Managing Uncertainty

It is a loaded question and one I struggle in answering when my prospective patients propose it. ‘Help with what? ‘ I think. Usually, the help relates to some discomforting symptoms. The honest answer is: ‘I don’t know’. The therapeutic relationship depends on so many variables: willingness to change, comfort in opening up to me, expectations of the speed of change, my insight into the root of their issues, and how well my medical ‘tool-kit’ matches up to these issues, amongst other things.

The response I have settled on for now is: “I don’t know, but I will be sure try my best.” Maybe not the best way wrangle patients in, because it is not certain; however, there is no certainty in medicine, or in life for that matter.

As a student, I was also seduced by certainty. I studied physics in college mesmerized by the power to predict the outcome of any object given its initial conditions. How far will Jimmy throw the ball if the angle of the throw is ‘such’ with a release velocity of ‘so and so’. Using the tools of Newtonian mechanics, we can find out! I was not the only one seduced by certainty though. The entirety of the enlightenment era was based on the premise that given precise enough measurements, we can unlock all the mysteries of life.

As I progressed through my physics studies, I encountered subfields that defied the certainty promised by the enlightenment era. In quantum physics, one cannot precisely predict both the location and speed of a particle as codified in Heisenberg’s uncertainty principle; furthermore, more precisely defining one parameter comes at the expense of being able to define the other.

A famous thought experiment that came about during a conversation between Einstein and Schrödinger captures the essence of strange quantum behavior. One is asked in this thought experiment to imagine a cat sealed off – though able to breath – in a black box with a poison vial and radioactive source that would shatter the glass and kill the cat if the radiation decays. The question is whether the cat is dead or alive? Because radioactive decay is random, one would have to answer: I don’t know, or that the cat exists in a state of suspension, both dead and alive. It is not until one opens the box that we arrive at a definite answer.

What I regarded as strange philosophy while studying physics, I now understand to more closely resemble reality. Life is rarely neat and predictable, more often astonishing in ways we could have never imaged, until it does.

Unlike the Schrödinger’s cat, we are not totally passive at the mercy of random radioactivity. We have a degree of agency in sculpting our futures; yet, as I sit with cancer patients awaiting their follow-up scans that they prey are clear, I am also aware that we are not in total control. So, how might we gracefully navigate our somewhat controllable but uncertain existences, or as Reinhold Niebuhr more poetically puts it:

“God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, And the wisdom to know the difference.”

The spiritual language is intentional. Many look to higher powers, because where else would you look to deal with things out of your own control? It sure beats looking down; however, a worldview is deeply personal, and something we each must find on their own. So, let us return to the more worldly matter of ‘how to deal with uncertainty?’

Much of uncertainty’s anguish centers on an inability to accept a possible outcome. For Schrödinger’s cat, if you are deeply attached to the animal, the possibility of its demise may create feelings of anxiety and fear in you. Therapy therefore revolves around processing the fear and anxiety rather than ensuring the preferred outcome, which is impossible.

Fear is a feeling of scarcity and isolation; countering fear involves surrounding yourself with love and support. The love of being enmeshed in supportive social relationships and networks have a way of dissolving sinking fear and loneliness.

Anxiety is like a run-away-freight-train. One projects a disorganized jumble of thoughts into the future that seem like they are covering possible scenarios; yet, if one looks back, the anxiety jumble does not have much of a basis in reality, and speaks more to the individual’s insecurities.

Medicants for anxiety involve exercises that focus thought and / or action. Controlled actions could involve anything from participating in a fine motor sport like dancing or billiards or focusing on writing controlled neat cursive in one’s correspondences. Controlling thought could involve placing your keys in different areas of your house every day or picturing the sequence from your day before bed. In either case, activating pictorial memory helps one’s thoughts to be more organized any focused. Controlled thoughts and action help guide the runaway freight train of anxiety back on track.

Let us return to the original question of ‘Can you help me?’ ‘I don’t know’ is the truth, not a placeholder, because uncertainty is baked into human existence. We are neither passive cats at the mercy of chance, nor are we omnipotent gods manipulating life like a chess board, but humble humans in the middle. In my practice, I collaborate with my patients to navigate along the tragic, awesome, and yes uncertain terrain of life.

Fear

• Surround oneself with love and support
• Seek-out loved ones, engage with nourishing communities

Anxiety

Focussed Actions

• Take up a sport or dance that requires fine motor movement such as ballroom dance or billiards
• Concentrate on your handwriting making it especially neat and fluid

Focusesed Thoughts

• Place your keys in a unique spot each evening. Picture where you left it for a moment or two before going to bed.
• While falling asleep at night, recapitulate the events of the day. For an extra challenge go through it backwards!