Stoic advice: my mother has cancer, and visualization exercises make it worse

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[Feel free to submit a question for this column, but please consider that it has become very popular and there now is a backlog, it may take me some time to get to yours.]

A. wrote: I could really use your advice on something that has been bothering me lately. I have been trying to practice Stoicism for quite some time and it has really helped me in several aspects of my everyday life. Unfortunately, a month ago my mother was diagnosed with an extremely rare and rather aggressive type of cancer. If she had not been at Stage I she would have only a few months of life. Still, the prognosis stays poor, but there is some hope. To cope with the situation I go through over and over the basic principles of Stoicism about death and grief and that has eased my pain a lot. I am focusing on the time I have with her trying to make the best of it, feeling blessed that she is still in my life without neglecting my other duties as a wife and a mother. What really confuses me right know is this. In order to prepare myself to get familiar with the worst case scenario, I have started to implement into my daily meditation routine the practice of “premeditatio malorum,” where I imagine her last days, the suffering, and her passing away.

Although I fully understand that this exercise is extremely helpful, mostly in terms of finding courage to deal with the upcoming difficulties, it also leaves me every time extremely overwhelmed, miserable, and spending time worrying about something that is out of my control. At some level, I think I’mm being ruled by fears triggered by excessive and irrational thinking (no Stoic at all), since after all there still some hope.

Do not engage in the premeditatio as a visualization exercise any more. It is clearly not working for you, and indeed it is making things worse. Consider, incidentally, that that’s not how the ancient Stoics did it anyway. They reflected on the possibility of bad events, talked to friends about it, or wrote it down in their diaries. There is no evidence that they engaged in any sort of visualization exercise.

The latter approach is actually an innovation of Cognitive Behavioral Therapy and similar techniques, as explained in Don Robertson’s book, Stoicism and the Art of Happiness. In fact, imagery and “imagery rescripting” are common tools in modern therapy (see here for resources). But they don’t work for everyone, and the one you are attempting is particularly dangerous, since it concerns a very traumatic event, like the death of a loved one.

Instead, I suggest going milder on yourself. Try some journaling, in which you write your thoughts about the situation. Not focusing just on the possible worst outcome, but actually analyzing what is going on, from the medical to the emotional aspects. Update your diary with the pertinent medical information and what it likely means for your mom and you. Write out how you are interacting with her, what thoughts come to mind, what precious memories the situation is triggering. Also, read about other people experiences similar to yours, though try to avoid the “positive at all costs” crowd (see this advice column I wrote about that). Write letters to friends, in the manner in which Seneca wrote to Lucilius, detailing not just your emotional responses, but how the current situation is a test of your Stoic philosophy.

And consider that, as you say, Stoicism is already helping you a lot. You know about how the Stoics thought about death and grief. Just as a partial reminder, here is what Seneca writes to Lucilius, in Letter LXIII, usually entitled “on grief for lost friends,” but which of course applies precisely to your situation as well:

“Let not the eyes be dry when we have lost a friend, nor let them overflow. We may weep, but we must not wail. [1] … Let us see to it that the recollection of those whom we have lost becomes a pleasant memory to us. [4] … Fortune has taken away, but Fortune has given. Let us greedily enjoy our friends, because we do not know how long this privilege will be ours. [7-8] … If we have other friends, we surely deserve ill at their hands and think ill of them, if they are of so little account that they fail to console us for the loss of one. If, on the other hand, we have no other friends, we have injured ourselves more than Fortune has injured us; since Fortune has robbed us of one friend, but we have robbed ourselves of every friend whom we have failed to make. [10] … It was just because I did not do this that I was unprepared when Fortune dealt me the sudden blow. Now is the time for you to reflect, not only that all things are mortal, but also that their mortality is subject to no fixed law. Whatever can happen at any time can happen to-day. [15]”

What Seneca says about having friends to console us applies also to your family, to whom you should turn for support and consolation, without fear of being a burden. That is, in part, what they are there for.

Moreover, you are focusing on living in the here and now, appreciating every moment you spend with your mom, which is the right thing to do. I have lost my mother recently, to cancer. Several years before I had lost my father, also to cancer. The way I handled the two situations, however, was very different precisely because I had started my Stoic practice shortly before my mother passed away. As you know, regret is not a Stoic value, since the past is outside of our control. But in a sense I do regret not having had the same tools with my father. I did not take his condition seriously enough, not in the sense that I didn’t know, rationally, what was going on, but that I did not internalize the meaning of it. As a result I kept postponing visits to Rome (I was living in Tennessee at the time), and when I did go it was always for very short periods of time. So I was still, somehow, caught unprepared when it finally happened.

With my mother, however, it was a very different story. I was aware, paying attention, focused on what was happening, and doing my best to be near her. Mind you, I did not have a particularly good relationship with either of my parents, so I’m not trying to paint an idyllic picture here. But I am still very glad that Stoicism helped me both to be present (mentally, not just physically) during my mother illness, and to put it in perspective, preparing me to deal with it, as Seneca says, by weeping but not wailing. I sincerely hope it will do the same for you.

_____

P.S.: during a discussion over at the Stoicism Facebook community someone suggested this useful summary of different methods of negative visualization.

See also this story about the calming effect of writing a diary.

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Categories: Stoic Advice

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6 replies

  1. Saludos from Puerto Rico!
    What if for a moment you look at your mother as a Stoic? In your meditations, find the virtues of a true Stoic within her and try to visualize the soldier fulfilling her duties according to providence. It is obvious that one has been fulfilled; and that is you, “a better soldier”!

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  2. I think negative visualistion has two functions. First, by thinking about a future event, and how one will deal with it, we can lessen our fear of it (through imagined exposure) and plan our response to it. Secondly, if the event feared comes to pass, we have a plan for coping which we can deploy immediately – we can “revert at once to ourselves”. It’s not clear from the question if A is already doing this, but maybe it would help if her visualization also included her own reaction to the situation, so she saw herself considering it from a Stoic perspective, accepting it, and fulfilling her duties as a daughter to the best of her ability. I don’t practice negative visualization that often, but when I have, and the event has come to pass, I think it has helped me regard it more “Stoically”.

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  3. Hi A, I’m P – for whom M wrote about positivity & cancer. That was worth 2 years of therapy! I followed up with an evidence review – there’s no relation between attitude & survival. I found that liberating.

    My heart is with you. I REALLY wish I had more non-cancer people in my life with whom I could be honest, cry WITH, & then move forward.

    When my father was in hospice in Jan, I read David Kuhl’s “What Dying People Want.” Its not morbid, more stoic. He recommends a series of questions to work through in journaling or family discussions.

    I’ve worked in palliative care for 15 years. Its helpful to resolve any unfinished business and help your mother do the same – if she’s open to it. And bonus – if she survives much longer, it strengthens your relationship & helps you be more in the moment.

    I think authenticity and stoicism will be extremely helpful. “Cancerland” often doesn’t allow one to embrace every aspect of mortality. I occasionally visualize death – not the suffering but the sensation of letting go. It’s taken 6 years to be able to do so.

    Living and loving deliberately during cancer is VERY difficult. I wish you the best. You are your mothers legacy no matter what happens.

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  4. I’ve noticed negative visualization has worked well for me sometimes and made things worse other times, so rather than working for some people and not others, it may just be that there are right and wrong ways to go about it. As for the death of others, what’s worked for me is learning to be stoic about ones own mortality, and then applying those same thoughts to the mortality of others.

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  5. Diagoras,

    Right, it’s possible that the premeditatio works some times but not others. The one A. is attempting is particularly difficult because it is so emotionally involving.

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  6. Two things:

    The first is that, according to Epictetus, we should engage in premeditation of future evils step by step, beginning with almost unimportant objects and gradually increasing the difficulty of the thing. Loved ones are the last step because that kind of thinking usually involves a great degree of psychological distress (cf. Encheiridion, 3; Discourses, I, 15). It is an exercise and, just as a beginner doesn’t dare to run a marathon, we should contemplate the most difficult of the situations only when we feel really prepared to do it. Impassibility in face of the loss of loved ones is a privilege of the sage (and we know the sage is only an ideal).

    Secondly, I’d like to add that premeditation of future evils shouldn’t be practiced unaccompanied by other meditations because it can increase our sense of vulnerability. Focusing on gratitude towards the people we love is perfect, and what Massimo has suggested about writing and journaling is a sound piece of advice. But I think A. could derive great benefit from performing very scrupulous nightly meditations, since they are not only a way of reviewing our mistakes in the day but also our positive actions. Feeling that we are living one day after the other in a way that is meaningful and dense certainly have a soothing effect on us.

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