The Treehouse

A story of opportunity, responsibility, and gratitude

Clinical therapy experiences in medical settings can provide us with many opportunities to truly learn about important life lessons.  One particular case comes to mind that illustrates this point.  The instructor on this life lesson was a middle-aged gentleman who was diagnosed with chronic myelogenous leukemia. He had undergone a bone marrow transplant in the hopes of a remission.  Unfortunately, he developed a fungal infection that had infiltrated his central nervous system. According to medical staff, it would be unlikely for the patient to survive for more than two weeks.

The referral for this patient was forwarded to behavioral medicine services because nurses had observed significant anxiety.  Specifically, this man was experiencing high levels of anxiety during the evening hours.  Further, he steadfastly refused sleep medications.  Family members and staff were growing increasingly concerned that he was not getting adequate rest and was becoming increasingly fatigued. 

Upon interviewing this patient, it became clear that he was experiencing most anxiety during the evening and nighttime hours. When asked about this pattern, he noted that his anxiety was triggered when he felt as if he was “dozing off”.  Upon further reflection, the patient reported that the sensation of dozing off provoked panic because he feared that he was losing consciousness and slipping into death.

Although it may seem obvious, it was important to directly ask the patient what it was about dying that he found particularly disturbing. When asked this question, he revealed that he was not especially frightened about the afterlife, nor pain, nor the process of dying. Instead, he reported that he was gravely concerned that he might die without passing on his legacy (life philosophy and beliefs) to his two adolescent sons.

The focus of the assessment interview then centered on helping him identify what prevented him from sharing his legacy with his children. Here, this man described how he truly valued the importance of a father demonstrating strength and courage in the face of adversity.  He also noted that he was an emotionally guarded individual who rarely overtly expressed his emotions.  A serious problem, he noted, was that he might breakdown and cry when he attempted to discuss his legacy with his boys.  As a result, they would be left with a final image of a father who was weak and cowardly in the face of death.

Borrowing from the social skills training literature and anxiety reduction literature, it was apparent that this man could benefit from a skills-based program designed to help him develop and effectively deliver, his final words to his children without incapacitating anxiety.  The man was able to acquire the ability to present his thoughts through role-playing and rehearsal with me.  The gentleman practiced his words until he felt ready to meet with his boys.  When he felt ready, he arranged to have his boys come to his room for a special meeting.  His wife waited outside in the hall. We conducted one final rehearsal and made plans for a follow-up session.

The man was seen shortly after meeting with his boys.  He was happy, peaceful, and smiling when he reflected on the meeting.  He felt that he was able to successfully give his boys a final and lasting gift of knowledge and understanding about important life values.  He also noted that he now felt more relaxed and less fearful about sleeping.  He died that night.

Cases like this serve as reminders to behavior therapist therapists about opportunity, responsibility, and gratitude. Opportunity - as behavior therapists, we have a tremendous opportunity to help people in moments of crisis and trauma. This opportunity must be accompanied by informed and effective care.  Our patients place their hopes and dreams for healing in our hands. We must make sure that their hope and trust is not misplaced.

Responsibility requires a commitment to providing contemporary and empirically supported interventions designed to promote symptom reduction and quality of life enhancement. Responsible learning and application of research assures that we can advance the science of therapy techniques.

Finally gratitude.  We have received a great inheritance from behavior therapy pioneers whose creative energy and willingness to share knowledge yielded a foundation for ever expanding and effective systems of intervention that characterize our field. Additionally, we can never forget how our patients will sometimes be our greatest teachers. We were enriched by this man's lesson about life.  In this small corner of the world, a man empowered by love for family was able to bravely fight and temporarily conquer a fatal illness.  With his mission of love completed he surrendered his fight.  His love and spirit remain present in our world to this day - living in the hearts and minds of his boys and in our hearts and minds as therapists.