Oct 29, 2011 - 5:26 pm
Denial as a Coping Mechanism
Hello again; its’ definitely been a while since we’ve talked. A few days ago, Dr. West, our hero, asked me to comment on a GRACE reader’s question about a relative who was in complete denial. The state of her unfortunate lung cancer situation was so obvious to all that the friend wondered what the patient could possibly be thinking when she refused to consider her physician’s suggestion that she get her ‘affairs in order’.
Denial is one of our psychological defense mechanisms and, believe it or not, it works very well for those who need such a defense. Denial is actually very functional, and I am frankly surprised that more cancer patients don’t employ it. Freud once said, and I am paraphrasing, that no human being could face the fact of their imminent death for very long; truly coming to grips with the fact that one is going to die, and probably sooner rather than later is a terrifying thought. This is when denial really kicks in as the way to avoid looking at this reality. Another very wise man once said: Acceptance is hope co-existing with reality. Denial is hope masquerading as reality.
So, why are some people more able to be accepting of their reality than others? There are many factors that may be involved in this process. Age is a significant one; in general, older patients are more accepting, I think, because of their cumulative life experiences. The older one is, the more losses they experience, and death is the ultimate loss. The patient who is dying knows they are losing more than their life; they are also losing everything and everyone they love. The “survivors” lose only the patient, which is certainly not an insignificant loss, but by comparison , it is not on par with the dying patient’s losses. Older patients have experienced a great many losses by the time they have reached the stage in life that they are considered elderly. Parents, spouses, even children, sometimes adult, may have gone before them, and their ability to cope with these losses normalizes their perspective on life and death.
Younger patients may have a greater sense of injustice, both around the fact that they have cancer and also the fact that it is killing them. This is especially true for those unfortunate people who feel they have done everything “right” in their lives to avoid cancer, and yet still, there it is, forcing them to endure rigorous treatments, possibly lose their jobs or be able to work gainfully, live on greatly reduced income, suffer great psychological pain for their loved ones and themselves, and still, in the end lose the battle. The developmental stage of life a younger person also factors into their emotional state. A person in mid-life who has already passed though many of the stages, including preparation for a career, marriage, parenthood, and yet still has not quite realized all of their goals and aspirations is far more likely to experience this sense of injustice and keep hoping for the miracle that will allow for some longevity.
Additionally, the fact that cancer patients are living longer than ever before, some with chronic cancer that may go into remission for awhile and then recur, creates the expectation that this could go on forever. Often when an irreversible event occurs, such as liver failure, or overwhelming tumor burden in any major organ, such as the lungs, the patient is unable to accept that death is imminent. Most patients that I have known do eventually move into acceptance, but a few never do.
So, is this really denial, or simply the inability to move with speed through all of the stages of grief in enough time to allow them to “get their affairs in order”? The needs that the denial masks may be so important or painful to the patient that the only way for them to tolerate the reality is to deny it. When I think about this process, I wonder why we as a society and a community of patients, caregivers, oncologists, and other assorted health care professionals often feel that people must come to acceptance before dying. Whose needs are being served if patients are confronted with their reality, when it is intolerable to them? Most of the time it is not the patient’s: it is all of the rest of us. So, do we really have a choice? If the patient needs denial, I believe it is OK to allow them stay in it. After all, it is they who are dying, and only they understand why it is necessary for them to stay in denial than to move into acceptance. Someday we will all be in the same position: maybe it won’t be cancer but just getting old, and we may make the same choice!