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OVERCOMING FEAR OF DEATH FOR DOCTORS & PATIENTS

Do doctors relate on a personal level to their patient's fear of death?

You are listening to ReachMD XM 157, the channel for medical professionals. Welcome to the Clinician's Roundtable. I am your host, Dr. Maurice Pickard and joining me today is Dr. Irvin Yalom. Dr. Yalom is the Emeritus Professor of Psychiatry at Stanford University School of Medicine and he is the author of the definitive textbooks Theory and Practice of Psychotherapy and also Existential Psychotherapy.

DR. MAURICE PICKARD:

Thank you very much for joining us Dr. Yalom.

DR. IRVIN YALOM:

Very pleased to be here and talk to my fellow physicians.

DR. MAURICE PICKARD:

We are going to be discussing "Staring at the Sun, Overcoming the Terror of Death," Dr. Yalom's newest best-selling book. Thank you very much again for being with us. Can you tell us when you wrote this book, who were you directing it towards?

DR. IRVIN YALOM:

Well, the last 10 books I have written, at least my audiences have always been secret audiences, always been my own psychiatric residents and people training in psychology, so I was pointing towards them, but I am writing it in such a way totally jargon free of my own psychiatric profession so that physicians can read this book and the general public can read this book because I am writing about things that are essentially human and apply to all of us.

DR. MAURICE PICKARD:

Early on in the book, you described Epicurus as a philosopher that you follow. Now, epicurean I had always thought had to do with eating and drinking and enjoying foods and pleasures. Could you tell me how you use this philosopher in your writing?

DR. IRVIN YALOM:

Now, Epicurus has got a bad rap in that he never was anyone who was interested in fine wines or fine foods. He really was someone who is an aesthetic. He believed that our needs are very few, that we can satisfy them easily, but he also considered himself a physician. He said I am a physician of the soul, physician of the mind and that philosophy that's the real vocation of philosophy, we administer to the mind, physicians administer to the body, and as he looked at what was going on in men's mind he felt that they were full of despair and although they did not know it, sometimes you just see by their behavior they were constantly consumed with accumulating money and property and fame and glory and nobody could rest and every time we got a desire and satisfy it, another one popped right in, and he felt that underneath all of this was our fear of death and so he made that his major kind of tool that his students would learn. He developed some arguments about what helped them deal with the terror of dying and by that way we could release man's potential to accomplish other things in their life other than keep fleeing from their fear of death.

DR. MAURICE PICKARD:

Then, how do you bring that into your office practice?

DR. IRVIN YALOM:

Sometimes I use some of his arguments very, very frankly. Let me give you the one that I always find very helpful for myself and for my patients. He called it the symmetry argument and the statement is very simple. He is saying that where you will be after your death is the same place that you were before your life, before you were born. In other words, there is a pool of darkness after you die, a pool of non-being and it's the same pool, same state of nonexistent situation before you were born. We have so much terror about the second pool, so little terror about the first one, but yet they are identical. That's why he called it the symmetry argument. There have been arguments by philosophers over 2500 years about this statement, but I think it contains a lot of power and soothing.

DR. MAURICE PICKARD:

In your book you mentioned <_____> what you call mighty thoughts to overcome anxiety. Could you tell me some of the other ones?

DR. IRVIN YALOM:

Well, one of them has to do with the whole question of, there is a rough formula which goes like this – the greater the sense of unlived life in you, the greater is your death anxiety. In other words, I ask a lot of patients when I see them, I often say that this is going to sound like a stupid question, but let me ask you this, what is it about death, that frightens you so much, that terrorizes you so much. Well, it seems like a silly question, but in fact people give you a broad diversity of answers and one of the answers that comes in that's very potent is I fear all the things I would not have done. In other words, the whole time you have got all of this potential and yet you have been afraid to really try to express it and try to live. A lot of people after they get a fatal diagnosis or a diagnosis that tells them their life is going to be limited, they want to go on and express themselves in other ways, may be artistic ways, may be to write or do various things. So when I see patients, I really want to take a look at the whole question of regrets. You know what kind of regrets they have about the way they lived their live and is there some way that they could come to me a year from now or two years from now and look back on these one or two years and perhaps I have lived a regret-free live. What can they do to change their life? So that's one. Another one would be the whole question of rippling. Just the idea that we throw a stone in a pond and ripples come out from that and they go on and on and on and even nano ripples that we can't even see with the naked eye. Well, I think that there are things that we do in life, something we give to people, some active virtue, some active help, some trait of ours that passes on to their children, to people that they teach and passes on to others and others and I think physicians are in a very, very powerful position this way because we have such a powerful rippling effect, what we do for our patients that is passed on to their children or to their parents in the future and that gets passed on and passed on. So in fact in the old days when there were family physicians, you take care, you deliver babies, and then you see these babies and deliver their babies, you realize how much you passed on to other people and it is certainly for people teaching in medical schools we realize that we are passing on so much that that's virtuous and wise to other people. In other words, it's a secular representation of the whole question of wanting to persist. It is not saying that we do persist in our own consciousness, but that part of us persists and these acts of virtues spread out to others.

If you have just joining us, you are listening to the Clinician's Roundtable on ReachMD XM 157, the channel for medical professionals. I am your host, Dr. Maurice Pickard and I am speaking with Dr. Irvin Yalom. Dr. Yalom is the Emeritus Professor of Psychiatry at Stanford and has written the best-selling book that we are now discussing " Staring at the Sun, Overcoming the Terror of Death."

DR. MAURICE PICKARD:

I would like to ask you also other than rippling, how do you incorporate what you call the "here and now" into a practice that is not a psychiatric practice.

DR. IRVIN YALOM:

That's a little difficult to answer, let me tell you why. One of the things about the "here and now," and by which I mean that a therapist with the patient or let's say you are working with the therapy group, we spend a lot of time looking at what is that transpires between the two of us because psychiatrist and therapist are interested in studying relationships and studying them in depth because we have a basic axiom, which is that if you want to know how the patient is responding to other people, you examine how they are responding to you because there is a microcosm, a social microcosm that occurs in the therapy room or in a group therapy situation and if the patient tells you about how they relate to others or how they are relating to their spouse, that information tends to be very flawed and very biased if you can see with your own eyes. So we are interested in looking at if some patients will respond to you as a therapist or as a physician, the respond in a very obsequious manner or they respond in a very arrogant manner or a very demanding or very confrontational manner while as therapists we take that. Look this patient is probably no doubt confrontational and aggressive and irritating and obsequious in all their other relationships, so we have a treasure trove of information to begin to look at because we are trying to change people.

DR. MAURICE PICKARD:

You know, in this day though brief office visits and psychopharmacology now replacing the kind of relationships that used to be called doctor-patient relationships that we really based so much of what went on in our offices in a positive way, what do you do to accomplish this?

DR. IRVIN YALOM:

It's a major problem in the field of psychotherapy because so much of the richness and the gains that we made in psychotherapy are being eliminated now with patient's only been given medications, almost every thing was studied that's been done, indicates. For example, look at the antidepressants. We know that the antidepressants plus psychotherapy are more effective than patients surely getting the medication. Psychotherapy is not anything that can be legislated to be only take, say 6 hours or 8 hours or only in 20-minute sessions or something like that. Unfortunately, it is a time consuming process. We need many hours to work with people who actually go into change the way they are.Yeah, medications can help say with the depression or help with anxiety or panic, but they don't change the way that person lives in the world and that means that sooner or later they are going to get themselves into the same kind of situation repeatedly in the future unless we can do something to help them change the way that they relate to others and to their own world.

DR. MAURICE PICKARD:

Everything I read, uses the word "existential" in a different way. It's been really one of my frustrations. I go to the dictionary, I get all kinds of answers and none of them seem to go along with each other. You used the word "existential psychotherapy" in a different way and I think it would help us if you could tell us how will you use it; it gives real meaning to your book.

DR. IRVIN YALOM:

I am using it in a quite a simplistic manner. I am using it simply as an adjectival form of existence, so if I talk about existential therapy, I am talking about therapy that also looks at issues relating to existence and when I talk about existence I am saying to you as the reader or as the audience, listen, take a few minutes and put aside all the other busy distractions you have, all the phone calls leave everything else, just sink deeply into yourself and meditate for 5 minutes on your own existence, what it is, what it means for you to be a living, existing creature right now, <_____> creature, and people when they do that they will get the certain kinds of basic concerns in their life. I wrote a textbook called Existential Psychotherapy and the book is divided into four parts and each part represents one of the major basic concerns I think has relevance to therapy. One of them is death. It's a conflict. All of us want to persist in our own being, all of us are self-aware of the fact that our existence is limited that we are facing a little <_____>, that is a tremendously basic conflict that we don't like to think about, but it's there and others have to do with the fact of search for meaning. Human beings are, it seems, in built that we need some kind of meaning in life. It may also be true, I think it is, that we are drawn into a universe that doesn't have any intrinsic meaning and so we have to go about searching for some way to create meaning in our lives. That would be another ultimate concern and so forth. So I am saying that an existentially oriented therapist or a person who has sensibility about existential issues will also look at issues like meaning in life and like confrontation with death in their therapy as well as how you get along with your parents or your boss or the trauma that you are facing in your current life.

DR. MAURICE PICKARD:

I think the physicians that are listening today have hurled the door often open that a patient will do allowing us to step through and talk about things, very often time doesn't allow us to take this opportunity, but I think talking with you and talking about the issues will make them certainly much more aware. I want to thank Dr. Irvin Yalom for being our guest today and we have been discussing his very thought provoking book "Staring at the Sun, Overcoming the Terror of Death."

I am Dr. Maurice Pickard and you have been listening to the Clinician's Roundtable on ReachMD XM 157, the channel for medical professionals.

To listen to our on-demand library, visit us at www.reachmd.com. If you have comments or questions or suggestions, call us at 888-XM157.

Thank you for listening.

I am Dr. Jordan Berlin from Vanderbilt University Medical Center in Nashville, Tennessee. You are listening to the first national radio channel created specifically for medical professionals, ReachMD XM 157.