The Little Green Monster:
Confronting the Fear in Chronic Disease

By Abby Caplin, MD

Abby Caplin, MD, MA, is a former allergist-immunologist with a San Francisco counseling practice for people living with medical conditions and illness.

At the age of 53, Maureen is an activist and what most people would call a real "go-getter." If you're in trouble, you'll want her on your side. She is a social worker with a strong sense of social justice. Since she was a teen, though, she has always lived with a "nervous stomach" and came to accept this bodily tendency as normal.

Despite years of chronic diarrhea, however, Maureen managed to keep physically fit. She traveled, hiked, climbed mountains and regularly attended aerobics classes. She's had her share of life stresses, of course: caring for her aging parents, raising her three adopted children and shouldering her ever-increasing workload due to state-mandated cutbacks.

A few years ago, Maureen settled in with her husband to watch the HBO series Six Feet Under. The program had barely begun, when she suddenly felt a bout of diarrhea coming on and ran to the bathroom. Instead of the usual diarrhea, Maureen discovered that she was bleeding. She knows now that she almost lost her life that night. Two days and three blood transfusions later, Maureen was handed her diagnosis: Crohn's disease. Being the fighter that she is, she was determined that Crohn's disease would not defeat her. She took her medications dutifully, and kept up with her usual activities, but complications ensued. By the time she found her way to my office, she could barely move her wrists and elbows, awkwardly driving her car and turning door handles. She felt victimized, angry and discouraged, and we spent time together looking at the stressors in her life, her belief systems, medication plans and, very importantly, her relationship to Crohn's disease.

One of the tools I have in my office is something called a "sandtray." It is a time-honored tool for healing. It's a wooden tray, about 1.5 x 2 feet, filled with sand, two to three inches deep. Following my instructions, Maureen selected every kind of small object imaginable from my shelves. She carefully chose the objects that seemed to "call out to her" and placed them into a basket. When she was satisfied that she had collected everything she needed, Maureen then thoughtfully placed the objects into the sandtray. "What's that?" I eventually asked, pointing to a little green plastic dragon with bared teeth sitting all alone, which she had placed facing away from the center of the tray. "Oh, that's Crohn's disease," she answered with a shudder, "my little green monster."

I have learned that most people suffering from inflammatory bowel disease have some version of a little green monster in their psyches, one that rears its ugly head of pain or discomfort, tramples on life's plans, growls annoyingly and bites viciously. Most of us just want the right pill, or combination of pills to make it go away. This is a more than reasonable request. For some, this actually happens, and the little green monster sinks into the sand. For others, it demands attention. For them, psychologically turning away from it does not make it go away. Maureen found that out, despite her commitment to following her doctors' recommendations and her dogged dedication to a "healthy" lifestyle. In reality, turning towards the "little green monster" is really what is required. If you don't look at it, it's hard to get perspective. It might actually be needing something from you that you haven't given it yet, and finding out what that is could be the royal road to healing. And here's something important to know: that little green monster might actually be a teacher. "A teacher?" you might ask. "What could this awful experience possibly teach me?"

For some, it helps to look more closely at ways of functioning, at their connections to family and friends, and what might be missing or what might need to change. Others may look toward their sense of spirituality and reconsider the meaning of their lives. Sometimes limitations can force people to consider other avenues and other ways of being that help them grow and heal. I also know that the search is ongoing, that it is individual, and that the "quest," as sociologist Arthur Frank puts it, is as important as finding the answers.

Cliff Kalibjian in his wonderful book Straight from The Gut: Living with Crohn's Disease and Ulcerative Colitis (2003) discusses many practical coping skills for people living with IBD (physical tips, faith, humor, guided imagery, etc.) and also comments on the importance of seeking support and finding meaning. Physician and author Larry Dossey also talks about this in his 1991 book Meaning and Medicine. Since then, additional studies of patients with cancer, heart disease and HIV continue to show the role of perceived meaning by looking at disease process, survival rates and immunological changes. The studies show that "meaning therapy" can be used effectively, together with physical interventions such as medications and surgery.

Several months later, Maureen faced yet another challenge. A routine mammogram revealed evidence of a possible breast tumor. (Fortunately, it was a false alarm.) Maureen made another sandtray, and this time she placed the little green monster next to a seated figure in meditation. For the first time, she noted with surprise the little painted heart present on the monster's chest. He didn't look quite so scary this time. "He's part of me, and while I don't like it when he comes, I'm not panicked anymore," she said.

This paper was first published in "Rumblings," a newsletter of the Northern California Chapter of the Crohn's and Colitis Foundation of America (CCFA).

Straight from The Gut: Living with Crohn's Disease and Ulcerative Colitis, Cliff Kalibjian, O'Reilly, U.K. (2003)