Adam Philip Stern, MD

When my first son was born 4 years ago, I proudly showed him off to my family.

“It feels strange to love someone so much when I don’t even know who he’s going to become,” I noted.

“But you know who he is right now,” my uncle responded.

I have thought about that comment a lot over the last 4 years. The last 3 have been challenging for me and my wife after I was unexpectedly diagnosed with metastatic kidney cancer when our son was only 1 year old.

Since then, my mind has had a tendency to spiral out of control with dread for what the future holds. I know that despite the incredible advances in cancer care these last few years, metastatic disease remains deadly for most patients. Still, no one can tell me how much time I have left. If I knew that it was a matter of months, I would probably stop working and spend more time someplace warm with the people I love. On the other hand, if I knew for certain that I had years ahead of me, I could more easily make long term investments in my future. Maybe I would apply for that 5year research grant or finally replace my beaten-up car with a new model.

Both of these paths and an infinite number of others are totally feasible, but I cannot know which road I am on. Sometimes the uncertainty in my life has left me with a sense of being emotionally paralyzed. When a decision needs to be made, I have a harder time coming to a conclusion and moving forward than I used to.

The dilemma reminds me of army ants, known for engaging in maladaptive death spirals when they become disoriented.

 These blind insects use pheromones of the ants who came before them to track and follow the colony’s intended path. When a group of ants become separated from the main party, though, the unprepared leader of the trail wanders aimlessly while the others each follow the ant directly in front of them. In this way, thousands of ants can form a gigantic spiraling mass of unproductive marching until eventually they become exhausted and die.

When I was first diagnosed, I regularly found myself caught in the emotional equivalent of an army ant death spiral. My thoughts circled and circled uselessly until I became emotionally drained and exhausted. Over time, though, I have learned skills to help break the spiral. The most meaningful of these techniques I have borrowed from my training as a psychiatrist.

First, I have begun to prioritize only the worry that can lead to change. It is reasonable for me to spend time thinking about the next treatment choice, but less useful, for example, to ruminate about whether the last choice was the right one.

Next, I try to process what it is about the circumstances at the time that is most affecting me. Were there underlying automatic thoughts or cognitive distortions that led me to a place of distress? I often try to write about my experience, both as a way of better understanding it and as a method of connection to all those other individuals out there who are like me. In what I think of as a form of sublimation, I have become dedicated to the cause of patient advocacy and have given my time to worthy patient-oriented initiatives, like the 

 program. Being a guide to others, as some longer-term patients have been to me, has given me a sense of value and purpose even through the trials of serious illness.

Finally, when I need to halt an emotional spiral, I deliberately stop trying to determine what the future will bring and redirect my thoughts and actions back to the current moment. I recall what my uncle said to me about my newborn son 4 years ago and realize that there can be enormous value in a moment even if the future remains uncertain.

This approach has indeed led to wonders that I thought had already been lost to the disease. When my wife and I first got married, for example, we used to talk about having 2 children. At the time I was diagnosed, we would speak in hypothetical terms about some point in the future when I might be rid of the disease and be healthy enough to have another child. Last year I underwent multiple treatments and surgeries, and we began to give up hope. Still, we went forward together, controlling only what we could, and in 2020 we welcomed our second little boy the world. I do not know what he will be like when he is older, but I know what he is like right now; like his brother before him, he is truly a wonder.

I am well aware that the future is uncertain. That has been intensely true for me these last few years, but I have come to acknowledge that it is also a universal phenomenon. Our patients certainly struggle with the unknowns in their lives, and not even the best prognosticators among us can know exactly what lies ahead. Nothing in this life is guaranteed except the moment we are in.

While I never would have wished to come upon these lessons by way of my current path, I am thankful for the gifts this journey has given me. I appreciate them now and look forward to discovering the unforeseen value in whatever comes next.

is the director of psychiatry at Beth Israel Deaconess Medical Center’s Berenson-Allen Center for Noninvasive Brain Stimulation, and an assistant professor of psychiatry at Harvard Medical School.

Articles

Remaining in the current moment is a good way to avoid toxic negative thoughts. 

Mindfulness of the Moment as an Antidote to Emotional Death Spiraling

I reactively put my phone to sleep and slid it into my pocket. I hoped he hadn’t seen me looking at Facebook from within these hospital walls . . . a crime of poor taste. . . beneath the dignity of an attending psychiatrist.

We stared at each other, trying to place the unexplained recognition we shared. His face was familiar, but mostly just struck me as tired.

“I recognize you, too. I just can’t -”

“My wife,” he announced proudly after figuring it out. “Failed tumor excision. You were the psychiatrist. I remember now.”

“Yes!” I responded with more positive emotion than anyone should after the phrase 

It had been almost 2 years since I first met this man’s wife. I had been called as a resident to perform a safety evaluation on someone who had just found out she had metastatic colon cancer. In the wake of the devastating diagnosis, she had been sent to one of my psychiatric mentors who took very seriously the woman’s casual references to “taking charge of her fate” if it turned out her cancer was inoperable. Maybe it would be better to end it 

By the time she woke up from the procedure that failed to rid her body of the tumor, she was accompanied by a one-to-one constant observer and a pink paper designating her a suicide risk. The psychiatrist had told the surgeon to order such scrutiny if the results of the surgery weren’t good.

Consultations like these always boil down to answering a question: does this patient need to be involuntarily hospitalized to prevent her from killing herself?

“I wake up, find out I’m going to die, and have to learn from 

,” she says pointing at the sitter, “that I’m on suicide precautions! That shrink had no right to tell my surgeon what I had said in her office. That bitch!”

I was in a tough spot. I was the resident psychiatrist who was assigned to tell the surgeon if the patient was safe or not. The patient was railing against one of my mentors for doing exactly what I would have done. She was demonstrating an abundance of displaced anger; it was futile to be angry about her prognosis, but her fury toward the psychiatrist would be heard.

“I don’t want to kill myself! I’m a fighter. I’m going to fight this thing. I don’t care if they couldn’t get it out. I’ll find someone who can.”

I just listened supportively-the old standby when I don’t know what else to do. It allowed the patient to begin the process of considering her own mortality, but it also afforded her the space she needed to eventually convince me that she would not take her own life. She was future-oriented, almost to the point of denial. It wasn’t a good sign for her long-term coping but it was reassuring for her short-term safety. The question wasn’t one of morality or the merits of a painless death. It was dumber than that.

Consultations like these always boil down to answering a question: does this patient need to be involuntarily hospitalized to prevent her from killing herself? From what I had gathered from our conversation, this middle-aged woman-who, according to her surgeon, was fated to die in slow motion from her cancer-wouldn’t need to be locked away for 3 to 7 days for her own protection. Not on my watch.

I took her at her word that she wanted to fight, and if she only had months left, I’d be damned if I were going to force her to spend one minute wasting away on the psychiatry unit. With permission from the patient, I notified my mentor about our conversation and she agreed that as long as she followed up with another treater and was denying suicidal intent, she was free to go without involuntary inpatient treatment.

Now, nearly 2 years later, much had changed. I had become an attending, which means that sometimes I wear sport coats, though I’m confident the patient’s husband had other things on his mind than my attire. He and I were alone in the elevator, and there was nothing that would mercifully prevent me from fulfilling my obligation to ask how his wife was doing.

“We left here last time. Went elsewhere. Found successful treatment after all. Didn’t think we’d be back here, but a couple of nights ago, all of a sudden she couldn’t speak. And now, here we are again.”

I’d be damned if I were going to force her to spend one minute wasting away on the psychiatry unit.

We had reached the lobby and exited from the privacy of our own elevator back into the world. The man’s sister approached and urged him to hurry up, but the patient’s husband’s voice conveyed an urgency that said he wanted to keep our conversation going.

“Let’s go. It’s going to take forever to get out of here,” his sister snapped again.

“Listen,” I said. “Would you mind if, nothing official or anything like that, I just stopped by your wife’s room tomorrow for a visit?”

It was the last thing I wanted to do but literally the only thing I could think to offer.

“That would be so nice. She liked you.”

It was a lie, of course. Her liking me was a figment of her regressed state, just like hating my mentor was a symptom of something else. Splitting into good and bad is one of the most comforting things we do when we’re scared.

I spent the night worrying about how the conversation would go the next day. I knew I was out of tricks.

When I arrived in her room 12 hours later, I felt some relief that her husband was not there. There, in the hospital bed with tubes coming out of her nose and side, was the woman I had met so many months earlier. Her eyes were open, but they were wandering with a rhythmicity I couldn’t follow.

“Hello,” I announced approaching the foot of her bed. “I’m Adam Stern. We met a couple of years ago.”

There was no response but the continued bouncing of her eyes from the midline to the right and back.

“I don’t know if you can understand me.”

multi-focal infarct CVA 2/2 hypercoagulable state;

“I just came by to say hello and. . .”

Once again I took the opportunity to listen, hoping it would save me one more time, but only the 

I began to walk back toward the door, but paused at the whiteboard. “I’ll let you rest now,” I said as I wrote in black marker.

I wasn’t sure who it was a message for or if anyone would even read it, but I wanted to leave something behind.

Two days later, when her name had disappeared from the floor’s census, I went back in hoping for some kind of closure. I didn’t find it, but I did notice that my note was still there. It was with her until the end.

When even listening fails, presence is all that’s left.

Dr. Stern is an Instructor at Harvard Medical School and the Director of Psychiatric Applications at the Berenson-Allen Center for Noninvasive Brain Stimulation at Beth Israel Deaconess Medical Center in Boston.

When even listening fails, presence is all that’s left. 

Adam Philip Stern, MD

Articles

Mindfulness of the Moment as an Antidote to Emotional Death Spiraling

Presence