My mother is 86 and lives in assisted living with her husband. Her cognitive functions, especially her short-term memory, are substantially impaired. She has always tended towards a brighter mood and, when things got tough, she had an effective strategy for navigating those challenges: she would engage others and talk and talk and talk until she was all talked out. It often left her listeners exhausted but it seemed to bring her the equanimity she sought. Despite her declining cognition, she has generally maintained her happy disposition and continues to engage others in much the same way she always has as a way of staying connected and working out her life challenges. But, of course, her and her husband’s declining cognition and function are urgent and undeniable enough that her habitual strategies arrive at a point of failure. She is afraid.
When we talk, she shares her day-to-day travails and seeks reassurance about concrete problems and upcoming concerns. She often brings up financial worries and I reassure her that the money for her and her husband’s assisted living and medical care will not run out. Our conversations have taken on a repetitive, ritualistic quality; she brings up her list of worries and I go down the list with reassurances. And it works … as far as it can. Because beyond her concrete worries lie the existential ones. Last time I spoke to her she said, “What will become of us?” This question, although particularly foregrounded for her, is a question that confronts us all.
I was thinking about this and what it may mean for our work with our patients. It struck me that as clinicians we need to address all the concrete problems and concerns related to a person’s life, mental illness, and treatment. This includes providing psychoeducation about the nature of their disorder(s), the steps of the assessment, the options for treatment, the pros and cons of each, including of medication adverse effects and dosing schedules, and what to expect from our working together. But in addition to this concrete everyday world, there is another looming one, the world of existential or ultimate concern, “What will become of me?”
Such questions arise from a realization of the enormity that lies beyond the near, ordered World Frame in which almost all of people’s time is spent. People who face existential threats, like a life-threatening illness, find that their World Frame becomes transparent or fractured (choose your metaphor) and they suddenly see beyond it. This fracturing of the World Frame also occurs after trauma, whether impersonal trauma like a hurricane or interpersonal trauma like being assaulted by a stranger or betrayed by a loved one.
“The courage to be is the courage to accept oneself, in spite of being unacceptable.” ― Paul Tillich
Although the existential realizations that lead to seeing beyond the World Frame occur at only certain moments in life, those moments of reflection permanently change the entirety of that person’s life: their past, present, and future. Views of the past may now be colored by regret and remorse. Regret is despondency over missed opportunities and foolish undertakings and yearnings for a do-over. Remorse is regret combined with guilt, a painful awareness of having hurt others through omission or commission and regretting one’s hurtful behaviors. The experience of the present may now be tinged with guilt and shame, confusion, estrangement, and helplessness. The view of the future can become suffused with a sense of loss and lack, of never being able to recapture what might have been, of an inability to ever set things right, and hopelessness of ever reaching one’s goals and dreams, or of achieving a sense of life’s wholeness or integrity. In other words, realizations of ultimate concern transcend the duration of their presence in consciousness. Although the effects of these realizations may be suppressed or repressed by the person having them, those defensive acts are ultimately ineffective. The effects (however they are expressed) of these realizations will now last forever and, as stated, lead to changed perceptions of life in its entirety.
What my conversations with my mother reminded me is that whenever we engage in meaningful conversations with loved ones or with patients, we should converse both on the level of quotidian concerns—those are often real and serious and worthy of discussion and resolution—and on the level of existential or ultimate concerns. These ultimate concerns often remain unstated by the speaker, either because of an inability to express these concerns in words or of embarrassment about discussing such topics; ones that most people are not used to or skilled at bringing up, even with people they love, trust, or who they depend on or who depend on them.
In what ways can the speaker’s ultimate concerns be addressed by the listener? I think that sooner or later, the listener should acknowledge them head on and bring them up explicitly as a point for further discussion. When to convert these concerns from an organizing but unstated background, one that colors every other communication, into a foreground point of discussion is a hard question worth asking. At what point will stating the unstated open the conversation to a deeper level of significance rather than to a premature shutting down and a more consolidated avoidance? I think the listener must trust his or her gut, while also not excusing their inaction through reference to, “It didn’t seem like the right time.” For many people with ultimate concerns time is not on their side. They may be facing death, the next episode of losing their minds, or the possibility of suicide.
Admittedly, foregrounding of ultimate concerns is not easy; one or both parties may prefer to not discuss this directly because it feels too awkward, embarrassing, shameful, etc. It is also difficult because we, even as trained professionals, often don’t have a script to follow. The conversation is new and may be filled with uncomfortable silences and abrupt changes in direction. Discussion is also difficult because sometimes the words are not there, maybe not-yet-there or maybe never-to-be-there. Some experiences can remain ineffable. And that is more than just ok; it is what it is and carries the weight of reality.
The important thing in ‘heavy conversations’ is to not always focus on or require words. Once the ice has been broken on the hidden topic of, for example, what it’s like to lose one’s mind in the midst of mania, being in the process of dying, or having one’s life stolen by an abuser or assaulter and to never be able to live the life that otherwise would have been, then the pair of people in dialogue have a achieved a higher level of intimacy. (And, yes, in psychiatry there should be a level of intimacy, not physical or other inappropriate intimacy, but intimacy that allows acknowledging and speaking about topics of ultimate concern, about those monsters peeking from behind the World Frame.) Once the ice has been broken, it should remain broken; the clinician doesn’t need to keep bringing up those ‘heavy topics,’ but should communicate in one way or another that she or he remembers and remains in a state of acknowledgement and is always ready to re-engage those topics.
I think that many people become mental health clinicians with the idea (visualization) of engaging with their patients or clients on a deeply meaningful level. All too often, through our training and the weight of administrative aspects of working in the current system and the scarcity of time, that kind of deep engagement gets lost or is never instilled. I would say that if you feel a sense of dissatisfaction or even burnout, it could be due to not only the presence of time-sucking and frustrating paperwork and administrative burdens, but also to the dearth of moments of deep engagement. One note of encouragement I can give is that broaching meaningful, even if fraught, topics that touch on ultimate concerns often does not take more time than discussing quotidian concerns, important though they too may be. Often patients are not looking to bare their souls and explore for extended periods on topics painful to them. More often they are looking to feel less alone, less estranged, to feel that some other human understands their life predicament. They want to look in your eyes and see the light of compassion and understanding. You are their connection, their lifeline to the rest of the world. Sometimes, you are the only one. The more we understand the power we potentially possess to effect good or harm, the heavier our burden becomes and also the more meaningful our work.
Until next time,
“Neurosis is the way of avoiding nonbeing by avoiding being” ― Paul Tillich
“She attempted to deal with her terror in a most ineffective and magical mode – a mode that I have seen many patients use: she attempted to elude death by refusing to live.” ― Irvin D. Yalom
“There are no dangerous thoughts; thinking it-self is dangerous.” ― Hannah Arendt
“Human existence is so fragile a thing and exposed to such dangers that I cannot love without trembling.” ― Simone Weil