The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [150]
Managing challenging issues with communication
Denial and collusion
Definitions
Denial is a complex phenomenon but most commonly can be defined as a strategy offering ‘psychological protection against the perception and processing of subjectively painful or distressing information’ (Goldbeck 1997, p.586).
Collusion is when two or more parties develop a ‘secret’ understanding, that is, withholding information from another person. It is important that health professionals resist invitations to collude with information that the patient has inaccurately understood (Macdonald 2004).
Related theory
A diagnosis of any potentially life-threatening illness can be experienced in many different ways and elicit strong emotional responses. Patients are likely to be distressed and experience a wide range of emotions which may arguably be lessened if ‘healthcare professionals (HCPs) were truthful and open with patients about their diagnosis and prognosis’ (Wilkinson et al. 2005, p.124).
Numerous coping strategies, including denial, may be used when someone is given a potentially life-threatening diagnosis such as cancer. Denial is not an uncommon reaction to a threatening diagnosis and is a well- recognized phenomenon in clinical practice (Vos and Haes 2007). Ten percent of patients deny the gravity of their diagnosis but usually still ask about potential treatments (Maguire 2000). As healthcare professionals, the more we understand about denial, the better equipped we are likely to feel to cope with it.
Literature on denial tends to be limited to the cancer field and prevalence rates are difficult to assess. Vos (2008) found that most lung cancer patients displayed some level of denial, which increased over the course of the illness. This outcome warrants the conclusion that in clinical practice, ‘denial in this group of patients has to be considered as a normal phenomenon and not as a sign of disturbed coping’ (Vos 2008, p.1170).
Healthcare professionals may view denial as a normal and acceptable response to a potentially life-threatening diagnosis or they may consider it problematic, especially as it can be seen to generate discomfort and uncertainty for them and the patient’s family.
Family members and healthcare professionals can collude with patient denial, perhaps as a means of protecting the patient or themselves from facing the full impact and pain of the situation. As healthcare professionals, we need to be aware of the pitfalls of colluding with patient or family denial and give consideration to how we may be contributing to it.
The concept of denial has been considered from different theoretical perspectives over time. Historically, in early psychoanalytic teaching denial was felt to be a maladaptive, immature defence which needed to be confronted. The emphasis was on the pathological nature of denial. More recently, the traditional view of denial as maladaptive is being challenged.
As human beings, we live our lives in our own individual, unique way and also deal with a life-threatening diagnosis in our own way. For some people, focusing on hope and cure is the priority, whilst for others it is first necessary to prepare themselves and their family for the possibility that their illness may be incurable. Denial is a complex, fluid process, as is living with a life-threatening diagnosis. Patients’ understanding of what is happening to them can fluctuate from minute to minute.
Denial is not an ‘all or none’ phenomenon. A patient may accept his illness in the morning, but by evening deny that he has it.
(Dein 2005, p.251)
Medical and nursing staff, family members and patients may all ‘be in denial’ at some point – to protect either themselves or those they care about.
Evidence-based approaches
Assessment of denial
In order to try to understand as fully as possible the emotions that patients are experiencing and the resources they have for coping, a careful assessment of each patient’s circumstances is important.
Healthcare professionals need to establish what information the patient has been given, before