Category: Anxiety

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How I learned to talk about death and dying

First step: Acknowledge it, together

By Steven Petrow

A serious illness is many things — terrifying, painful, life-altering. The prospect of losing a loved one, or your own life, becomes an unspeakable agony. It’s also isolating in a way I never could have imagined. I’ve been the one in that sickbed, and I’ve also done some time sitting beside it. I wouldn’t wish either experience on anyone.

Lately, however, I’ve been thinking about what memoirist Meghan O’Rourke has called “the long goodbye” and trying to focus on the one gift it does give us: the gift of time. Time to plan, but mostly time to unearth and process our feelings. And then, if we’re fortunate, to be able to share these deep-seated fears with those we love.

This is not easy. When my mother learned she had lung cancer several years ago, we both turned to humor to help absorb the meaning of her diagnosis and to deflect the pain. One afternoon, many months before she died, Mom said with a wry smile, “I think I’m really dying.” To which I replied, “You mean today? Because I’m going to the market, so if you really think so, I won’t shop for you.” “That’s hilarious,” Mom countered, a hungry smile now on her face. “What’s for dinner?” Very adroitly, pretty much reflexively, we had avoided the elephant in the room.

Mom’s health deteriorated over the next several weeks. Again, she raised the question of her death, but now without the smile. “Will dying be painful?” she asked. In that moment, I knew I needed to confront my own feelings about her mortality and not sidestep the conversation with facile banter.

I took Mom’s hand in mine and said, “Don’t worry, it won’t be painful.” I told her hospice had provided a “comfort kit,” which contained medications for restlessness, confusion, anxiety, sleeplessness, constipation and, of course, pain management. I could feel Mom’s hand relax. Finally, she said, with a palpable sense of relief, “Thank you.”

In the weeks after that, we began a new chapter. I hadn’t realized how much effort had gone into my denial. I thought about the many times I had said, “if you die …,” which denied what we both knew was inevitable. After I dropped the subjunctive and began to talk about when she died, a barrier was eliminated. She knew. I knew. Now, we knew together.

I don’t think Mom suffered in her final days. After she became “unresponsive” (considered part of “active dying”) I returned to that comfort kit at the direction of a nurse. I removed the liquid morphine and gently squeezed one drop, then a second into her mouth. When the end came a few hours later, my sister, brother and I sat on her hospital bed, holding hands with each other and our mother as she died. What a gift, I thought, as we helped her to let go honestly, openly, and — most importantly — together.

Three decades earlier, when I was newly in remission from my own cancer, I had so many worries — about recurrence, additional treatments, more surgery. But at its core the fear was always about dying, which I never acknowledged, which meant no opening for others to broach the topic. I tried hard to keep those anxieties buried away, mostly by taking anti-anxiety medications. I’d pop a Klonopin and for four hours I’d be “fine,” as I often repeated. Still, I felt detached from others, even myself, but in my mind, that was better than feeling. Or worse: talking about feelings with others.

I chose to be alone.

Every time when I returned to the hospital for follow-up labs and scans, I’d medicate. But drugs, it turns out, can do only so much. I’d still taste the fear in my throat, or notice the shallowness of my breathing. A few times I vomited — spontaneously — the associations too strong. No matter how hard I tried, I could not effectively lock away that demon, that fear.

Then I decided to volunteer at the cancer hospital that had given me so much, sharing my cancer “experience” with patients, which invariably included discussions of fear. I realized how helpful these conversations — about hair and weight loss, recurrence and remission, life and death — were to the patients I met in the hospital, either newly diagnosed or undergoing treatment. But these talks changed me, too.

For far too long, my fears had been caged inside me, dense and dark. Laura Wallace, a licensed clinical social worker whose practice focuses on transitions and loss, explained that acknowledging feelings of “loss and longing,” while deeply painful, is a much better alternative than anger, addiction and anxiety. Or denial.

Releasing these fears — into the rooms where I had these conversations, into the air outside the hospital when I would walk away — was liberating. Imagine a vial filled with dark blue worry. Release a drop into a small cup of water and it colors the water. Release another drop, this one into a gallon bucket, and it becomes nearly impossible to detect. By acknowledging and sharing my fears openly, I let them go and they began to dissolve. Eventually, I stopped taking those anti-anxiety medications.

In her recent memoir, “Going There,” journalist Katie Couric, whose husband died of colon cancer in 1998 at age 42, tells of feeling trapped between a rock and a hard place. “I was so worried about letting go of hope because I didn’t want Jay to spend whatever time he had left just waiting to die,” she wrote. “I think it takes extraordinary courage to be able to face death, and I think I was too scared, honestly.”

Couric’s words reverberated with me, especially as I’ve tried to take the lessons learned from my mother’s death, and my own illness: How to be present. How to balance today with tomorrow. How to find the courage to embrace what’s so often unspeakable.

A longtime friend, Barry Owen, succeeded in all three ways.

At 66, he revealed his pancreatic cancer diagnosis in a blog post. He knew, as did his husband, Dan, the unforgiving prognosis. (Stage IV pancreatic cancer has a five-year survival rate of 1 percent, according to Johns Hopkins Medicine.) “I have no illusions about this disease,” Barry wrote on his Caring Bridge blog, which was read by about 30 of his closest friends, including his two brothers.

Three months after his diagnosis, Barry pushed open the door to a conversation about dying. “Dan and I are starting to talk about planning, planning for my death,” he wrote. “This is not easy to write about.”

It was not easy to read about, either. But we joined the conversation with Barry and Dan, I hope, supporting them if not sharing their pain.

Barry did well enough for a while — long enough to celebrate his 67th birthday, to make a farewell tour to friends, and to enjoy the winter holidays. By spring, all that had changed. Eleven months after diagnosis, one of his caregivers posted the sentence everyone expected, yet dreaded. “So, yes, he is dying.” We understood. Barry’s followers made that final journey together with him.

During those final days I thought of “The Mary Tyler Moore Show,” one of Barry’s favorites, specifically the final scene where Mary, Rhoda, Lou, Ted and all the rest huddle, and walk offstage together, as one. It’s a tear-jerker, for sure.

We leaned in, through the Caring Bridge site. One friend acknowledged the heartbreak of losing Barry. His brother, Jamie, posted: “We all know the inevitable result, but it doesn’t keep me from becoming emotional every day.” I wrote that I’d burst into tears upon reading the news, but that I felt so deeply connected to his friends. Amid all this, a friend reminded us that Barry’s mantra had always been “Only connect,” which to him spoke to the importance of our relationships to help defeat “the isolation” — as novelist E.M. Forster put it — that keeps us apart.

I felt privileged to be among all these beautiful souls, so in touch with their feelings and able to express them. I thought then — as I do now — how rare this gift is. When Barry died, we held onto one another, tightly albeit it virtually. One friend posted, “Although I only know a few of all the friends around Barry, I feel part of you and share your grief.” Another wrote, “How terrible our loss.”

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That Mental Rut You’re Going Through Has a Name

— And Here’s What to Do About It

You’re not the only one who isn’t thriving right now—and that’s OK.

By Elizabeth Yuko

When someone asks you how you’re doing with genuine concern, you might be at a loss for how to articulate how you’re feeling lately. And it might be so hard to find the words because you’re not really feeling anything—or more specifically, you feel that your life has become sort of stagnant and directionless. In other words, you might be “languishing.”

Languishing can also be described as a “dulling of our emotions,” says Dion Metzger, M.D., a psychiatrist practicing in Atlanta. “It’s not sadness, but a lack of joy,” she says. “It’s a neutral feeling of emptiness.”

Even if you’re not familiar with the term, you may be familiar with the feeling—and you’re not alone. In fact, a 2021 survey on mental health found that around 20 percent of Americans are languishing, and this state of “blah” was found to be most common in millennials. So what exactly is languishing, how does it manifest, and how is it any different from, say, depression? We asked mental health experts for the key signs and helpful coping strategies for anyone who’s languishing.

What is languishing?

American sociologist and psychologist Corey Keyes, Ph.D. was the first to use the term languishing as a way to describe a person’s mental well-being. Much of his research has approached mental health as a continuum, with the idea that the absence of mental illness does not automatically translate into the presence of mental health. More specifically, on one end of the spectrum, Keyes would describe someone who is mentally healthy as “flourishing,” while someone with an absence of mental health would be “languishing.” In his seminal 2002 paper on the mental health continuum, Keyes notes that people who are languishing face a risk of a major depressive episode that is two times higher than those who are moderately mentally healthy, and almost six times greater than those who are flourishing.

“Languishing can feel like a gray cloud of ‘blah’ has settled over you,” says Carla Marie Manly, Ph.D., a clinical psychologist in Sonoma County, Calif., and author of Joy From Fear. And while languishing is often associated with depression, she explains that it “is often seen as a more temporary response to unremitting stress, disempowering experiences, and frustration.”

Languishing vs. Flourishing

In his work on the mental health continuum, Keyes indicated that, generally speaking, positive feelings and functioning in life indicate flourishing mental health. Languishing exists on the opposite end of the spectrum and refers to lower levels of positive feelings and lower functioning in life. As Dr. Metzger puts it, “languishing is joyless,” whereas a person who is “reaching [their] full potential of capturing life’s joy” is flourishing.

“Languishing involves a general ‘pulling back’ from life, and involves a decrease in positive feeling states,” Manly explains. “Flourishing, on the other hand, involves engaging with life in positive, healthy ways as well as enjoying positive mood states. That said, flourishing mental health does not mean that you are happy all the time or that your life is ‘perfect;’ flourishing involves facing life’s ups and downs with hope and resilience.”

The Signs of Languishing

Some of the most common markers of languishing are low motivation, difficulty concentrating, and poor energy, according to Dr. Metzger. It can also affect a person’s appetite and sleep. “Some experience reduced appetite, whereas others tend to overeat to self-soothe,” Manly adds. “Similarly, some experience poor or interrupted sleep, whereas others have hypersomnia (sleep more than usual).”

As Manly points out, languishing encompasses a wide range of experiences, including dysphoric mood states and an ongoing sense of ennui—both of which often result in reduced or no interest in interacting with others socially. Additional signs of languishing include a lack of focus, lack of purpose, disinterest in normally pleasurable activities, and inability to engage in necessary daily life tasks, or feeling “blue,” she adds.

The Key Difference Between Languishing and Depression

Because there’s some overlap in symptoms, at times it can be hard to differentiate between languishing and depression, but there are in fact some clear distinctions. Dr. Metzger likes to use a thermometer analogy. “Languishing is when we’re at zero degrees, neutral—not negative or positive. Depression is when the temperature goes into the negative numbers. These negatives include feelings of hopelessness. Languishing is a feeling of nothing, and depression is a feeling of sadness,” she explains.

And although languishing can involve or become clinical depression, not everyone who experiences languishing meets the criteria for depression, and vice versa. Clinical depression is a disorder outlined in The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), whereas languishing is not. “In general mental health terms, depression would be viewed as a clinical diagnosis, whereas languishing might be viewed more as a failure to thrive,” Manly says.

A Lot of People Are Languishing Right Now

If it seems like you’ve been hearing a lot about languishing lately—specifically, over the past two years—it’s not your imagination. “The combination of the social isolation, grief, and fear of the pandemic has brought languishing back into the spotlight,” Dr. Metzger explains. “It’s how many people are responding to the uncertainty and emotional rollercoaster of the past 22 months.”

Along the same lines, Manly notes that languishing can result when ongoing stressors create deep weariness and mental burnout. “Far from being abnormal or ‘lazy,’ those who experience languishing behavior during the pandemic are actually displaying natural responses to the highly stressful, exhausting, and disempowering nature of the pandemic,” she says.

How to Get Through a Period of Languishing

1 Take small, actionable steps forward each day.

Create a list of top priorities—the most important needs—and focus on accomplishing just two or three of them per day. “This might be as simple as taking a 15-minute walk each day to get an exercise routine going, or something more involved, like drafting a new resume or tackling house-cleaning one room at a time,” Manly says.

2 Reward yourself for every positive step forward.

As you complete the small tasks on your list, Manly suggests offering yourself a feel-good reward, like watching 30 minutes of your favorite show in exchange for every 30 minutes of cleaning, focused work, or other accomplishment. “This type of reward system supports the positive, flourishing-oriented mindset that’s so essential for getting unstuck from languishing energy,” she says.

3 Reach out for positive, affirming assistance.

Find a support group or mental health provider. “Avoid the urge to hide your difficulties and challenges,” Manly says. “We all need support when life gets rough.”

4 Identify and incorporate joy into your life.

During periods where you’re feeling nothingness or emptiness, Dr. Metzger suggests consciously identifying what brings you joy, and then making an effort to incorporate it into your life on a regular basis. “Be very intentional in seeking joy,” she advises. “Write down what brings you joy and incorporate it into your weekly routine. It’s the only way to undo the languish by counteracting it with positive emotions.”

5 Connect with people you trust and love.

You may not consider spending time with lots of other people (or certain people) something that brings you true joy—but there’s no doubt that interacting with people in your life who bring you comfort or make you feel relaxed and at-ease can help. “Connect with others to enjoy little bright spots in life such as a movie, cup of coffee, or baking project,” Manly says. “Laughter and friendship can be very good antidotes.”

6 Acknowledge and validate your own experience.

Lastly, if you recognize that you are languishing—and perhaps have been for quite some time—be kind to yourself, and keep in mind that we’ve all been through a lot. “If you are suffering, don’t blame yourself or expect yourself to magically pop out of languishing,” Manly says. “The pandemic has taken a toll on our bodies, minds, and spirits—it’s natural to feel quite low after all that has occurred.” Acknowledging how you feel (or how you don’t feel) doesn’t signal that you’ve given up; awareness is actually a big first step toward making positive moves forward.

Complete Article ↪HERE↩!

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Scared of dying?

Here’s how to beat back the fear and find peace.

Death ‘is life’s change agent,’ Steve Jobs said in a famous 2005 speech.

By Morey Stettner

If you’ve lived a full life, you’re more apt to accept death. You’re able to wrap your mind around your demise without anger, panic or woe.

Yet for many retirees, the prospect of their own passing is immobilizing. A flurry of negative emotions vies for attention, from fear (“I’m afraid of a long, painful decline”) to regret (“I won’t see my grandchildren grow up”).

If you experience what psychologists call death anxiety, you’re not alone. Roughly one in five adults say they’re afraid of dying.

Older people may feel less haunted by death, especially if they’re terminally ill and receive hospice care. Surrounded by nurses and aides who prioritize emotional support and comfort, hospice patients tend to view their impending death with serenity.

On the other hand, some otherwise healthy seniors cannot bear to think about death. Whether it’s the realization that they have fewer years left, to dread that months or years of physical suffering await them, a dark cloud of foreboding invades their everyday life.

What separates those folks who take death in stride from the ones who let it eat away at their wellbeing?

“Part of it is having a more relaxed, flexible attitude and a willingness to rescind control over how we will die,” said Katherine King, an assistant professor of psychology at William James College in Newton, Mass. “A lot of us don’t tolerate uncertainty very well.”

If you have a controlling personality, pondering your death can cause agitation. Coping with such a sweeping, impossible-to-control force can prove crippling.

Another source of death anxiety relates to your overall satisfaction with how you’ve navigated your spiritual, creative and financial life. Generally, those who are fulfilled in these areas accept with equanimity that death is the next stage.

Steve Jobs qualifies as someone who attained a measure of fulfillment. Confronting his pancreatic cancer, he described death as “very likely the single best invention of life.”

Like many terminally ill people, he waxed philosophical about death. While we’ll never know if he cursed his bad luck in private, he took a more reassuring position in public.

“It is life’s change agent,” he said in his now-famous 2005 commencement address to Stanford University graduates. “It clears out the old to make way for the new. Right now the new is you, but someday not too long from now, you will gradually become the old and be cleared away.”

Aging in itself enables some people to accept death. The more funerals we attend, the more we start to see death in a new light.

“Losing people around us like friends and loved ones creates a feeling that it’s time,” King said. “It’s a natural preparatory process. As you get into your 80s and 90s, it can seem like the next task” on your to-do list.

But for those who continue to resist (“I’m not ready to die!”), honest self-reflection can help.

Ask yourself, “Do I have any unfinished business to tend to?”

“People who fear death tend to believe they haven’t completed their lives,” said Connie Zweig, a retired psychotherapist in Los Angeles, Calif. “So the key is to move toward completion, whether it’s completing a relationship where you still feel wounded or a business project that’s important to you. It’s that longing to reach a resolution.”

By taking steps to repair ruptured relationships, reclaim discarded dreams or intensify your search for spiritual or religious affirmation, you can address the nagging feeling that something’s missing. Checking off all the boxes in your life thus reduces death anxiety.

Speaking of religion, it can work for or against you when you’re grappling with the notion of your demise. Naturally, your beliefs about life after death play a big role.

“If you think you’ll be buried and a tree will grow there, that’s enough for some people,” said Zweig, author of “The Inner Work Of Age.” “Others are more religious and their beliefs can either give them solace or dread.”

Regardless of what’s driving your fear or sadness about death, detaching yourself from your inner demons can work wonders. It’s liberating to rise above your anxiety and, like Steve Jobs, take a big-picture view of what life’s all about.

Zweig recalls counseling a 70-year-old woman who was grieving from the loss of her parents, brother and best friend. Unlike some people who grow to accept death as they mourn the passing of loved ones, Zweig’s patient expressed mounting stress as she thought about her end-of-life.

“I suggested that she meditate,” Zweig said. “She learned how to quiet her nervous system and quiet her mind so that she could watch her thoughts about death and let them go. They became less gripping and less overwhelming.”

After a few months of meditation, the woman attained a heightened state of calm in mind and body. Even her breathing gave her comfort.

“Each time I breathe in and out, I’m practicing dying,” she told Zweig. The regularity of her breathing reduced her fear and gave her strength to persevere.

“In that way, she acclimated to those previously disturbing thoughts,” Zweig said. “She found peace of mind.”

Complete Article ↪HERE↩!

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End-of-life conversations may be helpful to patients and families

By Lola Butcher

In the mid-1990s, psychiatrist Harvey Max Chochinov and his colleagues were researching depression and anxiety in patients approaching the end of their lives when they became curious about this question: Why do some dying people wish for death and contemplate suicide while others, burdened with similar symptoms, experience serenity and a will to live right up to their last days?

In the next decade, Chochinov’s team at the University of Manitoba in Canada developed a therapy designed to reduce depression, desire for death and suicidal thoughts at the end of life. Dignity therapy, as it is called, involves a guided conversation with a trained therapist to allow dying people to speak about the things that matter most to them.

“It is a conversation that we invite people into, to allow them to say the things they would want said before they are no longer in a position to be able to say it themselves,” Chochinov says.

Dignity therapy is little known to the general public but it has captivated end-of-life researchers around the world. Studies have yet to pin down what benefits it confers, but research keeps confirming one thing: Patients, families and clinicians love it.

These end-of-life conversations are important, says Deborah Carr, a sociologist at Boston University who studies well-being in the last stages of life. A key need of people who know they are dying is tending to relationships with people who matter to them. This includes “being able to communicate their wishes to family and ensuring that their loved ones are able to say goodbye without regret,” she says.

And the closer we get to death, the more we need to understand what our lives have amounted to, says Kenneth J. Doka, senior vice president for grief programs for Hospice Foundation of America. People “want to look back and say, ‘My life counted. My life mattered. My life had value, had some importance,’ in whatever way they define it,” Doka says. “I think dignity therapy speaks to that need to find meaning in life and does it in a very structured and very successful way.”

Chochinov’s search to understand why some people feel despair at the end of life while others do not led him to countries such as Belgium, the Netherlands and Luxembourg, where euthanasia and assisted suicide have long been legal. There he learned that the most common reason people gave for seeking assisted suicide was loss of dignity.

To learn more, Chochinov and his colleagues asked 213 terminal cancer patients to rate their sense of dignity on a seven-point scale. Nearly half reported a loss of dignity to some degree, and 7.5 percent identified loss of dignity as a significant concern. Patients in this latter group were much more likely to report pain, desire for death, anxiety and depression than those who reported little or no loss of dignity.

Dignity at the end of life means different things to different people, but in interviews with 50 terminally ill patients, Chochinov and colleagues found that one of the most common answers related to a dying person’s perception of how they were seen by others.

“Dignity is about being deserving of honor, respect or esteem,” Chochinov says. “Patients who felt a lost sense of dignity oftentimes perceived that others didn’t see them as somebody who had a continued sense of worth.”

Dignity therapy is tailored to enhance this sense of worth. In a session, a therapist — typically a clinician or social worker — carefully leads the patient through nine questions that help a person express how their life has been worthwhile.

“It’s not like a recipe, that you can just read out these nine questions and then call it dignity therapy,” Chochinov says. “We train therapists so that we can help them guide people through a very organic kind of conversation.”

The session typically lasts around an hour. About half is spent gathering biographical highlights, and the other half focuses on what Chochinov calls the “more wisdom-laden” thoughts the patient wants to share. A few days later, the patient receives an edited draft for review. “There’s an ethos of immediacy — your words matter, you matter,” he says. “They can edit it and they can sign off on it to say, ‘That is what I want as part of my legacy.’ ”

Chochinov estimates that nearly 100 peer-reviewed research papers, and at least four in-depth analyses — “systematic reviews” of the accumulated science — have been published so far on dignity therapy, and more studies are ongoing. The largest yet, of 560 patients treated at six sites across the country, is now being conducted by Diana Wilkie, a nursing professor at the University of Florida, and her colleagues.

Wilkie also helped conduct the first systematic review, published in 2015, which came up with a conundrum. When all studies were viewed together, the evidence that dignity therapy reduced the desire for death was lacking.

“The findings have been mixed,” she says. “In the smaller studies, you see benefit sometimes and sometimes not; in the larger studies, not.”

The most definitive study — Chochinov’s original clinical trial, of 326 adults in Canada, the United States and Australia who were expected to live six months or less — found that the therapy did not mitigate “outright distress such as depression, desire for death or suicidality,” although it provided other benefits, including an improved quality of life and a change in how the patients’ family regarded and appreciated them. A few years later, Miguel Julião, a Lisbon physician, and his colleagues conducted a much smaller trial in Portugal in which dignity therapy did reduce demoralization, desire for death, depression and anxiety.

Julião thinks the different outcomes reflect differences in the patient groups: His study focused on people experiencing high levels of distress, while Chochinov’s did not.

Positive and negative results also may depend upon how studies measure “success.” Scott Irwin, a psychiatrist at Cedars-Sinai Cancer in Los Angeles, worked at a San Diego hospice that introduced dignity therapy in 2009.

“It was absolutely worthwhile — no question,” Irwin says. “Not only did the patients love it, but the nurses loved it and got to know their patients better. It was sort of a transformative experience for patients and the care team.”

In Portugal, family members of dying individuals have prompted Julião to develop new uses for the therapy. He and Chochinov first adapted the interview to be appropriate for adolescents. More recently, they created a posthumous therapy for surviving friends and family members. In a study of this survivor interview protocol, “we have wonderful, wonderful comments from people saying, ‘It’s like I’m here with him or with her,’ ” Julião says.

For all its appeal, few patients receive dignity therapy. Though the tool is well-known among clinicians and social workers who specialize in caring for seriously ill patients, it is not routinely available in the United States, Doka says.

A primary barrier is time. The therapy is designed to last just one hour, but in Irwin’s experience at the hospice, patients were often too tired or pain-ridden to get through the entire interview in one session. On average, a therapist met with a patient four times. And the interview then had to be edited by someone trained to create a concise narrative that is true to the patient’s perspective and sensitive in dealing with any comments that might be painful for loved ones to read

Julião says he transcribes each patient’s interview himself and edits it into the legacy document. He says he has enthusiastic responses from clinicians and social workers attending the lectures and workshops he has conducted. “But they don’t do it clinically because it’s hard for clinicians to dedicate so much time to this.”

Dignity therapy is most widely available in Winnipeg, its birthplace, where all clinicians at Cancer Care Manitoba, the organization that provides cancer services in the province, have been trained in the protocol. If a patient expresses interest, or a clinician thinks a patient might be interested, a referral is made to one of the therapists, among them Chochinov.

A few months ago, he spent about an hour with a dying woman. She told him about her proudest accomplishments and shared some guidance for her loved ones.

A few days after he delivered a transcript of the conversation, the woman thanked him by email for their discussion and for the document that “will give my family something to treasure.”

“Dignity therapy is part of the bridge from here to there, from living my life fully to what remains at the end,” she wrote. “Thank you for helping me to tell this story.”

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4 ways that older people can bolster or improve their mental health

By Jelena Kecmanovic

Older people generally have fewer psychological problems than the rest of the population. They also have shown the least increase in anxiety and depression during the pandemic, despite being most vulnerable to covid-19.

Resilience among the elderly has been attributed to their ability to better regulate emotions, higher acceptance of the ups and downs of life, and wisdom that comes from having learned to see the big picture.

But old age brings many challenges that can harm mental health.

Even after she lost her second husband to cancer, she kept engaged by providing relationship coaching, gardening, walking her dogs, hiking and doing house repairs. “But when my left knee started giving me more and more trouble, so that eventually I could hardly walk, I felt really discouraged and depressed,” Landrum said.

Many older people do suffer from considerable mental health problems. Among those living outside group settings, the rate of clinically significant depressive symptoms is 8 to 16 percent and anxiety disorders is 10 to 15 percent. The elderly living in nursing homes fare worse. Most older adults with depression and anxiety do not receive treatment for it.

Late life depression, in turn, has been found by researchers to increase self-neglect, cardiovascular problems, morbidity, and risk of suicide. It also leads to worse social and cognitive functioning and compromised quality of life. And geriatric anxiety has been linked to heart problems and high blood pressure, among other problems.

Studies have illuminated some risk factors for geriatric depression and anxiety.

Elderly people who deal with significant physical problems or cognitive decline, who are lonely, or who are grieving or dealing with multiple losses are more likely to experience psychological problems, especially depression. So are older people who have a lot of regret about a life not well-lived and who struggle to find meaning in their lives.

Many existential concerns come to the forefront of people’s minds as they near the end of their lives.

They confront questions such as, “Have I led a meaningful life?” “What has my role been in this world?” or “Am I leaving something behind?” How people perceive, explore, process, and talk about these questions can affect their emotional well-being.

Here are four approaches that psychologists like me find can facilitate these explorations and consequently bolster or improve mental health.

Engage in life review

It is a truism that the older people get, the more they reminisce about the events that took place in the past, sometimes very long ago. Psychologically, there is a purpose to looking back.

One of the most influential psychologists of the 20th century, Erik Erikson, considered the last stage of life to be focused on reviewing life, integrating positive and negative memories, and coming away with a coherent sense of a purposeful life. He postulated that people who had a particularly hard time with this process could end up feeling despair.

“In my work with older patients, we often engage with the question, ‘What has it all been about?’ ” said Herbert Rappaport, a clinical psychologist in the Philadelphia area and the author of “Marking Time.” “It is powerful to help them construct their life stories and to witness how this leads to a sense of peace and acceptance of whatever comes next.”

Research shows that life review improves mental health.

But depressed individuals have a hard time recalling positive events or reflecting back on their lives in ways that are not negative and self-critical. They also tend to remember things in a more general, abstract way, without much detail.

A strategy that counteracts this tendency is to intentionally remember positive situations and times in your life, recalling as much concrete and sensory information as possible.

“I worked with an older woman in my practice who was worried about her daughter’s well-being once she’s gone, and she questioned if she’s done anything to help the next generation, and now it was too late,” said Jason M. Holland, a clinical psychologist in Gallatin, Tenn. “Writing about and discussing these feelings and reviewing her life in totality helped her realize that it’s not all negative and that she’s leaving an important legacy with her grandkid.”

Autobiographical writing or recording, storytelling, scrapbooking, making art that honors your life, family genealogy, oral history interviews, arranging old photographs and creating legacy projects are all ways that promote life review.

Consider sources of meaning

Much of popular psychology and self-help urges us to discover or create meaning in life. “I fear that this just adds more pressure for people, that this can become another reason to feel guilty and ashamed — ‘I’ve failed because I haven’t found the meaning of my life,’ ” said psychologist Joel Vos, author of “Meaning in Life: An Evidence-Based Handbook for Practitioners.”

He suggested that people engage instead with the meaningful activities that they are already doing.

In my own psychology practice, I have found that, during the pandemic, many people have gained more clarity about what really matters in their lives. This often centers on going beyond oneself: connecting with others, with the past and future, with God or spiritual concepts, or with nature. Another source of transcendence includes creating something in the world, from a tenderly tended garden to a painting to a nonprofit organization.

“It is never too late to orient yourself toward what’s meaningful. At 90 years old, I am a living example,” said Irvin Yalom, emeritus professor of psychiatry at Stanford University and the author of “Existential Psychotherapy” and “Staring at the Sun: Overcoming the Terror of Death.”

“I still see some patients, but just for a session each because my memory and energy are not what they used to be,” he said. “I connect with my children and play chess and talk with friends. Human connections make life worth living.”

Accept limitations

A common misconception I hear is that acceptance equals passive resignation or giving up. It actually means the opposite; it’s an active process of facing the limitations that come with age, employing courage and wisdom.

“One of the best predictors of successful aging is the ability to disengage from unattainable goals,” said Carsten Wrosch, a psychology professor at Concordia University in Montreal. “While grit and perseverance might be most important for younger people, the elderly with the best psychological outcomes let go of things they can’t do any more and shift toward things they can still do that are purposeful.”

Older adults often struggle with physical or cognitive limitations, with a loss of freedom, and with the ability to control their lives. “Losing control can be the most demoralizing. I suggest adjusting your expectations and finding anything, however small, that you can control,” Holland said.

Dealing with the hardships commonly faced in old age can even be a catalyst for growth. Illness, grief or another negative change sometimes results in an important reckoning. “Significant transition or change can lead to an existential crisis, a chance to reevaluate life and to eventually align it more with your values,” Rappaport said.

Deal with death anxiety

With the coronavirus death toll of at least 750,000 in the United States, many people here have faced death more immediately and more acutely than at any point in recent history. And yet, many still find it hard to talk about death and dying, avoiding news that could trigger death anxiety.

“Numerous studies show that people who have high death anxiety suffer from psychological problems and disorders,” said Rachel Menzies, clinical psychology postdoctoral research fellow at the University of Sydney and a co-author of “Mortals: How the Fear of Death Shaped Human Society.” “In general, death anxiety subsides later in life. But for some elderly, it can be very high and contribute to their depression and anxiety.”

To confront death anxiety, Menzies suggests reading obituaries or watching shows that involve death and dying, especially if these had been previously avoided.

“Visit cemeteries, nursing homes, or funeral homes — anything that will bring you in contact with death,” she said. “That way death becomes a normal part of life.”

Another often evaded topic is a discussion of one’s will and end-of-life preferences and directives. Tackling this now could decrease your fear of death, and provide a sense of dignity and control. And it will be a gift to the ones you are leaving behind.

An exercise I often use with patients, derived from Acceptance and Commitment therapy, a type of therapy which helps people to live with purpose and to stop being hostages of their anxiety and depression — is to have someone imagine their funeral and write their own eulogy and tombstone inscription. This may sound ghoulish, but it not only tends to reduce death anxiety, but also crystallizes the values that are important to people and urges them to put them in place before it is too late.

“Life well lived is the best antidote to death anxiety,” Yalom said.

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Grief-induced anxiety

— Calming the fears that follow loss

By Jessica DuLong

Millions of Americans are grieving loved ones taken by Covid-19. Yet even outside of a pandemic — with its staggering losses of lives, homes, economic security and normalcy — grief is hard work.

“The funny thing about grief is that no one ever feels like they’re doing it the right way,” said therapist Claire Bidwell Smith, author of “Anxiety: The Missing Stage of Grief.” But there is no right way, she insisted. The only “wrong” way is to not do it.

What often trips people up is misattributing the sensations of grief-related anxiety to some unrelated cause. “Probably 70% of my clients have gone into the hospital for a panic attack following a big loss,” Smith said.

After doctors rule out physical illness, clients come to her for counseling, frequently struggling to understand the link between their physical symptoms and bereavement.

This becomes especially problematic in grief-averse places like the United States, Smith explained.

With over 4 million reported Covid-19 deaths reported worldwide since December 2019, grief and loss have touched an untold number of hearts and minds. Smith recommends connecting the dots between loss and anxiety as a critical first step toward healing.

This conversation has been edited and condensed for clarity.

CNN: How are grief and anxiety related?

Claire Bidwell Smith: When some big change comes seemingly out of nowhere and disrupts life, we realize we’re not safe, things aren’t certain, we’re not in control.

All of that is true all of the time, but loss is a huge reminder. The life changes and emotional upheaval are so much bigger than most people understand. Grief, which is the series of emotions that accompany a significant loss, can drop you to your knees. That feeds anxiety.

Grieving people can begin feeling anxious about their own health or the safety of other loved ones. Sometimes, they don’t even realize what they are experiencing is anxiety or is in any way related to their grief.

Anxiety, a psychological condition that causes fear and worry, can present with many physical symptoms. These can be misleading, making you think you have heart palpitations, a stomach issue, a new sweating problem, headaches, insomnia. Many people think they have a medical problem and not an emotional one.

CNN: How do you help people ease their grief-related anxiety?

Smith: My first job is to help people connect the dots between their loss and their fears by tracing their anxiety on a time line: When was I last anxious? How were things before my loved one died?

If the loved one had a long illness, the anxiety might begin before the death. After a sudden death, the anxiety might start right away. Usually if someone’s going to veer into anxious territory, it’s something that happens quickly following loss.

Some people I see, who have never had anxiety in their lives, suddenly begin to have panic attacks right after the death of a loved one. Others, long familiar with anxiety, see symptoms really ratchet up after a loss, or maybe take on new manifestations.

CNN: What coping strategies can people use?

Smith: Seeking out support is really vital. There are so many more support groups and grief therapists available right now. And because of the pandemic, many are available virtually. You can often find support online and start tomorrow. If the therapists or groups you find are booked, get on a wait list. It’s never too late to work through your grief.

If people don’t seek out help to untangle their emotions, they get stuck in anger or guilt. Those play out in substance abuse, depression and anxiety, in relationship issues and in trouble at work and school. So, the domino effect of trying to muscle through and not seeking out support isn’t good.

CNN: What advice do you have for those resistant to formal mental health treatment?

Smith: Self-guided online courses are one option that many therapists provide. Even reading articles or books or listening to a podcast about grief can normalize your experience and help you give you more permission to mourn. You can feel like you’re going crazy, like something else is wrong with you, when really, it’s grief.

Social media offers so many grief resources. A simple search on Instagram for #grief can help you find solidarity with others. Even just reading about other people’s experiences through their posts and comments is valuable because it can help you realize you’re not alone.

CNN: Because of the pandemic, so many people have been unable to be with their dying loved ones. What impact might that have?

Smith: We will see more complicated grief, with extended periods of grieving where people may get stuck in a loop of guilt or regret or anger. That comes, in part, from the feeling that a lot of the losses were preventable, and because people were forced to say goodbye to loved ones over Zoom and FaceTime with nurses wearing masks and face shields. Those kinds of endings can lend themselves to complicated grief.

Clients I’m working with who have lost a loved one to Covid-19 are feeling anger as they watch people get vaccinated — or choose not to get vaccinated. Everyone’s posting reunion pictures. Someone who lost a parent to Covid a month ago is painfully aware of just how close they were to not having to go through this loss.

Initially, they have to work through shock, anger and guilt. Then we can begin to find new ways to say goodbye. That can look like doing self-compassion exercises or speaking with a pastor, minister or rabbi to work on absolution of guilt. It can involve finding spiritual connections to someone they have lost by writing them letters. I urge people to embrace their own sense of ritual and perhaps even hold memorials.

CNN: What role do meditation and mindfulness play in healing?

Smith: When we are grieving, and when we are anxious, we spend a lot of time dwelling in the past and fretting about the future. Meditation and mindfulness help bring our awareness to the present moment.

Meditation also helps us to understand our own thoughts, and how we can learn to detach from negative ideas and irrational fears.

CNN: You write that imagination can be another powerful tool. How?

Smith: I wasn’t there the night my mother died. Even today, I imagine myself crawling into her hospital bed and holding her and saying the goodbye that I didn’t get to. I’ve found catharsis in envisioning what I would have done, had I been able. But it took me years — definitely more than five — to get to that point.

Just like when athletes envision a course the night before, imagination can almost give your body a sense memory, which can be soothing. But it’s not something that people are ready to do right away.

CNN: What role does story play in coping with grief and loss?

Smith: People carry around stories of loss and death, but they often feel like they are suppressing them because they haven’t found good places to share them. How we hold a story is very indicative of how we feel emotionally. When we are holding a scary story, an uncomfortable story, a story of regret for a long time, it plays out in our day-to-day life.

Healing comes from finding outlets to explore a story and possibly find ways to reframe it. We can do that in therapy, counseling, support groups, online grief forums and grief writing classes, among other places.

CNN: You’ve come to believe that staying connected with our lost loved ones can be more healing than letting go. What does that look like?

Smith: That looks different for everyone, and it isn’t something most of us can do right away — we often just want our person back in front of us. But once they are ready, I encourage my clients to call upon their loved ones, continuing to be in conversation with them internally. There used to be this emphasis on letting go and moving on. Now, I feel it’s more important to move forward with the person you have lost.

For example, pondering: What advice would my dad give me about this job offer? What would my mom think of my new boyfriend?

Developing and fostering a relationship with our person can include sharing stories about them, taking on certain aspects of work they did or doing things in remembrance.

CNN: You quote Hope Edelman, author of “The AfterGrief,” who has said the crux of grief work is making meaning out of loss. Is there a way to foster the meaning-making that can have such lasting value?

Smith: In some ways, that stage comes naturally. However, we can’t get there until we work through guilt, regret and anger that stand in the way of our ability to make meaning. If we’re angry with our loved one or a situation that happened, a lot of people will hold onto that anger because it’s a very powerful emotion.

But I’ve never seen a grieving client who hasn’t questioned life in a new way. Where’s my person? Can they see me? Will I ever see them again? Why am I still here?

It’s really hard to go through huge loss and not have those questions. Those inquiries lead to finding meaning and transformation.

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Death and psychedelics

— How science is reviving this ancient connection

By

In November 1963, the writer and psychedelic explorer Aldous Huxley laid in bed, unable to speak. He was dying of cancer. One of his final acts was to pass a handwritten note to his wife Laura. 

His famous last words: “LSD, 100 µg, intramuscular.”

It was Huxley’s dying wish: a large dose of acid, please. Laura Huxley fulfilled the request twice during her husband’s final hours.

First synthesized 25 years before Huxley’s death, LSD was still legal in 1963. Scientists were studying it as a potential treatment for alcoholism and other ailments, as well as investigating its similarity to other psychedelics. It wasn’t until 1968 that the federal government outlawed these drugs due to their association with the cultural turbulence of the 1960s.

Today, several decades later, terminal cancer patients are once again taking psychedelics. This time around the drugs are being administered by doctors and scientists in controlled settings—and they are not microdoses. The results of this research have been nothing short of remarkable.

Laura Archera Huxley, 40-year-old musician and filmmaker, and husband Aldous Huxley, 61-year-old British novelist, pictured at their Hollywood home in Hollywood in 1956. On his deathbed seven years later, Huxley asked his wife for a massive dose of LSD.

Alleviating anxiety and despair

Terminal patients often suffer from feelings of intense anxiety and despair after receiving their diagnoses. For many, this is just too much to bear. The overall suicide risk for these patients is double or more compared to the general population, with suicide typically occurring in the first year after diagnosis.

Terminal patients have twice the suicide risk of the general public. Psychedelics may help reduce their fear and suffering.

That’s where psychedelic therapy may help. After a single large dose of psilocybin, taken in a curated space and supervised by a pair of doctors, many patients report feeling reborn. It’s not that the underlying physical disease has been cured. Rather, the drug prompts a shift in the theme of their emotional self-narrative—from anxiety and despair to acceptance and gratitude.

It may seem curious to think about psychedelic drugs, often associated with hippies and the Grateful Dead, as clinical-grade tools for overcoming our primordial aversion to death. But maybe it shouldn’t be. Maybe this is only surprising if your window of historical perspective is too narrow. Maybe these “novel findings” are, in a sense, a return to somewhere we’ve been before.

Psychedelics at the dawn of civilization

In late 2020 I spoke to Brian Muraresku, author of The Immortality Key: The Secret History of the Religion With No Name, about the use of psychoactive plant medicine throughout antiquity. Our podcast conversation covers this history in more detail, but it’s clear that humanity’s relationship with psychoactive plants extends back at least to ancient Greece—if not further. It’s hard to look at prehistoric cave paintings like the Tassili mushroom figure and not wonder if psychedelics played a part in their creation.

Western philosophy may have developed with help from psychedelics as well. In Plato’s well-known allegory of the cave, a group of prisoners live chained to a cave wall, seeing nothing but the shadows of objects projected onto it by fire. The shadows are their reality; they know nothing outside of it. Philosophers, Plato states, are like prisoners freed from the cave. They know the shadows are mere reflections, and they aim to understand deeper levels of reality.

Plato’s philosophical ideas might have been influenced by psychedelic experiences.

Was Plato tripping?

If that sounds like someone who’s explored those deeper levels with psychedelic assistance…well, maybe it was. In his book, Brian Muraresku explores the significance of the Eleusinian Mysteries, secret ceremonies that involved death and rebirth. For centuries, philosophers and mystics traveled to the Greek town of Eleusis to partake in a ritual that involved an elixir known as pharmakon athanasias, “the drug of immortality.”

“Within the toolkit of the archaic techniques of ecstasy–plant medicine just being one among many–something you find again and again, in Ancient Greece and other traditional societies, is this sense that to ‘die’ in this lifetime, or achieve a sense of timelessness in the here and now, is the real trick.” -Brian Muraresku

Contemporary archaeologists, digging outside Eleusis, have unearthed ancient chalices containing a residue of beer and Ergotized grain. Ergot is a fungus that grows on grain. It produces alkaloids similar to LSD. It’s possible, then, that influential thinkers like Plato were inspired by genuine psychedelic experiences.

This connection between psychedelics and death didn’t end with Eleusis. It survived, often repressed and hidden from view, right through the time of Aldous Huxley.

The connection re-emerges in the 1960s

In the 1960s, Timothy Leary co-wrote a book called The Psychedelic Experience: A manual based on the Tibetan Book of the Dead. Leary, the exiled Harvard professor and psychedelic guru, dedicated the book, “with profound admiration and gratitude,” to Aldous Huxley. It opens with a passage from The Doors of Perception, Huxley’s essay on the psychedelic experience. Huxley is asked if he can fix his attention on what the Tibetan Book of the Dead calls the Clear Light. He answers yes, “but only if there were somebody there to tell me about the Clear Light.”

It couldn’t be done alone. That’s the point of the Tibetan ritual, he says: You need “somebody sitting there all the time telling you what’s what.”

Huxley was describing a trip sitter, someone who guides a person along their psychedelic journey. Sometimes it’s an ayauasquero in the heart of the Amazon. Sometimes it’s a doctor holding your hand in a hospital.

Timothy Leary, shown at home in California in 1979, was deeply influenced by Huxley’s work.

Seeking rebirth within the mind

In his book, Leary grounded Eastern spiritual concepts in the understanding of neurology we had at the time. The states of consciousness achieved by meditation masters and those induced by three hits of Orange Sunshine, he wrote, may actually be the same. Both involve dissolving the ego (“death”) and allowing it to recrystallize as the default mode of consciousness returns (“rebirth”). 

Leary wasn’t talking about magic. Scientists know these as “non-ordinary brain states,” inducible by rigorous attentional practice (meditation), pharmacological intervention (psychedelics), and organic decay (dying).

The ability of psychedelics to induce these remarkable brain states may also be why they’re showing such promise in alleviating the very ordinary fear of death.

Today’s psychedelic treatments: Coping with death

So what, exactly, has recent research on psilocybin as an end-of-life anxiety treatment involved?

A few small studies have seen psilocybin administered to dozens of cancer patients. They’ve been conducted in a randomized, double-blind, placebo-controlled fashion. In general, a large majority of patients showed sustained, clinically significant reductions in measures of psychosocial stress and increased levels of overall well-being.

For example, in one study, 80% of the patients found that a single dose of psilocybin quickly relieved their distress. Remarkably, in some patients that positive effect lasted for more than six months.

Sprouting new physical connections

What’s going on at the neuronal level to produce those changes? We don’t know for sure, but some preclinical research has given us a hint. Both psilocybin and LSD have been shown to induce rapid and lasting antidepressant effects in lab animals.

Early studies hint at how psychedelics may produce positive changes in the brain.

Early indications are that psychedelics may allow brain circuits to rapidly sprout new physical connections. This is exciting, but again: These are non-human studies, and it’s early.

It’s gratifying to see any of these studies happening, frankly. This is research that’s been stalled by the Schedule I status of psychedelics for half a century. Much of this work requires obtaining a special federal waiver to study banned substances, which slows progress.

Potential help for end-of-life patients

Fortunately, the FDA recently designated psilocybin therapy as a “breakthrough therapy” and the DEA has proposed increasing the supply of psilocybin for research. This should speed up the rate at which we understand the clinical efficacy of psilocybin and related psychedelics.

Here’s more good news: In terms of psilocybin’s efficacy as a treatment for end-of-life anxiety, larger human trials are already underway.

Dr. Stephen Ross, one of the field’s leading researchers, has described the significance of this work: “If larger clinical trials prove successful, then we could ultimately have available a safe, effective, and inexpensive medication—dispensed under strict control—to alleviate the distress that increases suicide rates among cancer patients.”

Huxley: Ahead of his time

In one sense, Aldous Huxley was ahead of his time. More than a half-century before today’s renaissance in psychedelic research, his own experiences had evidently brought him to the conclusion that the best way to experience death was in a psychedelic trance.

In another sense, though, Huxley was one in a long line of creators stretching back to ancient Greek philosophers and perhaps even to prehistoric cave artists. They may all have used psychedelics to catalyze their outward creativity and comfort their inner distress.

Huxley titled his famous introspective essay, The Doors of Perception, after a quote from the English poet, William Blake: “If the doors of perception were cleansed everything would appear to [us] as it is, infinite.”

We will never know what he experienced in the final hours before his death, after handing that note to his wife. I like to think that for him, the last breath seemed to last forever.

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