For Every Yes, A Thousand Nos

One April afternoon, I thought I was going to die.

I was driving down the I 55, a few miles south of St Louis. Suddenly the car began gliding sideways, hydroplaning, spinning and turning on the freeway.

It came to a stop, perpendicular to the fast lane.

As I watched a SUV hurtle towards me, all I could think of was, “Wish I had side air-bags. Should’ve bought that BMW.”

Rather materialistic, as last thoughts go. A few milliseconds and it would all be over.

At the last moment, the driver of the SUV swerved to the right, and missed me by a few inches. Before another vehicle could attempt a similar performance, I managed to drive to the shoulder of the road and after a few minutes, I slowly rejoined the freeway.

Consider the following cases:

  • Steve, in his mid fifties, was diagnosed with advanced pancreatic cancer. For the first week he was a man transformed. He seemed happier than he had ever looked before as he strode in jauntily to my clinic.

    A few days later, the reality of his impending death hit him, and he despaired, “What am I going to do? What am I going to do?” He began to seek out different treatments, went to alternative health practitioners, and herbalists and naturopaths, even a native American shaman, before returning to his doctors’ care when the pain became too severe. By the time he died, the pain killers had dulled not only his physical pain but also the realization of his imminent death.

  • Tim cannot commit to anything or anyone. He flits from person to person, from job to job, from place to place. His mannerisms, his clothes, his lifestyle are reminiscent of a sophomore in college and not a 40 something year old male.
  • Sarah is married and has 2 kids, and works part time as a copywriter for a local ad agency. Although she smiles a lot, and generally seems happy, she has always felt empty inside, as if her emotions were brightly painted colors on a fragile shell.
    “I feel nothing inside. I feel disconnected. As if I am not completely here.”
  • Linda, who is single at 34, has only been in one long term relationship that ended when her boyfriend wanted to get married. Since then she’s been disappointed with the quality of men she meets. “I am too picky,” she says, not without a hint of pride. “I can’t just settle for any man, like some of my friends do,” she says.

    She describes some of the men she’s been meeting. There was that lawyer who was attractive, and successful, and not a chauvinist like all the others. But she just hated the fact that he had no interest in environmental issues, and besides, she could never be with a Republican.

    The doctor she was dating, he was far too wrapped up in his work.

    She liked Harvey, the bike riding rabble rousing carpenter, but he wasn’t intellectual enough. And so on.

    She’s afraid of becoming old alone. But she’s even more afraid of ending up with the wrong man.

  • Raj on the other hand seems to have everything under control. He is a successful artist, lauded by the media, embraced by the public. His girlfriend, a writer, is supportive, attractive, and they have the kind of relationship that other couples find irritating because it reminds them of their own lack of intimacy.

At first glance, there do not seem to be any similarities between these people. They seem vastly different. But in one fundamental way they are the same – their world view has been largely shaped by a universal force that affects almost every one of us. This universal force, acting powerfully on the psyche of any self-aware human being is the latent fear of death – existentially oriented psychoanalysts call this the “death anxiety”. Although we are not consciously aware of it, our choices in life, what we do, what we don’t do, what we spurn and what we embrace, and the manner in which we do all of these things is in reaction to the fear of death, this subconscious constantly rumbling death anxiety.

Now, let us examine the stories of these individuals through this existential perspective.

First, Steve. Of all these stories, Steve’s death anxiety is the most obvious. Faced with a terminal diagnosis, his fear propelled him into action, as he attempted to find a cure. Steve was driven by a desire to increase his denial of his impending and inevitable demise.

On the other hand, Tim’s way of life seems to have nothing to do with death anxiety. But let us examine the reasons for his inability to commit.

When I asked him, in therapy, “What do you suppose makes it difficult for you to commit?” (We psychiatrists tend to use 50 words, when 10 would do), Tim said that it’s because he hates to be “tied down”.
That was obviously a superficial explanation, a mere rephrasing of the question. So I asked him again, “Why do you hate being tied down?”

He paused and shrugged. “That’s just the way I am.”

I asked him what it felt like to commit to something.

“I was married once,” he said. “Felt like someone was smothering me. I can only get so close to people, before I start feeling like I need my own space.”

It took several weeks of therapy before Tim related a dream that bothered him every night. A nightmare, actually. “I am married to the same woman, and she is old. I am old. And I want to leave. But every night, wherever I go, she’s there waiting for me. I woke up feeling sick, and my heart was beating real fast.”

Tim’s nightmare was not particularly subtle. It didn’t take a psychiatrist to realize that he harbored a great fear of aging, and death, and that in his mind, constancy was linked to decay and dying.

In his seminal book on existential psychotherapy, Irvin Yalom writes, “For every yes, there must be a no.” But Yalom understates the case. I think it’s more accurate to say, “For every yes, there are a thousand nos.” When we commit to something – a job, a project, a relationship – we are effectively saying no to a thousand other things we might have done. As long as we keep all our options open, the infinite possibilities of life seem to be within our reach. But say yes to any one, and you have to say no to all the others.
For Tim, and so many like him, commitments are fuel to the fire of death anxiety.

What about Sarah’s feelings of emptiness? Could her suffering be explained by the concept of death anxiety?

Otto Rank, the famous psychoanalyst succinctly, once said, “A neurotic refuses the loan (life) in order to avoid paying the debt (death). ”

He might well have been describing Sarah’s situation. She reduces her fear of death by not allowing herself to completely embrace life. She cannot feel. She is numb. Therefore, she is not truly alive. And because she is not truly alive, perhaps she will never die.

Raj, on the face of it, seems quite different, unaffected by death anxiety. But if you take a closer look, you will see the chinks in his psychic armor, defects that reveal his latent death anxiety.

He does not derive as much pleasure from his art as he does from the appreciation that he gets. He and his girlfriend seem happy, but when they lie down and go to bed at night, each feels an unfathomable distance and loneliness. Behind his smile and his artist’s persona, sometimes, when he’s alone, Raj feels vulnerable and insecure. He worries that his art, like the page 3 newsprint, will fade into insignificance. He wonders if it’s his art that people truly appreciate, or his celebrity. Sometimes, he wonders if he’s just lucky, rather than truly talented.

People like Raj sublimate their death anxiety, transmuting fear into a drive for recognition and permanence, perhaps through art, or literature, or altruism, or having children. They are motivated to leaving behind legacies that will outlive their mortal selves. They seem to be in control of their life, and it is impressive, how they perform the highest form of psychic alchemy as they transform the anguish of dying into monuments that celebrate life.

If everything works out as planned, Raj, and people like him, often contribute greatly to society.
But if their talents are not recognized, or if they believe that they would be completely ignored by history, if life passes them by, they end up feeling alone, empty, sad, and depressed.

For years, I’d been determined to address death anxiety through Integral Self Therapy, the therapeutic method I was developing. I was convinced that when we confront and overcome our fear of death, we can make a quantum leap in our personal growth.

But how to overcome death anxiety?

Conventional therapy took too long. People’s psychological defense mechanisms were often too strong to be breached easily. Intellectually and cognitively, people often could understand the concept of death anxiety. But they just could not feel it in their heart. “Yes, I know I will die. I’ve thought about it, and I’m OK with it,”

I tried a Rogerian approach – the client knows the answers, I just had to be accepting and non-judgmental and allow the process to unfold. Perhaps this way, the death anxiety would reveal itself.

But it was of no use. Change was slow and minimal.

I tried direct questioning, the instrument of the psychotherapy novice, a bludgeon in a field of finesse.

“What do you think about death?”

“What will happen to you after you die?”

“What are you scared of the most?”

“What kind of death would you like to have?”

“When were you first aware of death and how did you respond to it?”

“Do you believe in rebirth, or heaven and hell? How strongly do you believe in it?”

Some responded by looking at me as if I were the reaper himself. Others embraced the topic, but in a philosophical and intellectual manner.

Some told me point blank, “I would rather not talk about this.”

And some held strong to their faith, questioned me about my religious beliefs. “Do you believe in Jesus Christ?” “Do you go to church?” “You believe in reincarnation, don’t you?”

“I am spiritual, but not religious,” I would reply, before returning the topic back to themselves.

I abandoned the questioning and almost gave up on the exploration of death anxiety itself.

And then, on that April afternoon, I almost died. For a few days after that, I contemplated the end of my life. One clear night, I looked up at the sky, at the stars strewn all over the universe and felt what it might be like to cease, to dissolve, to die.

The intensity of the experience, the actual emotional experience of my mortality was powerful and surprisingly liberating. I had never thought of myself as having any death anxiety. After all, I’m a physician. I see death all the time. No big deal. (A therapist would say that death anxiety drives physicians – by saving lives, they are trying to transcend their own mortality)
But now I realized: The emotional experience of death is vastly different from an intellectual understanding of one’s mortality.

That’s what I should do in therapy, I thought. The only way to expunge oneself of this death anxiety, was to confront it. Not through words and intellect, but through an emotional and experiential method.

But even before I could address the problem of how I might be able to do this through therapy, short of taking them on a drive down I 55 on a rainy day, I was reminded of all the patients I’d treated for post traumatic stress disorder, or PTSD. People who experience a life threatening event sometimes continue to feel fearful and anxious long after the threat of death has passed. The experience of death, then, was liberating to some, but disabling for others.

The last thing I wanted to create was a post traumatic stress disorder in susceptible patients.