The State of Denial
THE STATE OF DENIAL
The short description at the wikilink mentions the work of Elisabeth Kubler-Ross who described the state of denial wrt terminally ill patients in the book "On Death and Dying" (1967).
wikilink offers a rough outline of what is referred to as the "grief cycle", which are the common emotional responses experienced by terminally ill patients from first leaning about their condition to the moment of death. From the link, the 5 common emotional stages in order:
1.Denial â€" "I feel fine."; "This can't be happening, not to me."
Denial is usually only a temporary defense for the individual. This feeling is generally replaced with heightened awareness of possessions and individuals that will be left behind after death.
2.Anger â€" "Why me? It's not fair!"; "How can this happen to me?"; '"Who is to blame?"
Once in the second stage, the individual recognizes that denial cannot continue. Because of anger, the person is very difficult to care for due to misplaced feelings of rage and envy.
3.Bargaining â€" "I'll do anything for a few more years."; "I will give my life savings if..."
The third stage involves the hope that the individual can somehow postpone or delay death. Usually, the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle. Psychologically, the individual is saying, "I understand I will die, but if I could just do something to buy more time..."
4.Depression â€" "I'm so sad, why bother with anything?"; "I'm going to die soon so what's the point... What's the point?"; "I miss my loved one, why go on?"
During the fourth stage, the dying person begins to understand the certainty of death. Because of this, the individual may become silent, refuse visitors and spend much of the time crying and grieving. This process allows the dying person to disconnect from things of love and affection. It is not recommended to attempt to cheer up an individual who is in this stage. It is an important time for grieving that must be processed.
5.Acceptance â€" "It's going to be okay."; "I can't fight it, I may as well prepare for it."
In this last stage, individuals begin to come to terms with their mortality, or that of a loved one, or other tragic event.
From the link:
"KÃ¼bler-Ross originally applied these stages to people suffering from terminal illness, later to any form of catastrophic personal loss (job, income, freedom). This may also include significant life events such as the death of a loved one, major rejection, end of a relationship or divorce, drug addiction, incarceration, change in office environment, the onset of a disease or chronic illness, an infertility diagnosis, as well many tragedies and disasters."
The book itself offers a far more interesting look at the state of denial than the 5 stages of denial, anger, bargaining, depression and acceptance. What Kubler-Ross actually discovered is that the state of denial seemed to exist as much if not more within the attending physicians, nurses and next of kin than in the dying patients themselves. Certainly as interesting as the psychic reactions of the terminally ill patient were the reactions of the professional medical community caring for the patient toward Dr Kubler-Ross. From the book:
"Staff reactions to the seminar
As described earlier, the hospital staff reacted with great resistance, at times overt hostility, to our seminar. At the beginning, it was almost impossible to get permission from the attending staff to interview one of their patients. Residents were more difficult to approach than interns, the latter more resistant than externs or medical students. It appeared that the more training the physician had, the less he was ready to become involved in this type of work. Other authors have studied the physician's attitude toward death and the dying patient. We have not studied the individual reasons for this resistance but have observed it many times.
Approximately 9 out of 10 physicians reacted with discomfort, annoyance, or overt hostility when approached for their permission to talk to one of their patients. While some of them used the patient's poor physical or emotional health as a reason for their reluctance, others flatly denied having terminally ill patients under their care. Some expressed anger when their patients asked to talk to us, as if it reflected their inability to cope with them. While only a few flatly refused, the great majority regarded it as a special favor to us when they finally allowed an interview.
Early in my work with dying patients I observed the desperate need of the hospital staff to deny the existence of terminally ill patients on their ward.
Nurses reactions to the seminar
The nursing staff were more divided in their responses. Originally they met us with similar anger and often quite inappropriate remarks. Some referred to us as vultures and made it clear that our presence was unwarranted on their ward. there were others, though, who greeted us with relief and anticipation. Their motives were manifold. They were angry at certain doctors for the way and manner they conveyed the seriouslness of an illness to their pationts; they were angry at them for avoiding the issue or for leaving them out of rounds altogether. They were angry at the many unnecessary tests they ordered as a substitute for spending time with them. They sensed their own impotence in the face of death and when they became aware of the doctors' similar feelings, it angered them out of proportion. They blamed them for their inability to acknowledge that there was nothing else to be done for a given patient and for ordering tests soley to propve that somebody was doing something for them. They were bothered by the discomfort and lack of organization in regard to family members of such patients and were naturally much less able to avoid them than the doctors. Their empathy and exposure to the patients were greater, they felt, but also their frustrations and limitations.
... (during a meeting with nurses)..."We all met in a small conference room and each nurse was asked what she thought about the role of the nurses vis-a-vis a terminally ill patient. An older nurse broke the ice and expressed her dismay about "the waste of time spent on these patients." She pointed out the reality of the shortage of nursing staff and the "absolute absurdity of wasting the precious time on people who cannot be helped any longer."
A young nurse then added that she always felt very bad when "these people die on me," and yet another one was especially angry when "they die on me when the family were present" or she had "just shaken up the pillow." Only one out of twelve nurses felt that dying patients, too, needed their care, and while there was not very much they were able to do, they could at least make them physically comfortable. The whole meeting was a courageous expression of their dislike for this kind of work mikxed with a sense of anger, as if these patients committed an angry act against them by dying in their presence.
Clergy reactions to the seminar
Among all of the many chaplains, ministers, and rabbis and priests who have attended the seminar, I have seen few who avoided the issue or who showed as much hostility or displaced anger as I have seen among other members of the helping professions. What amazed me, however, was the number of clergy who felt quite comfortable using a prayer book or a chapter out of the Bible as the sole communication between them and the patients, thus avoiding listening to their needs and being exposed to questions they might be unable or unwilling to answer.
Student Reactions to the seminar
A great many of the students (so we learned later during the discussion) signed up because of some unresolved conflicts in their own life regarding the death of a loved or ambivilant figure, and a few came because they wanted to learn interviewing techniques. Most of them said they came in order to learn more about the complex problems of dying; only a few of them really meant it. Many a student came to the first interview quite self-confident, only to leave the room before the end of the interview. Many students had to make several attempts before they were able to sit through both interview and discussion, and then they were still shaken up when a patient requested to have the session in the audience rather than behind the mirror."
The interviews were generally conducted behind a one-way mirror. Even so, many students couldn't remain in the room during the whole interview. Note the irony that the person being interviewed, who is facing their impending death with a terminal illness, can handle themselves quite well while it is the the physicians, nurses, clergy and students who are going through their own form of denial.
In great contrast to the staff, the patients reacted favorably and overwhelmingly positively to our visits. Less than 2 percent of the questioned patients flatly refused to attend the seminar, only one patient out of over two hundred did not ever talk about the seriousness of her illness, problems resulting from her terminal illness, or fears of dying. All other patients welcomed the possibility of talking with someone who cared. Most of them tested us in one way or another, to assure themselves that we were actually willing to talk about the final hours or the final care. The majority of patients walcomed a breakthrough of their defenses, were relieved when the did not have to play a game of superficial conversation when deep down they were so troubled with real or unrealistic fears.
If we summarize briefly what these patients have taught us, the outstanding fact, to my mind, is that they are all aware of the seriousness of their illness whether they are told or not. They do not always share this knowledge with their doctor or next of kin. The reason for this is that it is painful to think of such a reality, and any implicit or explicit message not to talk about it is usually perceived by the patient and - for the moment - gladly accepted. There came a time, however, when all of our patients had a need to share some of their concerns, to lift the mask, to face reality, and to take care of vital matters while there was still time. They welcomed a breakthrough in their defenses, they appreciated our willingness to talk with them about their impending death and unfinished tasks. They wished to share with an understanding person some of their feelings, especially the ones of anger, rage, envy, guilt, and isolation. They clearly indicated that they used denial when the doctor or family member expected denial because of their dependency on them and their need to maintain a relationship.
This is one of the most profound but little noticed conclusions of the Kubler-Ross studies.The famous state of denial within many terminally ill patients exists partly as a response of the denial on the part of people within their environment. The hostility that Dr Kubler-Ross encountered seemed to be most pronounced from the most senior members of the helping profession, the attending physicians themselves. As she writes, "Approximately 9 out of 10 physicians reacted with discomfort, annoyance, or overt hostility when approached for their permission to talk to one of their patients." And as she also experienced, "While only a few flatly refused, the great majority regarded it as a special favor to us when they finally allowed an interview."
In a study which famously describes the initial reaction of denial and shock people tend to have when given catastrophic news of ones own impending death, it is the attending physicians, who themselves are perfectly healthy, that tend to experience the deepest and longest lasting denial.
The terminally ill person is often just reacting to the denial of the healthy people around them, especially their own attending physicians. She explains:
"It may not be a coincidence that one of the doctors best known for the total care of the dying patient, Cicely Saunders, started her work as a nurse and is now physician attending the terminally ill in a hospital set-up especially designed for their care. She has confirmed that the majority of patients know of they impending death whether they have been told or not. She feels quite comfortable discussing this matter with them, and since she does not need denial she is unlikely to meet much denial in her patients."
"Earlier conflicts and defense mechanisms allow us to predict to a certain degree what defense mechanisms a patient will use more extensively at the time of this crisis. Simple people with less education, sophistication, social ties, and professional obligations seem in general to have somewhat less difficulty in facing this final crisis than people of affluence who lose a great deal more in terms of material luxuries, comfort, and number of interpersonal relationships. It appears that people that have gone through a life of suffering, hard work, and labor, who have raised their children and have been gratified in their work, have shown greater ease at accepting death with peace and dignity compared to those who have been ambitiously controlling their environment, accumulating material goods, and a greater number of social relationships but fewer meaningful interpersonal relationships which would have been available at the end of life."
Within western education, the subject of denial isn't approached very well scientifically. The wikilink on denial
gives a good example of what I mean.
From the link:
Denial (also called abnegation) is a defense mechanism postulated by Sigmund Freud, in which a person is faced with a fact that is too uncomfortable to accept and rejects it instead, insisting that it is not true despite what may be overwhelming evidence.  The subject may use:
simple denial: deny the reality of the unpleasant fact altogether
minimisation: admit the fact but deny its seriousness (a combination of denial and rationalization)
projection: admit both the fact and seriousness but deny responsibility.
Denial of fact: In this form of denial, someone avoids a fact by lying. This lying can take the form of an outright falsehood (commission), leaving out certain details to tailor a story (omission), or by falsely agreeing to something (assent, also referred to as "yessing" behavior). Someone who is in denial of fact is typically using lies to avoid facts they think may be painful to themselves or others.
Denial of responsibility: This form of denial involves avoiding personal responsibility by:
blaming: a direct statement shifting culpability and may overlap with denial of fact
minimizing: an attempt to make the effects or results of an action appear to be less harmful than they may actually be, or
justifying: when someone takes a choice and attempts to make that choice look okay due to their perception of what is "right" in a situation.
Someone using denial of responsibility is usually attempting to avoid potential harm or pain by shifting attention away from themselves.
Denial of impact: Denial of impact involves a person's avoiding thinking about or understanding the harms his or her behavior has caused to self or others, i.e. denial of the consequences. Doing this enables that person to avoid feeling a sense of guilt and it can prevent him or her from developing remorse or empathy for others. Denial of impact reduces or eliminates a sense of pain or harm from poor decisions.
Denial of awareness: This type of denial is best discussed by looking at the concept of state dependent learning. People using this type of denial will avoid pain and harm by stating they were in a different state of awareness (such as alcohol or drug intoxication or on occasion mental health related). This type of denial often overlaps with denial of responsibility.
Denial of cycle: Many who use this type of denial will say things such as, "it just happened". Denial of cycle is where a person avoids looking at their decisions leading up to an event or does not consider their pattern of decision making and how harmful behavior is repeated. The pain and harm being avoided by this type of denial is more of the effort needed to change the focus from a singular event to looking at preceding events. It can also serve as a way to blame or justify behavior (see above).
Denial of denial: This can be a difficult concept for many people to identify with in themselves, but is a major barrier to changing hurtful behaviors. Denial of denial involves thoughts, actions and behaviors which bolster confidence that nothing needs to be changed in one's personal behavior. This form of denial typically overlaps with all of the other forms of denial, but involves more self-delusion. Denial at this level can have significant consequences both personally and at a societal level.
Concerning denial or collective denial, the subject has been recognized in literature for thousands of years. Consider Oedipus Rex, or the Philosophy of Plato.
Created on 07/03/2012 08:20 PM by admin
Updated on 08/12/2012 02:25 PM by admin