by Edmund Howe III, MD, JD 

Dr. Howe is Professor of Psychiatry, Uniformed Services University of the Health Sciences in Bethesda, Maryland.

Funding: No funding was provided for this article.

Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Innov Clin Neurosci. 2023;20(7–9):27–29.

Abstract

This commentary examines three critical therapeutic questions that arise for all patients, particularly for patients with psychiatric illness. These questions involve fearing death, forgiving oneself for past acts, and disclosing medical and psychiatric conditions to others. These questions, which can be critical to providing optimal medical care in some contexts, are prompted by the movie White Noise, as it might provoke questions regarding death and self-disclosure in patients. Specific responses that might be helpful to patients are offered.

Keywords: Death anxiety, fear of death, forgiving oneself, self-disclosing, White Noise, mental illness, terror management theory (TMT), meaning, positive psychology, cues

A patient recently asked me whether I had seen the movie White Noise, so that if I had, I could discuss it with him. This movie is about people fearing death. My patient had good reason to ask me this question; he had a medical condition such that he could die relatively soon. Death anxiety is common. Therefore, providers might want to anticipate how they want to respond if their patients raise this topic. The film’s focus on death anxiety brought to my mind the philosopher Martin Heidegger, who said that we should not distract ourselves from our fear of death, but, rather, should use this awareness as a constant wake-up call to remind us to cherish every moment.1,2 This association also brought to mind, as it always does, the related question of how should we regard Heidegger, knowing that he supported the Nazis? A third question this film raised stemmed from a nun who inspired others but had no faith herself. Her example, in turn, brought to mind the writer and philosopher Miguel de Unamuno, who wrote a similar story involving a priest. I thus asked these three questions: How should we respond to patients fearing death? Should we, thinking of Heidegger, advise them to forgive themselves for acts they regret in their pasts? And when, if ever, should we encourage them to disclose to others that they have mental or even, perhaps, any illness? l reviewed the recent literature on these subjects and present my findings here.

Death Anxiety

Death anxiety can result from fears of dying, loved ones dying, dying prematurely, the unknown, and how others will fare when one is dead. These fears may be especially intense now due to the COVID-19 pandemic and the Russian-Ukrainian War.3 A leading theoretical framework used to assess death anxiety is called terror management theory (TMT).4,5 It arose, in part, from the work of Ernest Becker, a cultural anthropologist who in 1974 was awarded a Pulitzer Prize for his book, The Denial of Death. This theory holds that we tend to have two main “buffers” or defenses for coping with death anxiety. One is to ally ourselves with others who share our same culture. The other is to increase our self-esteem. Both may be beneficial, but both may also contribute to negative outcomes. We might, in response to the fear of death, become more rigid, trust only those in our own cultural groups, and distrust those outside them. When we survive close encounters, we might become more compassionate. To increase our self-esteem, we might do things that make us feel better, but this might, paradoxically, include taking greater risks that could potentially lead to death, such as driving faster or driving while drunk.6–8

A third defense, separately discerned, is to feel and find more meaning in life, particularly through our relationships with others. Psychiatrist Viktor Frankl voiced this view almost a century ago when he first spoke of persons who had survived concentration camps in World War II, as he had. He thought that those who survived might have been those who were especially able to retain a sense of meaning in their lives.9 Based on this view, he started a new kind of psychotherapy, called logotherapy.

Psychiatrist Irvin Yalom subsequently introduced existential psychotherapy.10 We may recall Yalom’s work from his early writing on conducting group psychotherapy. In existential psychotherapy, he proposed four main topics that he believes concern most people, those being death, freedom, isolation, and meaninglessness, and discussed how we might best go about addressing each. He most recently co-wrote a book with his wife before she died.11 In this book, both he and his wife relate how they feel as her death nears. Here, he describes how he spoke of his most painful feelings with two patients. One had lost her husband and previously had met with two psychiatrists but had not been able to connect with either. Yalom shared with her how he felt knowing that five of his medical school classmates had died and knowing that he, just as well, could have died and been among them. This patient responded with what she called celebratory tears. This is exactly what she felt, she replied. “…there is someone else on [my] train after all” (Yalom’s emphasis).11 With a second patient, he echoed her previous words to him. He said that he too had been struggling and like her, for him, “…everything is insubstantial.” (Yalom’s emphasis).11 She said that hearing him say this was “a great gift…. A tremendous gift.”11 The responses of both of these patients highlight a profound, somewhat paradoxical, clinical reality, that when people feel they have no source of relief from their own or another’s death, hearing other people share that they also feel this might help them feel better by allowing them to feel less alone.

Yalom’s wife, Marilyn, shares perhaps the most important insight that psychiatrists and other providers should be aware of. She says, “Still, even if I am not afraid of death itself, I feel the continued sadness of separating from my loved ones. For all the philosophical treatises and for all the assurances of the medical profession, there is no cure for the simple fact that we must leave each other.”11 When reading this, I recalled a patient I saw who was dying from cancer, slowly, he thought. He had his heart set on outliving his wife, who also had cancer, so that he could care for her until her died. He then realized that this would not be the case. This deeply embittered him, so deeply that he then wanted to end his own life. He did not.

The field of positive psychology has stressed the importance in psychotherapy of focusing on patients having such strengths as the capacity to feel happiness and having meaning in their lives, as Frankl also urged. This emphasis opposes psychotherapists concentrating only on reducing or eliminating patients’ negative symptoms.12 Some studies have suggested that having therapists place their emphasis on increasing patients’ strengths could be more beneficial than focusing only or even primarily on their negative symptoms.13–16 Martin Seligman is a leading advocate for this approach. In recommending this approach, he has included his work with his own patients. He writes, for example, “Did I get a happy patient? No, I got an empty patient because the skills of positive emotion, engagement, meaning, and good relationships are entirely different from the skills of fighting anger, anxiety, and depression.”17

Forgiveness

Now, I address how we should regard Heidegger, and, in turn, how we might approach the difficult task of forgiving ourselves. Patients may ask how, when, and whether they should forgive themselves and others. Psychiatrists’ answers might profoundly affect their futures. Heidegger supported the Nazi regime. Should this affect how we see him, much less how we regard what he has said? This same question has been asked in regard to other well-known artists; composer Richard Wagner and the poet Ezra Pound are chief examples. An analogous question has been raised in regard to medical research and an anatomy atlas developed by Nazis who used humans for this work. Even if it is now beneficial, should we use these products at all or eschew them altogether, both to respect the persons who provided this data retrospectively and to hopefully reduce or prevent the possibility that these wrongs will ever recur in our future?

I shall use the response of Hannah Arendt to Heidegger as both a paradigmatic example and a way to approach this question. Arendt was a philosopher, well-respected by many in her own right. She had an affair with Heidegger when she was a university student and he was her professor. She, knowing of his allegiance with the Nazis, continued to see him up to the end of his life.18 Was she enlightened in choosing to do this or, as some believe, the opposite?19 Even as psychiatrists, we may feel we lack this answer. Still, with our patients, we may have to advise them about whether and when they should seek to forgive both themselves and others.20

Patient Self-disclosure

White Noise includes a nun and nurse who inspires others but has no faith herself, which she keeps secret. This choice mirrors that made by a fictitious priest, Don Manuel, about whom Miguel de Unamuno writes in a short story.21–23 A character states, regarding Don Manuel, “I have realized that the unwavering happiness of Don Manuel was the secular and worldly form of an infinite and eternal sadness that, with heroic sanctity, he hid from everyone else.”21 This nun and Don Manuel made me aware that I knew too little about when, if ever, patients should consider disclosing to others that they have a mental illness. Psychiatrists may, of course, struggle with this decision in regards to themselves, but their decision raises different questions. Patients risk losing the friendship of others if they share too much. However, at the same time, they might do much better if they are willing to take this risk. They might become free from shame and stigma. Thus, in some cases, psychiatrists might help their patients most by encouraging them to become willing to self-disclose. Patients can attend support groups for this purpose.24–31

Again, we might gain insight by looking to Arendt. The first book she wrote was a biography of Rahel Varnhagen, a woman who was Jewish and was born in Berlin, Germany, in 1771. She struggled with what it meant to be Jewish at that time, and, fortunately, came to most value this part of herself.32 She wrote later in her life that being Jewish was, to her, “something she would on no account wish to have missed.”32

Derwent May, who wrote a biography of Arendt, asserts that many believed that when Arendt wrote about Varnhagen, she was, to a great extent, writing about herself.32 Whether this is or is not true, one passage Arendt wrote in regard to Varnhagen’s self-disclosure is striking, and it should convey to us the exceptional attention we should pay to these questions if and when our patients raise or confront them. Arendt wrote that perhaps Varnhagen had learned “true and bottomless melancholy, the sadness of the peon who has experienced too much for it to be worth his while to tell the story.”33 The story might strike others, she says, “merely as horrifying.”33 When this is the case, Arendt adds, finally, the person who is so disclosing might remain to other people “merely a madman.”33 Keeping this conjecture by Arendt in mind, we might better grasp the dilemma that our patients confront.

Furthermore, if and when we do then intervene, we might do well to begin with an approach encouraged by positive psychology, which initially looks to patients’ strengths, and intervene in ways that strive to evoke and build upon these strengths. Psychiatrist James Griffith had outlined how we might best do this.34 He suggests that we initially ask our patients how they are responding to any current adversity they face or how they have responded to major adversities in the past. We should then ask them about the first thing they did in order to cope.34 This “agency thinking,” he suggests, “consists of attitudes and self-talk” that can sustain in our patients the belief that they can act effectively.34 This “shift-and-persist” approach, he adds, has been shown to be a “powerful factor” in the overall health of adults, even when they initially have factors that place them at greater risk.34

Conclusion

Many of us fear death, struggle with whether we should forgive ourselves and others, and sturggle with whether and/or how much to self-disclose. All these sources of anxiety might have additional negative effects because these struggles can function as cues triggering more wide-spread anxieties.35

I and the patient who asked me if I had seen this film both were fortunate. He was fortunate because he already had what I believe is the single most important strength for coping with death anxiety, the capacity to relate lovingly to other people. He also had a family present whom he could and did love. I was fortunate because I could then tell him that he already had as good a means of helping himself to quell this fear as exists—the capacity to love and having loved ones with him to whom he could express this love. He said then that he felt better.

Disclaimer

The opinions and assertions contained herein are those of the author and do not reflect those of the Uniformed Services University or the Department of Defense. Neither I nor my family members have a financial interest in any commercial product, service, or organization providing financial support for this research. References to non-Federal entities or products do not constitute or imply a Department of Defense or Uniformed Services University of the Health Sciences endorsement. This work was prepared by a military or civilian employee of the US Government as part of the individual’s official duties and therefore is in the public domain and does not possess copyright protection (public domain information may be freely distributed and copied; however, as a courtesy it is requested that the Uniformed Services University and the author be given an appropriate acknowledgment).

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