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When it's helpful to tune out the truth

By Ibby Caputo
Special to The Washington Post
Tuesday, April 27, 2010; HE01

A mother finds a lump in her breast while in the shower. It doesn't hurt, and she has to get breakfast on the table and go to work, so she ignores it.

A husband goes to the hospital to have a total knee replacement. While there, he shows signs of alcohol withdrawal, but when the doctor asks his wife if he has a drinking problem, she says he hardly drinks at all.

These are examples of denial, a common defense mechanism that is often misunderstood, according to psychiatrists. In extreme cases, such as when a woman denies signs of breast cancer, the results can be deadly. But more often, a healthy dose of denial helps people endure and process a disturbing reality they or one of their loved ones are facing.

"From a psychiatric perspective, denial is the mind's way of protecting the body and, actually, the mind, from some noxious truth," said Terry Rabinowitz, medical director of the psychiatric consultation service at Fletcher Allen Health Care in Burlington, Vt. "Think of the whole brain as comprising a bunch of different loudspeakers: Denial is the way for the brain or mind to turn down the volume on a certain set of speakers."

The concept of denial as a defense mechanism was introduced by Sigmund Freud, according to Hanoch Livneh, a psychologist who specializes in rehabilitation at Portland State University in Oregon.

"Freud literally thought about it as very pathological," Livneh said, "something that a normal person should not engage in."

In some cases, denial can indeed be pathological.

Lillie Shockney, administrative director of the Johns Hopkins Avon Foundation Breast Center and a two-time breast cancer survivor, said she sees such cases at least once a month. "A patient will come into the emergency room complaining of severe pain," she said, "not in the breast but in the spine or lungs, because the disease is everywhere."

Shockney said that in these cases, as soon as the patient's clothes come off, she can see the tumor eating through the breast tissue. She said such women will typically admit their breast has been in this condition for years, but when she asks if they thought it was cancer, they often remain silent.

"It doesn't matter how much I see it, I'm always stunned that someone can endure this," Shockney said.

It is a minority of patients who suffer in such a severe state of denial. Still, the majority of those with a life-threatening illness experience some form of denial, Shockney said. She can understand why.

"Breast cancer remains the most feared disease of all women, no matter what age, ethnicity or race," said Shockney. "From the time that a girl gets fitted for her first bra, she's taught the value of having breasts. Society places a lot of importance on sexiness and womanhood."

Very protective

Whether it stems from a fear of loss of womanhood or a fear of death, as Freud believed, or from myriad other anxieties, denial after a diagnosis can be a very protective defense mechanism, according to Livneh.

"The major function of denial is to alleviate anxiety. To find some way to cushion the very severe stress that may be under most conditions too much for the person to handle," Livneh said. He said that after the diagnosis of a life-threatening illness, a person might refuse to believe that she will die, experience pain from treatment or lose her hair. In these situations, denial can provide the emotional and mental space a person needs to process distressing information.

"Moderation in everything," Livneh said. He said it is normal to deny the severity, duration or far-reaching consequences of a condition as long as that process does not jeopardize medical intervention. Denial following diagnosis allows the ego to muster up the power and energy it needs to deal with the situation, he said.

Donald Northfelt, a medical oncologist who specializes in breast cancer at the Mayo Clinic, agrees.

"Denial in some ways can be a healthy thing because it can help patients overcome things that would be too traumatic if they were forced to face them straight on," Northfelt said.

Northfelt, who has been taking care of breast cancer patients for 20 years, said that when he was newly trained, he used to get frustrated with patients' denial. That does not happen as much anymore.

"Age and experience has given me a greater depth of understanding and I think more compassion for people who are experiencing denial about their medical situations," he said.

Northfelt said his obligation is to inform his patients to the best of his ability about what he knows, but he can compromise on some of their emotional or cultural needs.

"A patient may say to me, 'I don't want to hear the word "cancer." I don't believe I have cancer. I don't want to think about it,' " said Northfelt. But, he said, when he asks, "Are you willing to let me do what I think I need to do to make you well?" and the patient says yes, then he is fine with leaving the explicit mention of cancer out of his discussions with the patient. In addition to adjusting to his patients' emotional needs, Northfelt also recognizes that people from some cultures are more comfortable talking openly about illness than others.

"As long as the person shows movement away from relying on denial as an exclusive way of dealing with pain and anxiety," then the denial is adaptive, said Livneh.

Livneh said he does not advise confronting patients directly about their denial. "Any attempt to confront denial in an aggressive way really backfires," he said. "You must allow [patients] to act at their own pace."

In " 'Nothing Is Wrong, Doctor': Understanding and Managing Denial in Patients With Cancer," an article published in the journal Cancer Investigations in 2006, Rabinowitz advises providers to listen to their patients to help them move out of denial.

"Empathic listening is being able to put yourself in a place so that you can hear how I feel, and you can truly appreciate how I feel even though you may not have the same feelings or same life experiences," Rabinowitz said.

Physicians do it, too

Doctors sometimes begin to understand their patients better when they experience denial themselves.

"I think all of us in the medical profession are susceptible to that," Northfelt said. He then told a story about how his left leg had become painful and swollen during a long automobile trip he took last summer. By the time Northfelt arrived home, he said, his left leg was twice as big as his right.

"My wife saw it and became extremely alarmed," he said. So Northfelt went to the hospital. A scan revealed a huge blood clot.

"That possibility had occurred to me in the back of my mind, but I really did not want to think that that was happening to me," Northfelt said. "I spend endless time creating my own explanations about what's going on with me or making my own diagnosis."

But while denial can be dangerous, life without some measure of denial would be a catastrophe, said Livneh.

"We would be swamped with so much negative stimuli we could not handle it," he said.

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