There is an old story that illustrates some points that I believe are central to the practice of clinical health psychology. It goes something like this:
Once there was a carpenter who was working on a house. He had a favorite hammer that he typically used, one larger than is commonly seen. It looked more like a small sledge hammer than anything else. Even a person who knew nothing at all about carpentry would regard it as a most formidable-looking tool.
The carpenter typically guided his hammer blows with great accuracy. On this particular day, though, while lost in thought, the carpenter had the misfortune of missing the nail entirely and striking his thumb with great force. For an instant, the carpenter stared in stunned disbelief at his smashed thumb, a sense of detached horror rising within him. Had it ended there, it might have been tolerable. But of course, it did not end there. In the next instant his thumb exploded with pain.
The carpenter had never felt pain like this before. It overwhelmed him. It consumed him. He screamed a curse at the hammer. He screamed a curse at himself. The pain swept away his reason. For a few seconds it was so bad that he was even afraid that he would die. But seconds passed, and he did not die. As he began to regain his rationality, he realized what he had done to himself, and that the overwhelming pain would go on and on. Then an even more frightening thought struck him: He was going to live.
Had it been the old psychoanalyst, Otto Rank, reading this essay, at this point I suspect that he would have been at least been smiling. Perhaps he would have even laughed out loud. This joke embodies a central tenant of Rank's Theory, a notion that anyone who practices clinical health psychology has probably intuitively surmised. For those who are unfamiliar with this often forgotten theory, Ernest Becker's Pulitzer-prize winning book on Rank, The Denial of Death, is recommended.
Rank believed that the core of the personality is inhabited by two profound fears: the fear of death and the fear of life. Of these two, the fear of death seems more immediately understandable. Rank insightfully noted though that people may also fear life as well. When life becomes too difficult, too overwhelming, too painful, the thought of continuing to face life seems so frightening that the idea of death seems preferable. It is, in fact, when persons are overwhelmed by life, that they became driven toward suicide as an alternative.
Perhaps in no other area of psychology are Rank's ideas seen as clearly as in the field of clinical health psychology. Nowhere is death anxiety seen more clearly than in patients suffering from terminal or potentially terminal conditions. Facing one's own mortality is a frightening experience. In response to even the possibility of a diagnosis of a terminal condition, some people respond the way a deer does at night to the oncoming headlights of a car. They freeze, and their very inability to act may further jeopardize them. Death anxiety, when experienced has a way of stopping one in one's tracks. It shreds the fabric of one's life, and turns it inside out. In an instant, matters that had seemed important become trivial, and a person can become disoriented by it all.
In contrast, there are many medical conditions that, while not terminal, can leave the patient experiencing chronic pain, having to face living life with gross disfigurement, the loss of physical function, or the loss of mental function. These could be thought of as "little death" experiences. They are not the end of life, but the end of life as a person knew it. Anyone suffering such a loss is likely to go through a grieving process. The sense of Self that was known has ended.
It should not be forgotten that the Self can die before the body. The runner who is injured and becomes a paraplegic, finds that the sense of identity as a runner has ended. The pain of facing this transition is Rank's life anxiety. In its most extreme form, death can be perceived as an attractive alternative to enduring the labor pains involved in the creation of a new sense of Self. A central part of clinical health psychology is helping patients to deal with such matters of life and death. To do so, the psychologist must be willing to descend with the patient into the depths of the medical inferno.
The treatment of death anxiety can stretch a psychologist into realms beyond the scientific. As patients struggle to adjust to the notion of their own death, or its possibility, their concerns often move into the realm of existential and spiritual considerations. They may wonder about the meaning of their lives, fear death itself, and beyond this, may wonder if there is a life after death. These are non-scientific concerns, but nevertheless, ones the psychologist must feel comfortable exploring. If the psychologist has not dealt with these issues, he or she will probably have little success in guiding patients through these times.
Even the strongest person can be shaken by the horrors of some medical cures. Beyond this, life anxiety is even more common in persons with preexisting emotional difficulties or characterological disorders. These persons may go through life like eggshells, intact and functioning but with underlying psychological fragility. When faced with an extreme life stressor, such a person may simply shatter.
I am aware of a case where a woman was diagnosed with cancer, but was given a relatively good prognosis provided that she was willing to undergo chemotherapy. However, this woman was told that a side effect of this chemotherapy would be that for the six months to a year that she was undergoing it, she would go bald.
This woman's self-esteem had always been heavily invested in her appearance, and the thought of going bald meant to her the end of her identity as she knew it. She feared that if she was bald, no one could stand to look at her, much less love her. More deeply, she did not believe she could tolerate the shame of having anyone look at her. She did not believe that she could tolerate looking at herself.
The woman considered the possibility of treatment, and finally decided that she would rather die. The thought of having to deal with such an assault on her self-esteem was simply too much: She was overwhelmed by life anxiety. It is my understanding that she went on to reject treatment and accept the consequences.
There are many other examples of the above scenario. Patients who fear pain, needles or surgery may refuse treatment outright, or avoid entering a hospital altogether. Once a patient told me that out of a fear of germs, she would rather die than be admitted to a hospital. Another patient confided that he would choose life in a wheelchair over a rectal examination for a lumbar spinal chord injury. More commonly, patients' fears may simply compromise their motivation for their own rehabilitation.
In cases of life anxiety, the clinical health psychologist must find ways of supporting the patient through the course of necessary treatment. The focus here, of course, is not to correct the psychological difficulty, for that is of secondary importance. The primary goal is first to get the person through the medical treatment they require. Matters of life and death take precedence. It is only after this has been accomplished that the psychological difficulties can be addressed.
Some time ago, I met with a woman who had a heart condition. I will refer to her as Betty. Betty had gone to see her physician, who, she reported, informed her that she probably had only six weeks to live. Betty was thunderstruck by this, and was flooded by overwhelming anxiety.
In the weeks that followed, a number of psychological issues which had laid dormant for years came boiling to the surface. These had to do with unresolved feelings of guilt, and fears of facing her own mortality. Betty became morbidly preoccupied with her own death, and became panicked when she convinced herself that upon death, God would sentence her to Hell for eternity.
About six weeks later I met with Betty for the first time. She was in a state of stark terror, saying that she had only days, if not seconds to live. Her life had become a non-ending panic attack, and she was hoping to resolve some of her psychological and spiritual issues before she died.
Betty went back for more medical tests, and I consulted with her physician. It came as a surprise to all of us when the tests found that now she was no longer in any imminent danger of dying. Initially after hearing the news, Betty felt both relief and anger. Despite this though, she continued to feel panicked, preoccupied with guilt, and concerned about death and the afterlife. Eventually she became exhausted and sank into a deep depression. She found continuing to live to be an unbearable burden, and she began thinking about death as a relief from the unbearable pain of life. At that point she began to have suicidal ideation.
Treatment of a disorder like this is complicated. Betty continued to see her physician, who now prescribed both antidepressant and antianxiety medications for her depression and panic conditions. Ironically, her severe panic attacks did place a strain on her heart, and increased the risk that she might actually die. While her medical condition continued to be monitored, it alone no longer continued to pose an imminent threat to her life.
On the psychological front, we proceeded with psychotherapy. At times I attempted to allow Betty to vent her emotions, but this simply tended to lead to hysteria, and in her case was not at all beneficial. Betty had many irrational thoughts about guilt, and was prone to obsessively blaming herself. We talked about these matters from a psychological perspective, and I attempted bolster her ability to make more rational judgments. Betty's irrational thinking was at the root of her depression and anxiety. Over the course of psychotherapy, I enlisted the help of other professionals to treat these difficulties.
Betty could at times become morbidly hypochondriacal. She would construe any physical twinge or pang as a clear indication that death would follow in seconds. I consulted with Betty's physicians, and worked with her to develop a more accurate assessment of her condition. Her physicians had tried to tell her this, but they had not been able to penetrate Betty's wall of panic.
On other occasions, questions about religion, spirituality and the afterlife also came up, as these were a core part of her belief system. We discussed her belief system, where it came from, and tried to sort out which parts of it were solid and reasonable, and which parts were products of her own childhood traumas. As part of this process, I consulted with the pastor of Betty's church. He was very supportive, and also told Betty that her spiritual fears were unfounded.
Over the course of treatment, Betty began to improve. First we worked to clarify her belief system, and the facts about her medical condition. We were then able to use this as a foundation to address her irrational fears. We attempted to bring her emotional reactions in line with her belief system and the facts of her medical case, and she eventually found this to be comforting.
What I like about the practice of clinical health psychology is that it is a profession in which the boundaries between itself and other professions are blurred. It requires the practicing psychologist to be attuned to other professions and to work more closely in collaboration with them.
The spectrum of clinical health psychology also blurs the boundaries between medical and psychological diagnoses. On one hand are medical patients with terminal conditions who are in denial of death. By denying that they could die, they may give up their only chance of living in the pursuit of an illusion of health. On the other hand, there are somatoform patients with nothing medically wrong, who convince themselves that death is immanent. In so doing, they may retreat from life, and use an illusion of illness to become dependent on others.
At the deepest level, the practice of clinical health psychology requires the practitioner to deal with the most fundamental matters of life and death. It sometimes involves helping patients to face death. More commonly though, it involves helping patients to face life, after the life they had known comes to an end.
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