cernan was the pilot for Gemini 9A in 1966, Lunar Module Pilot for Apollo 10 in 1969, Commander for Apollo 17, and the eleventh man to walk on the moon. He is quoted in White (2014), “You . . . say to yourself, ‘That’s humanity, love, feeling, and thought.’ You don’t see the barriers of color and religion and politics that divide this world. You wonder, if you could get everyone in the world up there, wouldn’t they have a different feeling?” (p. 37).

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Several astronauts have had such changing perspectives of their own experiences in space. William Anders, Apollo 8 Lunar Module Pilot and photographer of “Earthrise,” is quoted as describing the unintended consequence of seeing earth: "We came all this way to explore the Moon, and the most important thing is that we discovered the Earth" (Museumofflight.org, 2008).

A quote by Karen Nyberg, Shuttle Space Mission STS-124, Mission Specialist 1, as she reflected on the impact of being in space, holds additional importance. In the future, I would like to be more of an advocate for animal conservation. Every single part of the Earth reacts with every other part. It’s one thing. Every little animal is important in that ecosystem. [Seeing the planet from above] makes you realize that, and makes you want to be a little more proactive in keeping it that way. If I could get every Earthling to do one circle of the Earth, I think things would run a little differently (Drake, 2018, p. 74).

Kathleen Sullivan was with Space Shuttle missions STS 41-G in 1984 as Mission Specialist 1 and the first woman to walk in space. For STS-31 in 1990 she was Mission Specialist 3, and for STS-45 in 1992 she was Mission Specialist 1. Sullivan importantly reflected that, “The thing that grew in me over these flights was a real motivation and desire … to not just enjoy these sights and take these pictures but to make it matter” (Drake, 2018, p. 72).

Another powerful reflection is from Nicole Stott, who was International Space Station Flight Engineer 2 for Expedition 20; Flight Engineer 5 for Expedition 21; STS-128 Mission Specialist 5; STS-133 Mission Specialist 1, and who painted the first watercolor during one of those missions, states: You realize you’re not from Florida or the United States. You’re an earthling. The bottom line is we are all earthlings…..I want people to look at [the paintings] and maybe think differently about where we live…..You can see Earth as your home, really looking at your home planet. People don’t consider it that way all the time. People don’t realize they’re in space. And if you think about it that way perhaps you’ll take better care of it (Billman, 2016).

White (2012) has developed the idea of the overview effect and considers the potential it has for transforming and transcending the lives of individuals on earth. Although only 572 individuals have been launched into space (Worldspaceflight.org, 2019), this perspective is contemplated as a philosophy of change in the world. White (2012) advances the idea of the potential for creating a more peaceful world through the overview effect. How would everything change if we began to think of ourselves as a seven billion member team, a crew on a spacecraft? What if we expanded our thinking to include other sentient life as part of that team, and perhaps even beyond, to consider everything on the Earth as team members? Would it reduce all conflict on the Earth? No, there are conflicts on teams and crews, disagreements about the best way to proceed in winning a game, a battle, or a trophy. However, the balance between cooperation and conflict might well be restored to something more appropriate to a species seeking to evolve and prosper (p. 29).

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Awe and Self-Transcendence Space travel can have an enduring, powerful, and long-lasting positive impact on the psychological well-being of astronauts (Ritsher, Ihle, and Kanas, 2005; Ihle, Kanas, and Boyd, 2006; Suedfeld and Weiszbeck, 2004). Astronauts come from different backgrounds--engineers, scientists, pilots. Some are religious; others are non-religious--and yet they report experiences that seemingly go beyond the hard-nosed scientific facts to the experience of emotion. As some reflect: “On the face of it, awe and wonder are experiences that transcend religion, culture, politics, and just about every other ‘contextualizing’ feature of human existence that one could imagine” (Gallagher, Reinerman-Jones, Janz, Bockelman, & Templer, 2015, p. 2). As some reflect: The overview effect might be, from the astronaut’s perspective, one of the most positive aspects of space flight, raising new questions about the effect of powerful, transformative experiences on well-being in extreme conditions. Astronauts’ descriptions of this experience suggest something deeper and more intense than a mere acknowledgment of beauty; their language reflects feelings of wonder, reverence, humility, and unity. Among other things, the feeling of viewing Earth from space might be identified as awe (Yaden, et. al., 2016, p. 4).

As much as the overview effect is a meaningful aspect of the astronauts’ experience in space, Yaden, et. al. (2016) continue to propose: …..that the overview effect might usefully be understood in terms of awe and self- transcendent experience, with concomitant changes to the observer’s self-schema and value system, which in some cases could be considered transformative…..Awe and self- transcendence are among the deepest and most powerful aspects of the human experience; it should come as no surprise that they emerge as we gaze upon our home planet and our whole world comes into view (p. 8).

There has been a resurgence of interest in the psychological constructs of awe and self- transcendence in the scientific literature, particularly in the larger context of emotion research over the past few years. Though its origin as a psychological concept has historical foundations, it has typically been viewed through the lens of religion, philosophy, and sociology (Keltner and Haidt, 2003). Maslow (1964) made the most serious treatment of the subject by interviewing hundreds of people and developing descriptions of “peak experiences.” In describing aspects of self-actualizing individuals, he considered awe and transcendence as characteristics that could be experienced in one’s daily life in the midst of family, friends, and neighbors. Awe is often associated with great works of art, a beautiful landscape, an incredibly clear starry night, an ocean sunset, the eclipse of the sun or moon, witnessing childbirth, viewing Earth from space, and overwhelming scenes of devastation.

The modern research literature of the concept of awe and its place in emotion research began with the now classic article by Keltner and Haidt (2003). They defined awe as “the feeling of being diminished in the presence of something greater than the self ” (Keltner and Haidt, 2003, p.297). They argued that it is a specific “complex” emotion, what they have termed a “prototypical model of awe.” The meaning of prototypical, in this case, is that it can be a representative emotion that may encompass several concepts that can all be related more directly to awe or are in a more divergent conceptual domain.

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Some variants may be so similar to the prototype that they still share the same name (e.g., embarrassment after a faux pas, and embarrassment at being the center of attention). Other variants are different enough that they warrant a different name (e.g., embarrassment vs. shame as members of the ‘self-conscious emotion' family) (Keltner and Haidt, 2003, p. 303).

Within this model, they posit that, as an emotion, awe has more or less diffuse boundaries but can be characterized by two stable, dimensions of cognitive appraisal. These are summarized by Keltner and Haidt (2003) and Chirico and Yaden (2018, p. 223) as: 1. Vastness: this appraisal dimension refers to the perception of stimuli as perceptually and/ or conceptually vast. Both sweeping views and understanding a complex theory (such as theory of relativity) could be counted as potential elicitors of awe. 2. Need for accommodation: this appraisal dimension refers to altering mental frames or schemas according to new incoming information. These appraisals account for the diverse nature of the stimuli that can elicit experiences of awe.

Vastness refers to any experience where an awe-inducing stimulus is perceived as much larger than the self or the experience is beyond a person’s level of ordinary experience or frame of reference. Accommodation, then, is an internal--and sometimes external--response from this emotional appraisal in which the self is diminished (altered mental frame or schema) and needs to cognitively adapt to new information. This occurs when one’s frame of reference is expanded beyond one’s current sense of the environment, thereby making cognitive accommodation necessary.

Vastness means that the stimulus strongly challenges the perceiver’s accustomed frame of reference. While this may be a matter of sheer physical size (e.g., the Grand Canyon or the Eiffel Tower), a stimulus can also be vast in terms of explanatory power (e.g. a theory of physics), social import (e.g. a person or historical event that affects millions of people), sensory detail (e.g. a complex musical or visual piece), conceptual breadth (e.g. a work of art or literature that ties together a rich range of ideas, breaking new conceptual ground), or volume of unexpected information (e.g. the drop of pond water that contains an elaborate world of its own) (Shiota, Thrash, Danvers, and Dombrowski, 2014, p. 363). The experience of awe can be pleasurable and uncomfortable or overwhelming (Keltner and Haidt, 2003; Yaden, et. al., 2016; Shiota, Keltner, and Mossman, 2007). Although arising out of emotion research, awe has been characterized as having several qualities that place it on the border between an emotional state and altered state of consciousness due to its capacity to alter the senses of time, space, and self (Piff, et. al., 2015).

When a stimulus is associated with awe and is experienced as perceptually vast in its scope, the existing mental and cognitive structures of one’s sense of self have difficulty making accommodations to the experience. As one’s sense of self is experienced as diminished, accommodation of the experience is motivated by engaging in prosocial behaviors within the context of social groups and interactions with others (Piff, Dietze, Feinberg, Stancato, and Keltner, 2015). This is a social constructionist view as individuals collaborate with their social group to engage in a collective action for others. Piff et al. elaborate and note, “Action within collectives, including collaboration, cooperation, and coaction, requires a diminished emphasis on the self and its interests and a shift to attending to the larger entities one is a part of (e.g.,

Journal of Health and Human Experience Volume V, No. 2 39 Articles small groups, social collectives, and humanity)” (p. 883). Engaging in prosocial behavior, then, requires the positive emotion of awe and a diminishment of the self and self-identity.

Awe, as a positive emotion, produces a sense of a small self (a diminished sense of self and identity) which is a central characteristic. The experience of the self is diminished as the dimension of something perceived as vast takes overwhelming precedence of the perceptual field and the experience of the self merges into the background. The perception of self and one’s identity as it merges into the background potentially generates the possibility of transformation (Chirco and Yaden, 2018).

Piff, Dietze, Feinberg, Stancato, and Keltner (2015) investigated the effect of awe as central in relational and prosocial behaviors. They state that because “. . . awe can trigger a relative diminishment of the individual self and its interests vis-a-vis something perceived to be more vast than oneself, we reasoned that awe should promote more selfless, other-oriented behaviors” (p. 895). Awe and its impact on the small self (feelings of smallness, insignificance, and something greater than the self ), as a central positive emotion, accounts for a sense of altruism, generosity, and prosocial behaviors toward others. In five studies conducted by experimentally inducing awe, subjects demonstrated generosity in an economic game. They endorsed more ethical decisions, showed increased generosity toward strangers, and reported more prosocial values. A naturalistic induction of awe (such as looking up in the midst of tall, towering trees) led to increased helpfulness, greater ethicality, and decreased entitlement. The experience of the small self affects prosociality in a broad fashion.

Self-transcendence, then, begins to emanate from an awe-inspiring experience and has the potential to create cognitive and schematic changes in the ways that people perceive themselves (small or diminished self ) and others in generally positive ways. It may lead to profound changes motivated and directed outwardly rather than inwardly, culminating in prosocial behaviors such as in a humanitarian emphasis, altruism, and living one’s life for the good of others. As Piff, Dietze, Feinberg, Stancato, and Keltner (2015) note in their investigation “…..awe, although often fleeting and hard to describe, serves a vital social function. By diminishing the emphasis on the individual self, awe may encourage people to forego strict self-interest to improve the welfare of others” (p.897).

The experience of self-transcendence from space travel and walking on the moon (the “Overview Effect”) can be seen in the life-changing motivations and subsequent activities of some astronauts upon their return to earth. The personal transformation of astronauts has fostered their own motivation to create organizations and pursue directions that positively influence humanity in their own personal attempts to create a better world.

Edwin “Buzz” Aldrin, Jr. (Command Pilot for Gemini 12, Lunar Module Pilot for Apollo 11, and second man to walk on the moon) has been a lifelong advocate for continuing and increasing space travel and is considered a “Global Statesman for Space,” particularly missions to Mars (BuzzAldrin.com, 2019).

Edgar Mitchell (Apollo 14 Lunar Module Pilot and sixth man to walk on the moon) has been quoted: "In you develop an instant global consciousness, a people orientation, an intense dissatisfaction with the state of the world, and a compulsion to do something about it. From out there on the Moon, international politics look so petty. You want to grab a

40 Volume V, No. 2 Journal of Health and Human Experience Articles politician by the scruff of the neck and drag him a quarter of a million miles out and say, 'Look at that, you [censored].” He goes on to say: “We went to the Moon as technicians; we returned as humanitarians" (quoted in Mitchell’s online bio for the New Mexico Museum of Space History, 2019). The Institute of Noetic Sciences (IONS) was initiated by Mitchell in 1973 because he was motivated by his personal experience in space to bring together science and inner experience, researching altered states of consciousness.

James Irwin (Apollo 15 Lunar Module Pilot and eighth person to walk on the moon) created the High Flight Foundation following his personal conversion experience to Christianity to encourage others to consider faith and “experience the Highest Flight possible with God.” He is famously quoted as saying, “Jesus walking on the Earth is more important than man walking on the moon” (High Flight Foundation, 2019).

Charles Duke (Apollo 16 Lunar Module Pilot and tenth person to walk on the moon) attributes his re-discovery of Christianity, after an accomplished Apollo career, to have been a major factor in the restoration of his marriage and life in general (Duke and Duke, 2011).

Awe has been incorporated in studies of emotion and emotional states. Considered a positive emotion with the potential for self-transcendence, it has been significant in studies where prosociality, altruism, compassion, and gratitude are experienced (Keltner and Haidt, 1999, 2003). Emotion research, whether considering emotions as positive or negative, focuses on typically context-specific experiences as elicitors of those emotions based on an individual’s internal scripts (Russell, 2003). Although there are differing theories of emotion, there seems to be a consensus regarding the internal focus of how emotion is used in the service of the self. Emotion has been the central and core construct to the experience of human beings, both positive and negative. This is a long-standing conception of emotion that views its function is self-preservation and self-serving. The intrapersonal functions of emotion have been described by Levenson (1999) where emotions “serve to establish our position vis-à-vis our environment, pulling us toward certain people, objects, actions, and ideas, and pushing us away from others” (p. 481). In addition, Keltner and Haidt (1999) have argued for the social-functional nature of interpersonal emotions, suggesting that emotions structure social relationships such as parent- child and romantic relationships.

Self-transcendence emanates from experiences of awe in which the vastness of the eliciting stimulus diminishes one’s sense of self (the small self ) and leads to an internal accommodation which may constitute an external response (Chirco and Yaden, 2018), which is self-transforming through the construction of new meanings to the self. Gaggioli (2016) draws on the functions of such transformative experiences: First, a transformative experience is a sudden and profound change in the self-world, which has peculiar phenomenological features that distinguish it from linear and gradual psychological change. Second, a transformative experience has an epistemic dimension and a personal dimension: not only it changes what you know, it also changes how you experience being yourself. Third, a transformative experience can be modelled as an emergent phenomenon that results from complex self-organization dynamics (p. 98).

The perception of self, that merges into the background as the small self, can become more accepting of others and promote prosocial behaviors. “Awe exerts a specific and likely

Journal of Health and Human Experience Volume V, No. 2 41 Articles unique effect on prosociality that is distinct from the influences of other positive emotions, not confounded by more general positive affect, and not reducible to experiences in nature (Piff, Dietze, Feinberg, Stancato, and Keltner, 2015, p. 896).

Considerations of Awe, Self-Transcendence, and the Human Dimension in Healthcare The predominant focus of research for psychologists investigating emotions has centered around negative emotions such as anger, hostility, sadness, disgust, fear, and anxiety. Considering how important it is to understand these emotionally charged experiences, recent research has been focused on more positive emotions such as awe, compassion, and gratitude and their positive affect for health such as being associated with lower levels of proinflammatory cytokines (Stellar, et. al., 2015), supporting a link between positive emotions and health in older adults (Ong, Mroczek, and Riffin, 2011). And in a review by Lyubomirsky, King, and Diener (2005) the relevant experimental literature reveals compelling evidence that positive affect fosters the following resources, skills, and behaviors: sociability and activity, altruism, liking of self and others, strong bodies and immune systems, and effective conflict resolution skills.

The science behind awe and transcendence has increased our awareness of facets of everyday living that encompass reactions to the environment. Awe and transcendence encourage us to step out of the restrictions and confinements of the ego to a diminishment of self, and that allows for changes in one’s mental structures to more transcendent prosocial actions. Bai and colleagues (2017) focused several experiments on the central construct of awe and the concept of the diminished or small self as it is experienced in daily life, the laboratory, and in natural settings within the cultures of China and the United States. They found that “on days when participants experienced awe, their perceived self-size was smaller than on days when they experienced joy, even after controlling for general positivity and negativity” (p. 191). The general conclusion of these authors was that individuals who experience awe in daily life find a diminishment of the self (small self ) which allows the individual to become more aligned to other people and to enter into more social interactions outside of the self that promote the integration into social groups.

The sense of self is additionally affected in other ways leading to positive experiences and the resultant diminishment of the self. Several experiments investigating awe by Rudd, Vohs, and Aaker (2012) confirmed their predictions that experiencing awe, relative to other states, caused people to perceive that they had more time available and less impatience. Furthermore, by expanding time perception, awe as compared with other states, led participants to more strongly desire wanting to spend time helping other people and to partake in experiential goods over material ones. A small dose of awe even gave participants a momentary boost in life satisfaction. Thus, these results not only have implications for how people spend their time, but also underscore the importance and promise of cultivating an experience of awe in everyday life. Changes in decision making and well-being were due to awe’s ability to alter the subjective experience of time. Experiences of awe tend to bring people into the present moment and being in the present moment underlies awe’s capacity to adjust time perception, influence decisions, and make life feel more satisfying. Piff, Deitze, Feinberg, Stancato, and Keltner (2015) have directed research that argues for awe to be experienced in a more general sense: “…..(by) diminishing the emphasis on the individual self, awe may encourage people to forego strict self- interest to improve the welfare of others” (p. 897).

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McCormack, MacIntyre, O’Shea, and Herring (2018) found in their research that health and mental care are emotionally taxing professions that can lead to mental and emotional exhaustion and compassion fatigue. Their review was designed to synthesize the research evidence for the prevalence and causes of burnout among applied psychologists and allied mental health professionals. They found that the leading cause of burnout for applied psychologists was emotional and cognitive exhaustion and the subsequent distancing from patients. In another study of 7,288 physicians, Shanafelt and colleagues (2012) found that 45.8% experienced at least one symptom of burnout using an inventory that measured burnout. The higher levels of burnout were associated with more direct levels of care (family medicine, general internal medicine, and emergency medicine). Van Mol, Kompanje, Benoit, Bakker, and Nijkamp (2015) reviewed the prevalence rates of compassion fatigue, burnout, vicarious traumatization, and secondary post-traumatic stress among intensive care units (ICU) personnel. Although definitional perspectives and measuring instruments in these studies were criticized, the conclusion that ICU personnel are faced with emotional distress and highly charged emotional environments (for patients, relatives, and healthcare professionals) which may impact personal lives mentally and physically was well documented.

Konis and colleagues (2015) conducted a study with 200 hospital professionals that included physicians, university educated nurses, assistant nurses, other health professionals, and medical/nursing students. The results of their study indicated that healthcare workers’ mental and emotional health can be adversely affected by their work environment and the coping strategies they employ. Their findings suggested that workers in healthcare are far more susceptible to stress and burnout than workers in other industries. The personal repercussions can include problematic alcohol use, relationship and family problems, compromised satisfaction in work-life balance, symptoms of depression, and suicidal ideations. Of particular note, there are professional implications to how it affects quality of care for patients.

When patients meet with their practitioners, whether in their physician’s office, at their bedside in the hospital, in a psychologist’s consultation office, or alongside family members, ultimately, it is the practitioner’s interactions with patients that define the fundamental purposes and meanings of treatment for patients. Interactions in healthcare, for both patients and practitioners, are fundamentally social encounters which can facilitate healing. For example, cancer patients are often thrust into diagnosis and treatment decisions (in some cases there may only be one treatment available for a particular disease) in which relying on the physician’s/ surgeon’s skills is all the patient has. The treating physician uses one’s skills and the available technology for the goal of alleviating pain/suffering. What is often left out of the mix is the personal meaning that patients give their disease process and how important the human relationship is with their practitioners. Research has shown that social support has a buffering effect on stress through interactions and relationships both for patients and practitioners.

Thorne and colleagues (2005) have shown that cancer patients have a desire for human connection: While we may never be able to quantify a relationship between communication experiences and physiological aspects of disease progression, it seems evident that communication between patients and providers has a profound impact on the human experiences of undergoing care for cancer, living with cancer, and making choices in relation to the challenges of that disease (p. 896).

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When patients see their practitioners, they are often hoping that their healthcare team may offer a response that leads to change, hope, and health, physically and mentally.

The interactions we have with patients is ultimately a human, social experience and, at the heart of this experience, are the emotions expressed and experienced within each of us. As practitioners, we are affected by the constant emotional pain and suffering of our patients. Accompanying such experiences are the awe-inspiring reactions of patients who demonstrate courage, returns from the brink of death, successfully living with and moving beyond disease processes. The healthcare workplace is one of the most stressful environments to work in, which can lead to negative and adverse psychological reactions and the potential for burnout among healthcare workers. Street, Jr., Makoul, Arora, and Epstein (2009) focused on the healing pathways of communication between patients and practitioners and how they affect health outcomes. They identified seven pathways through which communication can lead to better health which included “increased access to care, greater patient knowledge and shared understanding, higher quality medical decisions, enhanced therapeutic alliances, increased social support, patient agency and empowerment, and better management of emotions” (p. 295). In a study by Converso, Loera, Viotti, and Martini (2015) they found that a patient’s gratitude affected nurses’ experiences in three dimensions of burnout. Specifically, perceived support/gratitude expressed by patients reduced nurses’ emotional exhaustion and depersonalization and increased their sense of personal accomplishment. These results affected oncology nurses more positively than emergency room nurses.

Healthcare is, first and foremost, a social and relational experience as well as one’s participation in the healing process, physically, mentally, emotionally, and spiritually. Patterson (2018) recognized that the many experiences of awe that medical students experience in training are often not reinforced: “…..students talk about the deeply moving experience of first hearing fetal heart sounds, delivering their first baby, assisting in major surgery or being with the dying.” Patterson advocates for a double vision whereby the focus should be: …..on the biological, physiological and pathological in the conventional medical scientific care of our patients. And we must simultaneously focus on the unique human being we are treating, especially being respectful, amazed and in awe of their ability to navigate the health care system and the many barriers and obstacles of disease, trauma, mental illness, family upheaval, financial stress, aging, and the approach of death itself (2018).

Healthcare itself and its practitioners are the creators of meaning in the healthcare setting and face the emotionally charged experiences of people who are hurting, in pain, and suffering. Patients contribute by adding their own personal meaning to a healthcare encounter and showing support for healthcare personnel who are caring for them.

The result of advanced technology in medicine and increasing financial imperatives have forced organizations to make significant changes to healthcare delivery. One of the potential consequences is increasing dehumanizing experiences for patients and practitioners. To counter such potential dehumanization, new initiatives are underway. The healthcare industry has found several initiatives to promote the human connection in healthcare. Examples of these initiatives include mindfulness skills through Compassion Cultivation Training (2019). CCT is an 8-week educational program designed to help one improve resilience and improve feeling more connected to others--ultimately increasing one’s overall sense of well-being. This has been in

44 Volume V, No. 2 Journal of Health and Human Experience Articles the Sharp Healthcare System (2018) for professionals in healthcare providing the needed skills for developing a compassionate and collaborative healthcare environment for both patients and practitioners. The Center for Humanizing Critical Care (2019) was established to bring together researchers and clinicians in assisting patients and their families to process and counter life-threatening illnesses and injuries while keeping their humanity intact. They cite their goal is to transform the way patients and their families are cared for in intensive care units while assisting them through the transition back to normal life.

Positive emotional interactions that utilize awe, compassion, empathy, gratitude, and mindfulness have a growing research base in healthcare, promoting these positive emotions and advocating for the positive human dimension in healthcare. When these are employed in healthcare settings, positive effects have been experienced for both patients and practitioners. Decety and Fotopoulou (2015) have acknowledged the therapeutic effectiveness of empathy and compassion in the clinical setting. When patients feel they are heard and understood, the facilitation of treatment effectiveness can lead to improved patient outcomes. When patients’ communications of their thoughts and feelings are taken seriously, they are likely to be less defensive, and more willing to supply information to build a sense of trust with their healthcare team. This expands the prospects for improved patient satisfaction, patient adherence to treatment regimens, and increased physician good health/well-being and professional satisfaction. A report from a conference on advancing compassionate care (Lown, et. al., 2014) presents a process model of compassion. The approach integrates concepts from cognitive and social science research as well as the research evolving in the social neuroscience of empathy and compassion. The framework of this project was designed to develop collaborative relationships between patients/families and their healthcare team.

The positive aspects of the human relationship in healthcare cannot be underestimated as a dimension in the total aspects of healing, trust in the healthcare relationship, satisfaction in patient and physician health, and overall well-being in healthcare. Experiencing awe in the human condition, and utilizing elements of mindfulness, compassion, and gratitude, can offer opportunities to change one’s mindset and create medical actions that transcend the conventional approaches to healthcare treatment. As healthcare systems become more attuned to this aspect of the human dimension in healthcare, and begin to address this through training in awe, compassion, and mindfulness, new avenues of research can begin to address the nuances of how patients and practitioners benefit.

Concluding Discussion The Apollo 11 moon landing of 50 years ago gave us a perspective of the moon and our world we had not experienced previously. As the astronauts of the Apollo 11 mission are quoted as expressing a sense of awe over their view of Earth from the moon, other astronauts have also had similar experiences. White (2014) coined the term “The Overview Effect” to describe these encounters that astronauts have experienced while in space. White’s term represents …a cognitive shift in awareness reported by some astronauts and cosmonauts during spaceflight, often while viewing Earth from orbit, in transit between the Earth and the moon, or from the lunar surface….The experience often transforms astronauts’ perspective on the planet and humanity’s place in the universe. Some common aspects of it are a feeling

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of awe for the planet, a profound understanding of the interconnection of all life, and a renewed sense of responsibility for taking care of the environment (p. 2).

The science of awe and self-transcendence has shown how experiences of awe in everyday life create a diminishment in one’s sense of self and identity (i.e. the small self ) which broadens a person’s capacity to become relatively open to awe, altruism, compassion, gratitude, and mindfulness. This elevates social and prosocial connections to others. Piff, Deitze, Feinberg, Stancato, and Keltner (2015) have supported experiences of awe in a more general sense. As they promote: “….diminishing the emphasis on the individual self, awe may encourage people to forego strict self-interest to improve the welfare of others (p. 897).

Emotion research over the past few decades is focused on positive emotions such as awe, compassion, and gratitude. Learning to cultivate an attitude of awe becomes a buffer to the stresses, compassion fatigue, and burnout associated with more conventional and relationally distancing experiences in patient care. Patients and practitioners can both experience the benefits of awe and the subsequent self-transcendence experiences that allow for more human connectedness in healthcare settings. When patients feel heard by their practitioners, it enhances healing, increases trust, promotes adherence to treatment regimes, reduces defensiveness, improves patient satisfaction, improves physician health and professional satisfaction, and increases feelings of well-being. The role of enhancing the human dimension in healthcare cannot be underestimated as an essential positive and healing part of healthcare treatment itself. As the Journal of Health and Human Experience so strongly has promoted, ultimately and primordially healthcare is human care. Picture 4

“Starry Night” (Caption:) by Vincent Van Gogh, 1889

“Starry Night” by Vincent Van Gogh, 1889 46 Volume V, No. 2 Journal of Health and Human Experience

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