When a person says, "It's all bad news! I turn off the TV so I don't have to listen," others tend to nod their heads in understanding.
When a person says, "It's all bad news! I don't want to hear about what's not working right in my body," others sometimes step back and start whispering about "denial."
When is a person in denial?
A person in denial is a person who does not acknowledge the reality of a situation or the potential real significance or impact of a situation.
Denial is a form of coping with the overwhelming fear, anxiety, and helplessness that can come with anticipating or hearing serious bad news. It keeps at a distance anything that overwhelmingly challenges our view of self or threatens how we envision our personal future.
Denial can be helpful or harmful.
"Based on what you're describing, this seems to be more than normal forgetfulness. I'm worried he has mild to moderate dementia."
"Okay."
"I'm going to refer him to a neurologist."
"Okay."
"Do you have any questions?"
"No. We'll probably hold on seeing the neurologist. I don't think this is dementia. Everyone gets forgetful with old age."
One month later, "We decided to make an appointment with the specialist. Twice my husband left the house to check the mailbox, and both times he wandered off and we had to call the police. We'll see what the specialist says."
Short term denial can be beneficial. It can give a person time to process shocking, painful, and unexpected news so that they can later be ready to talk, make big decisions, and take action.
I once heard an oncologist comparing a person's denial to the swings of a pendulum, oscillating from one set of thoughts and moods to the other. In the afternoon, a person may understand the reality of a situation and be able to recite the average statistics for people with their same disease, statistics that indicate a poor prognosis. The following morning, the same person may swing towards some amount of denial ("I'm going to make it! I'll be the outlier!") to be able to roll out of bed each morning, get dressed, and start the day.
Denial can be harmful when it persists and colors every decision making. It can prevent a person from taking steps to address a serious issue, physical or psychiatric.
A veteran walks in one day to the emergency room. "The duct tape won't keep my back together anymore." It turns out the veteran had been taping together the edges of an enlarging, bleeding growth on his back for over a year. When asked why he didn't get it checked out earlier, he replies, "The duct tape was working. Why mess with something that's working?"
Another veteran glares at the medical student attempting to discuss his social habits. "It's just enough to take the edge off. I have a fast metabolism, and I can handle more. I could stop if I wanted to. My family have stopped talking to me about not drinking because they know it gets on my nerves!"
Denial can prevent a person from seeking a diagnosis for a new throat lump, following up on test results for intermittently bloody urine, showing up for a specialist appointment to discuss treatment options for a newly diagnosed multiple sclerosis, or seeking a counselor to manage severe anxiety. It can prevent a person from naming a power of attorney, completing a will, or getting their finances in order.
When is a person "in denial" not really in denial?
"I knew something was seriously wrong. It was the worst chest pain of my life. But Easter weekend is a special weekend for us, and I decided keeping quiet and being with my family was more important than getting checked out. I always had a plan to show up in the ER first thing Monday morning," the 65 year old man explains while lying in the cardiac intensive care unit (ICU) hospital bed.
Sometimes a person weighs risks and benefits of various actions (and inaction!) and deliberately makes a decision that another person may not agree with (read Post 18: Decisions Based on Love Can Be the Hardest to Support). This is not denial.
"I'm not saying that this cancer isn't going to kill me. I'm saying I need to make sure my family is taken care of when I'm gone. I need to keep working and finish making payments on our truck. I don't have time to waste sitting in an oncology office."
A person that seems to be in denial may actually be a person with preconceived notions about a diagnosis or medical situation, preventing them from moving forward until the preconceived notions are addressed.
"That can't be right. My uncle just had his foot amputated because of diabetes, and I don't eat like him. I was really stressed about a work presentation the day they drew blood. I don't believe those labs. I don't have diabetes."
Clarifying misconceptions and addressing disproportionate fears usually results in a person being able to move on and meaningfully discuss next steps.
Miscommunication or lack of communication can result in a person's ignorance of the true significance of a health problem or medical situation, which healthcare providers can confuse with denial.
A neurologist expresses frustration with a family's seemingly casual approach to his patient's future. "Some of their expectations do not make sense. If he survives, I expect his quality of life to be poor." It turns out every time the neurologist said, "many strokes," the family was hearing, "mini strokes." After the family learns what the neurologist is actually saying, the family is able to express hopes and goals of care more in line with their loved one's realistic prognosis.
So if a person wants to take a break from bad news or is not ready to discuss bad news, are they in denial?
A person's readiness to discuss life altering bad news may not sync up with a healthcare provider's timetable to complete their agenda (relay information, develop a plan, place orders). This is not necessarily denial.
Perhaps this particular time is the anniversary of a major life event, good or bad. "She's really grieving. Her daughter passed away a year ago yesterday. I don't think she's hearing anything you're saying."
Perhaps this is not the first serious bad news the person is hearing today, and they are still processing it. "They told me I'll have to start dialysis. I can't talk about anything else."
Perhaps the person is physically and mentally exhausted. "He just had physical therapy and two back to back appointments. Bad idea. I don't think he's able to focus on what you're saying."
Perhaps the person just heard spectacular news and wants only to soak in the happiness. "I'm getting twin grandbabies in 7 1/2 months! I'll stay alive and greet them at the door, so to speak. I only want to talk about how we can make that happen."
Sometimes it's not denial. Sometimes it's just really bad timing.
What can a person do if they are not ready to hear or talk about bad news?
For the person recognizing that they are "shutting down," "zoning out," or lashing out in anger in response to serious bad news, honor that need to take a break from the bad news (read Post 70: It's Not Cowardly to Not Want to Know). Realize that your brain is trying to protect you and get you used to a potentially scary or upsetting reality in order to process it. Sometimes news is so unexpected, shocking, life altering, or painful that a person cannot initially accept it. This would be a time to protect yourself and speak up to the healthcare provider.
"I'm in shock. I'm really not hearing anything. I need time to process. Can we talk about this on another day?"
(Serious news commonly requires major decision making. A person in prolonged denial avoids any decision making related to the bad news for as long as possible. Panic and fear usually underlie denial, and rarely can a person retain new information and make deliberate decisions while experiencing panic and fear. Read Post 33: Seven Ways to Approach a Person in Denial.)
A person who is not in denial, but also not mentally present nor emotionally ready to discuss serious news (that is, the timing is really bad) should also speak up to the healthcare provider.
"I wasn't expecting this today, and I'm feeling very anxious. Can we please pause for a moment? I'd like my family to hear this in case I miss anything."
A healthcare provider may be so focused on their agenda or have such limited time with a person that they may ignore or not be able to recognize a person's facial expressions or body language screaming, "Time out!"
A healthcare provider may forget to ask for permission to discuss bad news ("Would it be okay if I share with you the MRI results?") or forego making warning statements ("I'm afraid the news isn't good") before jumping in to discuss test results, treatment options, and even prognosis.
This would be the time to jump in yourself. "Excuse me! I apologize for interrupting, but I'm feeling extremely overwhelmed right now."
If the need to make decisions and take action is time sensitive, such as in the hospital, the healthcare provider can speak with the person's medical power of attorney [MPOA; read Post 4: Eleven Common Myths About The Medical Power of Attorney (MPOA)] until the person is ready to hear, discuss, and make decisions themselves. "I don't think I can listen to this right now. Talk to my husband. He's my MPOA. He can make decisions for me."
Sometimes it's denial, and sometimes it's just really bad timing. Either way, a person has the right to feel as prepared as possible when they have to hear life altering bad news and make difficult life changing decisions.