DENIAL

Denial is normal. It is an exaggeration of the normal process of selective attention. We have to be able to select information in order to function normally. (For example, to focus on the potential dangers around us all the time could bring disabling anxiety.)

Denial is a normal coping mechanism for a person with advanced cancer, who will fluctuate in the degree of acceptance of illness and impending death. (see Coping with Dying)

«  “Neither the sun nor death can be looked at with a steady eye.” (La Rochefoucauld)

Life-changing news (“You have cancer.”) is overwhelming if all the consequences are immediately considered. The only way to adjust is to deny certain elements and focus on others. Normal adjustment to bad news takes time.

It is not possible or healthy to think continuously of bad news. This is seen most clearly in grieving children who can seem sad one minute and happy the next. Children facing death can be greatly helped by relaxation techniques or hypnosis (for example, taking them on an imaginary journey in a space ship where they are back in control and having fun, thus giving them a rest from their emotions). Some adults facing death do this for themselves, continuing to plan for the future, (scheduling holidays, designing renovations to their homes, etc.) while also knowing they only have a short time to live.

It can sometimes be helpful to ask a patient “If someone could wave a magic wand and make you better, what would you do today?” This helps to discover some of what has been important to that person, and also encourages him to take a brief rest from his emotions.

Denial is helpful when used appropriately, and when it does not hinder other adjustments (practical, financial, emotional, spiritual).

Excessive denial – Persistent refusal to discuss an illness is due to fear. Some people adopt an attitude of total denial (for example, calling a fungating breast cancer a “rash”). Asked a question like “What did the surgeon say about the operation?” they quickly change the subject. Such people are usually lacking confidence in their own abilities and never benefit from the boost in confidence that comes from facing and adjusting to problems.

Confronting someone with information he does not want is not helpful and can be unkind. Often the patient forgets he has heard the information and yet may demonstrate increased anxiety, or sometimes anger. It is usually unhelpful to confront repeated denial, but it is important not to collude.

Mrs. L.E., 66, who had never wanted to discuss her illness, was getting very weak due to advanced colon cancer with liver metastases. As the doctor stood up to leave her bedside one day, she said "So you think I’m getting better." The doctor sat down with her again. He agreed that her nausea and vomiting were better, but said the illness was about the same and could not be completely cured. This enabled future conversations to remain honest. To collude would have made it uncomfortable for the doctor to go back again as she became progressively weaker. She soon began to talk about her dying and said she felt relieved to do so.

Denial must be respected as a coping mechanism. Some people refuse to discuss or think about their illness right up to the time they die. However, most people reach a stage when it becomes a relief to discuss some of their fears. Extreme denial prevents the sharing and discussing of unrealistic fears, and anxiety tends to escalate. It also blocks meaningful communication with the family. (see Communication Problems)

The aim of discussing a person’s illness is to reduce anxiety. The skill is in choosing the right moment and the right words. Remember that a person who prefers denial to discussion tends to be frightened and under-confident. Careful explanation can reduce anxiety (which, however, may be replaced with appropriate sadness). A patient will convey verbally or non-verbally whether the information or explanation is excessive or unhelpful at that particular time.

Testing denial – Ask “Can you help me by explaining what you understand about your illness?” The most common immediate reply to this question is “Nothing.” Avoid the temptation to give premature explanations. Continue to ask questions and listen. (see Talking with Patients)

«  Ask how the person felt at each stage. (“How did you feel when the doctor said it was an ulcer?”)

«  See if there is partial acceptance. (“Are there times when you feel it may be more serious than an ulcer?”)

«  Challenge inconsistencies. (“You have told me your illness is due to your fall in the bedroom. Do you think all this illness could be due to a fall?”)

«  Avoid giving unrequested information.

«  Check level of acceptance at each visit. (“How do you feel things are going at the moment?”)

A patient who denies his illness with one person may not do so with another. John Hinton interviewed 80 married patients dying of cancer and found that 69% spoke about their illness to their spouse, 35% to the staff and 85% to the interviewer.

Inadequate denial can also cause anxiety. Occasionally patients confront the facts relentlessly and allow themselves little relief from their fears. Most people have sad or morbid thoughts intermittently, but there are some patients who seem unable to think of anything else. Sometimes it is a form of self-punishment (guilt, depression) or a way of punishing others (anger). Cognitive approaches, which give the person insight into the connection between thoughts and feelings, can be helpful. (see Anxiety) 

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.