COMMUNICATION PROBLEMS

«  “Poor communication causes more suffering than any other problem except unrelieved pain. It is also the easiest problem (in terms of the therapist’s time and skill) to treat.” (Averil Stedeford)

Communication problems are common. The emotional crisis of an ill or dying person within a family tends to reduce its members’ ability to communicate.

This can cause:

• Misunderstandings

• Disagreements

• Emotional upsets

• Emotional coldness

• Altered behavior

• Poor adjustment to change (see Adjustment Reaction)

The most important factor in a family’s coping and adjustment is the degree of openness in the family. Openness is the ability to communicate thoughts and feelings to each other. Families vary considerably in their level of openness. In any family the longer and more intense the stress, the more difficult it is for relationships to remain open.

There are 3 main reasons why communication problems are so common in families facing death:

1. Avoidance

2. Lack of emotional energy

3. Fear

1. Family processes operate to reduce emotional tension and maintain equilibrium. The usual “emotional reflex” concerning death is to avoid the issue and hope that the disruption will not occur. "We didn’t want to upset each other..." “ is a commonly heard comment when families are finally helped to communicate together.

2. Families become emotionally exhausted by the stress of permanent uncertainty. In a changing situation emotions may alternate between hopes of life, and fears of death. Uncertainty reduces the energy available for communication, at a time when a great increase in the normal level of communication is needed to adjust to changing roles and powerful emotions.

3. Family members often fear expressing emotions. (“He mustn’t see me crying.”) Some families feel very unsafe with the idea of expressing their deepest feelings, in case it results in embarrassment or anger, violence or even madness. There is sometimes a feeling that to “break down” in tears may somehow cause a mental “breakdown”. These attitudes may be reinforced by family myths. (“Men in our family don’t cry.”)

Collusion ("Please don’t tell . . .") is a common problem. Family members often fear telling the sick person the truth, usually to protect the person they love and to spare him anguish. (“What’s the point of upsetting him?” “He’ll give up hope.”) Sometimes family members fear the patient’s anger about earlier deceits. (“We’ve known for months but we couldn’t tell her.”) Sometimes family members know that the patient has always coped with life crises by denial. Denial is therefore the family’s best attempt at coping – the situation in which they feel most comfortable. Nevertheless, “comfort” is costly. Collusion distorts all communication. Family members have to adjust all their conversations. (“She mustn’t see I’m upset.”) Important emotional business is left unresolved, which makes it more difficult for the family members to resolve their grief. The patient becomes increasingly isolated, which can cause anxiety, and/or depression, and lowers the threshold for symptoms (especially pain and nausea).

One way of managing the situation is to talk separately, first with the family members, then with the patient:

• Encourage family members to ventilate their feelings and worries.

• Elicit their good reasons for not telling. (“I’d like you to tell me your reasons for deciding not to tell him.”)

• Establish the emotional cost. (“What effect is all this having on you?”)

• Ask permission to talk to the patient alone to discover his feelings. Usually the family reluctantly agrees because their own “solution” to the problem is uncomfortable. They may say “You won’t tell him, will you?” Emphasize that you want to ask questions only to find out how the patient feels.

The patient is often greatly relieved to be able to share worries and feelings in answer to your questions, and to ask you his own questions. Occasionally the reaction is anger. (“Talking about it won’t change it.”) Occasionally the patient wants to deny the illness (and it is his denial which has led to the collusion).

It is essential to see the whole family together again, usually briefly, to facilitate communication and to interpret what each member understands. A comment such as "You’ve all been finding it difficult to talk about this illness – I guess you’ve not wanted to upset each other", often brings visible relief. It allows family members to start sharing the one issue that has been worrying all of them. (see Denial, Talking with Families, Talking with Patients)

Denial by the patient can disrupt family communications and can often be the main cause of collusion. (“Don’t talk about it.”) Some couples, particularly couples who have been very close, may know the truth but find discussing their impending separation too sad and painful. It can be easier for each to talk to professionals about separation and death than for the couple to speak to each other. In this situation it can be helpful to set the couple a practical task. Looking at old family photographs can allow some couples to share feelings of sadness without actually having to discuss them.

“Don’t be morbid.” Some families fear what might happen if sad or upsetting subjects are mentioned. They may dread mentioning certain words, like "making a will" or "priest" in case the patient assumes death is near. A counselor may need to be careful, returning gently to sensitive words to encourage further discussion, and not being put off by the obvious avoidance of the family. Another method is to grasp the feared word and simply ask "Have you ever thought of making a will?" If the response is "Don’t be morbid", a comment like "Most people find it takes away a lot of worries", can encourage the family to realize it is safe to discuss such things.

"Should we tell the children?" The worry about telling children in the family also commonly applies to telling elderly parents. The sooner a person finds out, the sooner he can start the process of adjustment. The more time there is to adjust, the less of a shock the outcome will be.

Parents also need to know that:

• Children can cope very well provided they are included and feel it is safe to ask questions.

• Children can mask their distress from their parents.

• Children who are included in the situation can be very supportive.

• Children who are denied the opportunity to be supportive often regret it or resent it later. ("if only I had known . . .") 

• 50% of children have major problems in bereavement. Anticipation and preparation reduce later psychological problems.

It is important for the counselor to acknowledge that parents understand their children better than anyone else. A family meeting can be offered to help parents to talk to their children and to realize how much their children already understand or want to know. It is usually best to leave the timing of the meeting to the parents. (see Grief)

The use of metaphor (talking about a situation which resembles this one) can make it possible to discuss distressing events.

Mrs. E.S., a teacher for many years, was dying in a private hospital room with her husband and teen-age son and daughter present. It was probably the last time they would all be together (the son was leaving the next day for college). It was difficult for them to talk meaningfully because the woman denied her short prognosis, and would not allow words like “cancer” or “dying” to be used. This meant that her husband and children did not really know what to say (in case they said the “wrong thing”) and there was an atmosphere of tension and awkwardness. The doctor asked them all to imagine a political situation where each of them might be taken away by the secret police at any moment and asked “What would you each say to the other members of your family?” (a good question to consider whether a person is well or ill). They began to express their love for each other, to say good bye and to cry together. Having been sitting widely separated, they ended up cuddling together on the bed. The woman died two days later.

It is often safe to ask “if questions”. (“If your life were short what would you say to ... ?”) This is useful for patients who want to deny and yet need to make adjustments or arrangements. (“If you needed a lot more nursing help and became weaker, would you want to stay at home?”)

«  “Considerable suffering is caused by poor communication and much of this is avoidable.” (Averil Stedeford)

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.