About the phenomenon called denial

Denial, essentially, is normal. It is merely an exaggeration of the common process of selective attention. We have to be able to select information in order to routinely function. However, to, for example, continually focus on the potential dangers around us could result in disabling anxiety.

Denial is a typical coping mechanism for a person with advanced cancer, who will fluctuate in the degree of acceptance of their illness and impending death.

Receiving life-changing news such as, “You have cancer,” can be overwhelming if all of the consequences are immediately considered. A characteristic way to adjust is to deny certain elements while focusing on others. Usually, adjustment to bad news takes time.

It neither is possible nor healthy to continuously think 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 have only 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 can be helpful when used appropriately, and when it does not hinder other adjustments (practical, financial, emotional or spiritual).

Excessive denial

Persistent refusal to discuss an illness is usually 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?” the person may quickly change the subject. Such people may be lacking confidence in their own abilities and, consequently, may never benefit from the boost in confidence that comes from facing and adjusting to problems.

Confronting someone with information they do not want may not be helpful and can be considered unkind. Often the patient forgets they have heard the information, and yet may demonstrate increased anxiety, or, even, anger. It usually is not helpful 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. One day, as the doctor stood up to leave her bedside, 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 impending death, and said she felt relieved to do so.

Denial must be recognized and 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, both, reasonable and unrealistic fears, and anxiety tends to escalate. It also blocks meaningful communication with others, including the family.

An essential aim of discussing a person’s illness with them is to reduce their anxiety. The skill is in choosing the right moment and suitable words. Remember that a person who prefers denial to discussion tends to be frightened and lacking in confidence. Careful explanation can reduce anxiety (which, however, may be replaced by appropriate sadness). Most often, a patient will convey verbally or non-verbally if the information or explanation is excessive or unhelpful at that particular time.

Testing denial

Ask the patient, “Can you help me by explaining what you understand about your illness?” The most common and immediate reply is, “Nothing.” Avoid the temptation to give premature explanations. Continue to ask questions, and be sure to listen.

• Ask the person how they 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 that?”)
• Avoid giving unrequested information.
• At each visit, check their level of acceptance. (“How do you feel things are going?”)

Excessive denial also can cause anxiety. But, occasionally, patients confront the facts relentlessly and allow themselves little relief from their fears. Most people seem to experience sad, even 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.