Overcoming Fear: Half Can Make You Whole
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 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—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. 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 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.
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.
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.
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.