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OVERCOMING
FEAR:
HALF* Can Make You Whole
*Hope,
Action, Love, Faith
(The diagnosis and treatment of fear)
William
M. Buchholz, M.D., Medical Oncology
Susan W. Buchholz, Ph.D., Clinical Psychology
Introduction
When
patients and families are confronted with a diagnosis of cancer there
is an almost overwhelming series of thoughts and feelings. There are
questions about prognosis, decisions about treatment to be made, and
uncertainty about the future. Almost always there is fear, too. Even
after the cancer has been successfully treated, fear may remain.
As a medical oncologist and clinical psychologist working as a
team, we have been struck by the need to treat fear as a problem
separate from the cancer. Besides being emotionally painful, it
is destructive. Fear does not just diminish quality of life. It
can create confusion and lead to decisions that do not necessarily
eliminate either the fear or the danger. Even more insidiously,
fear disturbs relationships, multiplying itself by disrupting the
very support systems needed to cope with fear.
The following paper presents our perspective on what fear is and
how to deal with it. The treatment of cancer should include both
therapies to eliminate the disease as well as to diminish the fear
associated with it. We believe ultimately fear can be integrated
into a healing process so one can become whole again.
The Nature of Fear
Fear occurs when we perceive danger or
are confronted by the threat of loss. Although there may be danger
in the present (i.e., there is a fire in the room now), fear is
always in the future or past, anticipating or remembering something
unpleasant (i.e., expecting a fire outside when you leave the room).
Both danger and fear may be present at the same time, but fear is
not the same as danger and often requires a different response.
If you are in danger, you may need to take action to avoid the
source of harm. If you are in fear, however, you need to confront
the fear rather than avoid it. Besides indicating a threat or loss,
fear can be a signal of an unmet need. The nature of that need,
too, must be recognized before you can respond appropriately.
Although there are countless specific fears, we consider them
in three broad groups or categories: threats to or needs for Identity
(who I am), Love (relationships), or Safety (physical and psychic
integrity). Some fears may fit into more than one category. Similarly,
there are three components to fear: the cognitive, emotional, and
physical. For example, you may simultaneously have thoughts about
having surgery, feel the emotions accompanying these thoughts, and
experience your body's responses including a rapid heart rate, increased
sweating, etc.
Although sometimes difficult, it is very useful to look at fear
in an objective fashion, becoming an observer rather than a participant.
This way you can learn to distinguish the thoughts from the feelings,
and separate them further from your body's responses. By dividing
the fear into its component parts, it becomes weaker and you become
stronger. You learn to discriminate between the danger and the fear
of danger. You gain enough emotional distance to make calmer and
perhaps better decisions. With the fear is a sense of vulnerability. In truth, it is when
we are vulnerable that the potential for personal growth is the
greatest. This growth occurs when you leave the relative safety
of the known for the unknown, breaking new ground and entering areas
you have not yet fully explored. This usually feels as if you are
taking a risk. In order to overcome the natural resistance to change,
you must apply a motivating force. Fear can supply the emotional
force necessary to produce movement, but it must be channeled in
the right direction for it to be effective.
HALF can make you Whole
Sometimes the only satisfactory reply to fear is not an answer
but a response that goes directly to a solution. The mnemonic, "HALF"
which stands for Hope, Action, Love, and Faith, is
our reminder of the ways you can respond effectively to fear. These
broad categories suggest ways to organize your response depending
on the nature of the fear and your specific circumstances.
HOPE
Hope and fear are on the opposite sides of the same
coin. Each involves projecting into a time in the future. Each has
emotional and cognitive components. Hope is the expectation that
out of multiple possible outcomes, the one you desire will happen.
Fear is the expectation that the one you don't want will happen.
The emotions generated by these expectations are opposite, too.
Hope generates optimism and calm; fear begets depression and anxiety.
Hope is a stimulus for positive action, supplying the motivation
to reach a goal. Fear generally prevents action or causes a reaction
to avoid the problem without proceeding toward a solution.
Hope is particularly useful when addressing cognitive fears since
hope is primarily an intellectual process which draws positive emotions
along with it. For example, if you are confronting fears that dominate
your mind with images of dying, step back from the emotions and
explore the contents of your thoughts. When you examine the possible
futures from an optimistic viewpoint, often you find that your chances
are better than your fearful emotions had previously allowed you
to consider. By purposefully looking at optimistic future events,
you generate positive energy in yourself and can even spread this
energy to others as well.
By separating the thoughts from the emotions, you uncover more
possibilities. Fear's emotional fog may keep you looking at individual
trees and obscure the forest. Thoughts must be recognized for what
they are, creations of the mind. You can create optimistic thoughts
as well as pessimistic ones.
The first step is to create a place for hope. This requires returning
to the present, focusing on what is happening right now. By concentrating
on your breathing or some other object, you leave the future which
seems filled with fearful thoughts and enter the present moment.
When you are in the present, you will notice that thoughts arise
spontaneously, both pleasant and unpleasant. Recognize that you
have a choice and select the more hopeful thoughts on which you
wish to focus. Because fear has a strong emotional charge, the unpleasant
thoughts often return. Simply repeat the process again and again,
following the breathing back to the present and then entertaining
the more pleasant thoughts. Remember the Chinese proverb, "You can't
prevent the birds of sorrow from flying over your head. You don't
have to let them build a nest in your hair."
There can be a danger as well as a cost to using hope. The danger
comes when hope becomes denial. This occurs when hope is used to
prevent the introduction of important information and interferes
with appropriate responses to events. An example would be "hoping"
that an ulcerated mass in the breast is an infection without having
it evaluated by a physician. Hope also becomes pathological when
it prevents communication because other people cannot share your
belief system or when it prevents you from getting help when you
need it.
The cost of hope is potential disappointment. Attaching to some
goal and discovering that it is unobtainable is emotionally wrenching.
Some people choose not to entertain hopes to avoid such disappointments.
If hope either feels too risky or is not working, you may need to
use some other coping strategy.
Being hopeless is different from not using hope. Without hope,
if you continue to look into the future and see only darkness, then
you have no direction and remain in despair. If, however, you are
able to stay in the present, you become free from fear and can enjoy
whatever is there for you right now. The benefit of a meditation
practice (Vipassana, Zen, Transcendental Meditation, Yoga, etc.)
is that it offers an option to our usual lifestyle of living either
in the past or the future. In truth, we only have present moments,
one at a time. Living in the here and now requires great discipline
and practice, but is worth the effort. The British philosopher,
Ludwig Wittgenstein, once said, "If we take eternity not to mean
infinite temporal duration but timelessness, then the eternal life
belongs to those who live in the present."
ACTION
Action--or inaction--can be either the consequence
of fear or help to resolve it. Some people, when confronted with
fear, become paralyzed and unable to act. Others stay overly busy
to avoid being overwhelmed. Neither response results in action toward
a goal. Taking purposeful action can lead to both the relief of
that fear and the avoidance of danger. Action is particularly useful
as a response to fears that pertain to physical danger or safety,
though it may apply to all forms of fear in certain circumstances.
A common response to a diagnosis of cancer or any serious problem
is to seek more information. Most people want the facts or at least
the probabilities of outcomes. The "facts" however, are rarely black
and white and there is always the possibility that there is more
information available. Sometimes only a few facts are needed to
make a decision and act. Other times more research is needed to
make the best decision. Some people continue to gather information
in an attempt to regain a sense of control. The search for information
becomes its own end and neither serves to provide a direction for
action nor does it actually reduce the fear. There comes a time
when you must act on the information already available and not seek
the fourth or fifth opinion.
Some people engage in intense activity to distract themselves
from the emotional impact of the fear. They forget that in action
there is both movement and stillness. Sometimes when you are fearful,
the best response is to cease activity and become purposefully quiet
and receptive, exploring your thoughts and feelings cautiously.
Like beginning a workout at the gym, you can "start low and go slow"
Next time, before busying yourself with some activity, try staying
with just the edges of the thoughts and feelings you have. Actively
quieting the chatter in your mind so you can stay attentive to present
thoughts and attend to present emotions does require discipline
and practice. Pace yourself as you can grow stronger each time you
let yourself do an "emotional workout" and allow yourself to get
off the roller coaster of fear and activity.
Some individuals are so naturally aware of their emotions they
feel like they are lost in a thick fog that drowns out the rest
of their experience rather than going up and down on a roller coaster.
For them, taking action helps reduce the fear. Even simple actions
like taking a walk can help. Making a ritual of self care (a bubble
bath, listening to music, a massage, etc.) is often useful. Action
can break fear's hold on you. Free of its grip, thinking becomes
clearer and new possibilities emerge. You can then explore options
and take constructive action.
What happens after you have examined a fear and find there are
so many things to do you don"t know where to start? Too many choices
can be bewildering. You need to set priorities. Often the first
step is to consider what your heart really wants. This might not
be easy since you may not be accustomed to thinking about or asking
for what you want. Once you have a goal in mind, think of one small
step you can do now to help you get what you want. Once you take
that small step, you are no longer a prisoner of fear but empowered
to take one step after another towards your goal. If you still can"t
decide on a specific goal consider the following: living to be a
very healthy, very happy, and very old person.
As on any trail, where the path is heading might not be visible
when you start out. How then can you plan ahead? Truthfully, you
may not be able to prepare yourself for every possibility. You may
have to trust, as Goethe did, that "Whatever you can do or dream,
you can begin...(that) boldness has genius, power and magic in it.Ó
Think back at the times you were able to achieve what you wanted
in spite of your doubts. You didn't know exactly how you were going
to do it when you started but somehow you managed. You could do
that again. After all, the best preparation for success is a history
of being successful.
LOVE
Love is expressed in many forms. It is not limited
to romantic "I love you" expressions but is present in any form
of support. The central element of love is the relationship between
people. Love can be expressed silently with compassionate listening,
with patience, or by letting another know that you understand. Love
can be given overtly in countless acts of service: driving to an
appointment; taking on extra responsibilities; buying little gifts.
It is less important to distinguish love from support than it is
to recognize that they stem from the same source-- a sense of an
affirming relationship.
Feeling affirmed and supported takes the sting out of fear. Love
slips beneath fear's grip and loosens its hold. It doesn't answer
fear's questions but makes them irrelevant for at least a moment.
Whether the fear is that of physical danger or abandonment, receiving
support creates a sense of security and safety. Receiving love and
support assuages the fear of being unworthy and strengthens one's
identity as someone who deserves to exist. Even the Bible speaks
of love as being greater than hope or faith.
Unfortunately, even when people recognize how powerful it is,
they often don't ask for love and support. In times of fear, when
love is most needed, it can be hardest to request. Perhaps because
people don't know how to love themselves or that they deserve love,
they can't imagine that someone else could love them either. Perhaps
they feel that love is scarce, and there is not enough to go around.
Perhaps early childhood disappointments of needing to be loved and
feeling abandoned have made people doubt that they can ever have
those needs met. Perhaps there is concern that asking for support
will create an intolerable social obligation. If you truly allow yourself to be loved, somewhere in the process
you reveal the fragile child within. Love can be the deepest form
of intimacy and expose the greatest vulnerability. "If I ask for
love and am refused, I can't imagine how I will continue to exist,"
whispers a tiny voice inside. "I cannot risk being told I am unlovable
or unworthy. I have to protect myself regardless of the cost."
There are countless ways of defending against the vulnerability
that the need for love conjures. Some people focus on the needs
of others and only experience love vicariously. Others stay too
busy and don't notice the love that is waiting for them. Some may
appear strong--looking as if they don't need support. Others appear
angry--scaring away the very people whose love they most desire.
In one way or another people avoid asking for support until they
are forced by fear itself to confront their needs.
Fortunately, when fear becomes intolerable, and the risk of rejection
is less than the pressure of the fear, something gives. In the process
it becomes possible for you to accept your own fragility as real.
You realize both that you do need someone to help you, and that
it is ok to ask. If you ask for support as an act of compassion
for yourself, it is an act of love whether or not you actually receive
love from someone else. The tragedy lies in waiting too long. You
could have asked earlier.
What you want or need often changes from time to time. At one
point you may need someone simply to hear your distress without
offering solutions. The next time you may want to have an intimate
dialogue about your relationship. There is no standard request form,
nor any universal response. There is only the process. You experience
fear and recognize that in order to feel safer you need to feel
loved. As an act of compassion and commitment to yourself you reach
out to whoever is there, sometimes even when it isn't easy, and
let them know that you are feeling fragile. Could they help you
please? Sometimes you may specifically request that they do something.
Other times you may not be able to express what you need and will
have to trust that by continuing the dialogue you will discover
it. Only by speaking out do you have a reasonable chance of getting
what you really need. Rarely do others accurately read your mind
or anticipate your needs. They may not have even noticed your distress
or are distracted by their own fears. Asking for help indirectly
or expecting others to volunteer their love is like sending a message
in a bottle. It might get there or it might not. It is better to
speak directly and ask clearly for what you want.
Receiving help is easier for some people than others. Typically
it is harder for men, but some women may have equal difficulty.
Even when you ask for it directly support doesn't always appear
the way you expect it. Often love is given, but you don't recognize
it because of the "gift wrapping." It may be your neighbor waving
at you when you get out of the car. Perhaps it is a co-worker who
feels awkward at "prying into your private affairs" but sincerely
wants to help. It may be your children who really want to do chores
but need more direction. It may be your partner, who is hurting
himself, and trying to conceal his pain by being distant when he
most wants to be close. You must be observant and open to love in
all its disguises.
By communicating openly with others, you can practice asking for
and specifying the kind of support you need before you are desperate.
This may require some planning. It may be helpful to have a list
of things for people to do when they ask, "What can I do?" By giving
them a choice of specific things, you make it easier for them to
express their love. They feel better. You have taken a risk and
grown larger by incorporating their love. The next time, when you
really need something, it will be easier to ask.
FAITH
Each person has her or his own understanding of what
faith is. Many people think of faith in relationship to religion
or a spiritual practice. Others have a similar kind of faith in
medicine, trusting it to provide a cure for their illness. With
the deepest respect for the many differing views, we will consider
faith as a relationship between the believer and the object of faith.
For the purposes of discussion we will consider that object of faith
to be a Deity or Universal Truth. If this definition is uncomfortable,
please feel free to substitute your own.
In the relationship between the believer and the object of faith,
something is exchanged. The believer demonstrates his/her confidence
and trust in the object of belief. The Deity provides protection
and a perceptible presence. The essential part of faith is this
active connection where both parties honor and care for/about each
other.
Although it may be represented externally, the object of faith
is generally felt within. Different religions describe this presence
as the Holy Spirit (Christianity), Shekhinah (Judaism), Buddha Mind
(Buddhism), Tao, etc. The external form may be pictured as Christ,
a Pieta, a Bodhisattva (Kannon, Kwan Yuen, Avalokiteshvara) or some
other manifestation of a deity. Regardless of the specific form,
the common experience is that of a powerful and compassionate force
present within.
Faith can be a specific response to fears about safety or to feeling
out of control. Some individuals believe that unless they personally
control events, things won't turn out the way they want. Only reluctantly
do they allow someone else to be in charge. They are comfortable
only if they have some influence or control over others or other
people have proven their trustworthiness. The central issue is really
one of trust. Faith goes past the limits of human control of events and assigns
control to a higher force. That force is held to be benign and interested
in what happens to you. Faith is an appropriate response to fears
that defy logic or ask unanswerable questions. Faith provides a
feeling of safety in response to the emotional content of the fears.
It does not change the picture of the outcome, as using hope does.
Hope starts by focusing on an idea, and positive feelings follow.
Faith goes more directly to the feelings. Although there may be
faith that there will be a specific outcome, commonly faith is reassuring
because it gives a general answer that whatever happens, "it will
be all right."
If you have a practice of faith, you have probably already used
it to respond to such fears. What can you do if you don't have such
a practice or have been "turned off" in the past? There may come
a time when the physical danger is quite real and cannot be avoided,
and it becomes clear that you no longer have control over events.
At this point you either give up, concluding that the universe is
chaotic and uncaring, or continue on, trusting that it is benign
and events will some how be all right even if you don't understand.
There is no research or proof either way. You might as well choose
the one that feels the best.
If you cannot accept the teachings and/or dogma of an organized
religion, or if your concept of God is incompatible with your experiences,
it is still possible to use faith constructively. In Star Wars,
Luke Skywalker was taught to feel the Force rather than think about
it. That required trust, not logic. You can nurture a sense of trust
simply using some object or doctrine as a way of focusing your attention.
Maintaining faith requires affirming your relationship with the
object of faith, its power and intent to help, and your commitment
even in the face of doubt. Keeping faith can be hard work, particularly
when challenged by doubts or by conflicting events. Regular prayer,
meditation, or some spiritual practice is required. The form will
be suggested by what is comfortable or natural to you. It may be
the religion of your family or something you have discovered for
yourself. What makes it work is the regularity of practice. There
is not enough time to become proficient if the only time you use
it is in a crisis. Practice now.
Being Whole
Beyond its impact on the quality of life, on
relationships, or on decisions, fear prevents us from being whole.
Fearful thoughts divide our consciousness between the future and
the present. The feelings of fear prevent us from a calm acceptance
of what is real. Fear prevents us from distinguishing our true identity
from our persona. Dr. Erik Cassel defined suffering as "a threat
to the intactness of the individual." Fear is certainly a source
of great suffering.
Being whole means including all parts of ourselves, bitter and
sweet, strong and weak. Fear makes us realize how fragile life is,
how attached we are to life and all its pleasures. Understanding
life's fragility brings us to appreciate its preciousness too. That
is fear's gift.
The coping responses described above (Hope, Action, Love, and
Faith) are not designed to banish fear from your life, but to tame
it. They can prevent you from being dominated by fear and allow
your higher self to reassert control. They are tools to use to make
your life safer and more comfortable.
There is, however, a state beyond fear. In this state you can
feel peaceful, safe, loved, and whole. You can reach it only by
accepting that fear is part of you and confronting it directly.
Each momentary confrontation with fear is an opportunity to take
another step through it. You may not be able to stay in a state
of such wholeness continuously, but only touch it for a short while.
In that instant, however, you have become victorious. You have overcome
fear and become whole again.
Biosketch:
William M. Buchholz, MD is a graduate of Harvard and Stanford Medical
School. He is an Internist and Oncologist practicing in Mountain
View since 1978.
Susan W. Buchholz, Ph.D., trained as a Physician Assistant at
Johns Hopkins and received her Ph.D. in Clinical Psychology from
the Fielding Institute. Working together, they offer consultation
and comprehensive treatments for patients with cancer and other
medical problems. They have given workshops and lectures on topics
including Cancer Prevention, the Successful Cancer Patient, and
Hope and Denial.
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