Why I Encourage My Seriously Ill Patients To Imagine The Worst

I was eight months pregnant, huddled on my couch alone in a dark house, one hand hovering over the remote’s pause button, the other partially covering my eyes, wondering if “Buffalo Bill” was going to skin the teenage girl alive.

That was 25 years ago, but the vivid memory of watching “The Silence of the Lambs” returned when I read last month that the movie’s director, Jonathan Demme, had died. And I’ve been pondering the question of why I chose to watch a movie that I knew would scare the living daylights out of me.

Do we gain something by willingly immersing ourselves in scary situations? Are there lessons for me, a doctor who cares for people facing serious illnesses and potentially frightening futures?

After all, doctors often try to protect patients from thinking about the “what ifs.” Why worry about things that might happen? We can deal with them if they do.

But there is evidence that people not only are strong enough to face these potentially threatening situations, but may actually benefit from doing so. Facing worst-case scenarios in a safe environment can help people prepare themselves and practice how they might react.

Consider the large body of scary children’s stories. Fairy tales and Disney movies are laden with wolves with large teeth, wicked witches, dragons breathing fire, even menacing adults. Yet far from harming children, exposure to such stories helps them build skills for dealing with frightening or threatening situations in real life.

Famed child psychologist Bruno Bettelheim’s classic "The Uses of Enchantment" made a compelling case for the importance of these stories in helping children learn to manage anxiety, make moral decisions and find heroic qualities within themselves.

Psychological research has also shown the benefits, for adults, of mental simulation — visualizing stressful situations and how we would respond. In fact, people who participate in such exercises feel better and report better coping strategies than people who simply imagine resolving the situation, or those who avoid imagining it at all.

In medical training, doctors go beyond visualization to simulation labs with mannequins that let them practice procedures they might need to do later on real people under emergency conditions. In these safe spaces, they can get used to and overcome initial feelings of panic without risking harm to an actual patient.

In my experience as a palliative care doctor, patients, too, often express a sense of relief when they are given a chance to imagine how they might handle bad news: that their cancer has progressed, or that treatment is no longer working, or that death is near.

Sometimes, the chance to engage in this type of “simulation exercise” gives patients a sense of control and preparedness that eludes them when they avoid exploring these darker areas. In the face of the uncertainty of serious or life-limiting illness, anything that restores a sense of control should be considered an option worth exploring.

Of course, not all children have the constitution for weathering the scarier fairy tales, and not all patients with serious illness choose to explore — or benefit from exploring — the worst-case scenarios. In fact, an intentional choice not to engage in scenario planning can sometimes be an effective and useful coping strategy for managing extreme stress and anxiety.

I know this from experience with patients. I also know it from personal experience.

When my husband was battling advanced esophageal cancer (the same disease that led to Demme’s death), he chose to stay focused on the positive. Beating the cancer was the only future he wanted to imagine, and that didn’t change.

For me, imagining and planning for alternatives we hoped we wouldn’t have to face was enormously reassuring. Once I knew I was prepared for the worst, I could join him in hoping for the best.

When his cancer recurred and progressed rapidly to death, I felt as prepared as I could have felt, since I’d faced my fear and practiced managing it. But I still wonder if the end of his life might have been easier — for both of us — if we could have talked together about his approaching death.

Still, it was a powerful lesson to me, and one that has been reinforced through work with my patients, that there can be intense ambivalence about these choices. Just as I watched “The Silence of the Lambs” through partially covered eyes, people with serious illness at once want to face their fears, and want to turn away from them.

So what, then, should we do, we doctors and families of those who live with serious illness? I think all we can do is to honor the courage that it takes to face scary possibilities, recognizing that doing so can help people alleviate anxiety -- but that it also can be overwhelming.

We can — and, in many cases, should — offer to play the scarier scenes, and to watch along with them. But the remote control needs to be in their hands. They get to decide whether, when and how much to preview these possible futures.

Fear is a part of life and probably of death, as well. Maybe the lesson from Demme, Bettelheim and many people living with serious illness is that we don’t have to be afraid of being afraid.

Dr. Kathryn Kirkland, chief of palliative care at Dartmouth-Hitchcock Medical Center in New Hampshire and a professor at the Geisel School of Medicine, is a Public Voices Fellow with the OpEd Project.