14 Existential hypnotherapy in life-threatening illness
INTRODUCTION
Supporting someone who is experiencing an existential crisis requires high levels of personal and professional development. This work is never easy, as it requires us to look at our own personal vulnerability, reminding us that we too are mortal. Kearney (2000) says that to fear death is neither a sign of weakness nor a reason for shame; it is part of what makes us alive and human. Dame Cicely Saunders (1995) founder of the hospice movement, further suggests that what we learn from the challenge of working with the dying, helps us on both a personal and professional level; because it teaches us to avoid our professional mask, and learn the skill of just being ‘person to person’ in the depths of their pain.
The rewards associated with this area of work come when we are invited by the patient to be a companion on their special journey. Just as birthing is greatly assisted by a competent midwife, likewise, facing one’s own mortality and/or impending death, can be facilitated by a competent therapist or healthcare professional (HCP) who is willing to walk alongside someone. Many feel unprepared to do this. However, experienced palliative care professionals all suggest that we should let the patient be our teachers when we journey with them, as this will teach us as much about living as about dying (Kearney 2000, Kubler-Ross 1997, Saunders 1995). The notion of the companion will be explored throughout this chapter using existential literature, along with the experiences of the authors, who have been privileged to walk alongside patients, as companions on their existential journey. When reflecting on these experiences, by working in this way, death has become less of a stranger to us, and more of a familiar acquaintance.
EXISTENTIAL THEORY
Existentialism (from the Danish and German term Existenz) is the philosophy concerned with the subjective, personal dimension of human existence in terms of the existing individual (Honderich 1995). It describes the distinctively human mode of being, the ontological ‘givens’ of existence and the clarification of what it means to be alive (Deurzen-Smith 1995). The Danish writer and social critic Soren Kierkegaard (1813–1855) discussed how human existence is essentially one of anxiety, set with tension between the finite and infinite. Thus, the challenge of living is to find a balance between possibility and necessity and in the process, become ‘true’ to oneself, i.e. through being self determining (Kierkegaard 1844).
The German philosopher, Heidegger (1927), is most often regarded as the founder of Existentialism. He used the word Dasein to denote as ‘human being’ the kind of being for whom ‘being’ or existence raises all sorts of questions and issues (Inwood 1997). This ‘human being’ ‘Dasein’, also entails a number of other concepts such as being-in-the-world and being-towards-death. In other words, being human always involves living within a particular set of circumstances, having a particular past and looking towards a particular future. Resolutely to face these facts and to live with them is to live authentically (Inwood 1997). By contrast ‘inauthenticity’ is seen as a defence against the anxiety of this realization and is marked by a resignation to convention, conformity and duty, i.e. by doing what people imagine is expected of them (Deurzen-Smith 1988).
According to Heidegger (1927), the most fundamental philosophical questions are: ‘why is there something rather than nothing?’ and ‘what is the meaning of being?’ We do not actually know the answer to these questions, but most people sooner or later ask them; especially when diagnosed with a life-threatening illness. Drawing upon an existential hypnotherapy approach to our work, allows for the patient to confront and clarify the meaning of their diagnosis and the underlying related anxiety, rather than just attempt to reduce or eliminate it. As an attempt to undertake a complete overview of existential theory is beyond the scope of this text, the authors intend to describe some of the major existential principles, which theoretically and philosophically underpin the psycho-hypnotherapy clinical work discussed in this chapter.
THE MEANING OF EXISTENTIAL ANXIETY
The experience of meaninglessness and the creation of meaning are closely related to the experience of angst or existential anxiety. King and Citrenbaum (1993: 16) argue that this existential anxiety occurs against the backdrop of the personal realization that ‘I am alone in the world and I have to contend with my mortality, and other limitations, by taking responsibility for myself in the face of endless challenges and confusions’. When therapists work existentially, they concern themselves with the ‘givens’ of human existence which are: death, anxiety, meaningless, isolation, choice, freedom and responsibility and how these are negotiated (or not). This is undertaken through the interpretations and meanings given to the experience of self, others, and the world, and how in turn, this shapes our sense of reality (Deurzen-Smith 1988). As such, it regards that all people’s forms of human dilemma, tragedy and suffering are fundamentally problems about ‘being in the world’. Spinelli (1989) argues that as a result, all patients difficulties are seen to reflect their attempts to avoid, resist or deny the angst and uncertainty that authentic living demands.
Existentialists see anxiety as a ‘calling card to the future’ (King & Citrenbaum 1993: 16). They report that people are addicted to emotional safety in today’s uncertain world; and go on to argue that to be attached to emotional safety is to be attached to the illusion of psychological safety. A diagnosis of a life-threatening illness challenges the average person to move away from the sameness of everyday life, and the accompanying anxiety becomes the cue for that person to want to flee back to sameness and when this is not possible, anxiety increases.
The key to effective existential hypnosis is the therapist–patient dialogue; in particular what is communicated about hypnosis and what is communicated during hypnosis. Hypnotherapy techniques can teach patients to reduce their anxiety to a manageable level (see below). King and Citrenbaum (1993: 17) argue that the aim of therapy is to never totally eliminate the feeling of anxiety, because that would doom the therapy to failure: as death is the only total anxiety reducer life has to offer. They go on to suggest that learning to be anxious in the right way, not too much or too little, is the key to living a reflective, meaningful human life and adjusting to a life-threatening illness. Kierkegaard (1844: 155) said that ‘whoever has learnt to be anxious in the right way has learnt the ultimate’.
WORKING WITH EXISTENTIAL ISSUES
This requires the following three factors:
PERSONAL PREPARATION OF THE THERAPIST
For the therapist to be a potent practitioner, it is essential that they have undergone personal preparation enabling them to be comfortable listening to, and discussing issues relating to death and dying. Patients soon pick up on whether therapists are ‘big enough’ to cope with their unspoken fears. Fear of dying is very common and Rinpoche (1998: 187) suggests that the deepest reason that we are afraid of death is possibly because we do not know who we are. He goes on to remind us that being with someone who is dying ‘makes us poignantly aware not only of their mortality, but of our own’. It is important therefore, that before working in this way, the therapist needs to have addressed issues relating to their own mortality and have worked through personal fears about dying. Personal growth for the therapist should come about through processing thoughts and feelings about their mortality, utilizing personal therapy, supervision and ongoing training.
Neimeyer (1994) studied the concept of death anxiety and found that it is generally present in the normal population, and not just when there is an immediate threat to one’s life. Neimeyer identified that there are 25 individual fears relating to death; these ranged from fear about being alone, fears relating to suffering, being in pain, and death being the end of everything. With this in mind, the therapist needs to ascertain what the patient’s individual fear(s) is/are and what impact this has on them. They also need to be aware of their own personal anxiety in relation to death and be aware of how this impacts on their work with patients.
A diagnosis of cancer, or any other life-threatening illness, can leave the patient feeling that their world has been torn apart, resulting in personal suffering as they perceive their impending destruction (Cassell 1991). As patients face their existential crisis, an amount of anxiety is to be expected (Barraclough 1999). Learning to work with anxiety is important, while also recognizing that it may be accompanied by fear. Kearney (1997) suggests that fear for patients facing their own mortality can occur for a number of reasons; it may be linked to anticipation of physical pain and distress, emotional pain relating to separation from those they love, and dependency and loss of control, which they imagine, lies ahead. When faced with this crisis, a patient’s natural reaction is to try to find ways of gaining some control and search for understanding.
Existential crises can relate to spirituality. Walter (1997) linked spirituality with a personal search for purpose and meaning. A study by Narayanasamy (1996) identified that an intense spiritual awakening could potentially be identified when patients are diagnosed with a chronic and life-threatening illness, as it is a pivotal life event. This leads patients to begin asking questions such as, ‘Why me?’, ‘Why now?’ and many others. The important lesson for both the therapist and the patient is that generally there are no answers to these questions. However, having the opportunity to share these questions should never be underestimated, along with having another person empathize with their dilemma. By connecting to another and having their questions heard, validated and normalized can in itself be extremely powerful. Cunningham (2000) shares this view saying that ‘connectedness’ is the route to healing.
If the person has someone to share their concerns with, it prevents them from feeling isolated and alone. Kearney (2000) suggests that if patients split off from parts of themselves and from others, fear and meaninglessness will continue to dominate for these vulnerable individuals. This is why the person who is struggling and suffering with the burden of illness and the uncertainty of their mortal life will require attendance to their whole experience of living and dying. The temptation to split mind, body and spirit can cause problems in existential care and although the therapist may have a strong driver to ‘fix things’ for patients on a variety of levels; including emotionally, physically and even spiritually, it is best to resist our initial urge to rush in and rescue, because through working together and paying attention to the whole, the answers will emerge.
Being curious
People experienced in the use of curiosity as a technique offer the following: Mindell (2003: 37) suggests that curiosity is about having the skill to ‘notice what we are experiencing, which feelings are occurring in any given moment’ and ‘what is driving the quest to gain understanding of the person’s journey.’ Johns (2004) recommends that this state of open curiosity requires a level of mindfulness, coupled with the knowledge that support exists, to enable them to reflect and process the experience, without becoming overwhelmed. This is where the therapist provides skilled companionship to the patient. Box 14.1 gives a Model, which represents this way of working.
