The Therapeutic Application Of Denial
A few years ago, a patient of mine was diagnosed with lung cancer. A metastatic work up revealed a small mass in his liver that had the radiographic appearance of a benign liver cyst. But in the setting of a newly diagnosed lung cancer, we couldn’t be sure it wasn’t a metastatic lesion, so we decided to biopsy it. Due to scheduling issues, we couldn’t get it done for seven days.
Two days into the seven, he called me in a panic over the possibility that the lesion in his liver was cancer, a fact, if true, he understood would change his prognosis from good to dismal. I offered him a prescription for Valium, which he accepted gratefully, and then suggested a strategy to help him manage his anxiety that took him by surprise: denial.
CONTROLLED DISTRACTION VS. WILLFUL IGNORANCE
Denial gets a bad rap it doesn’t entirely deserve. Refusing to face up to the truth is almost always considered a bad thing: it prevents you from taking appropriate, proactive action to mitigate disaster and manage its consequences. But a complete refusal to acknowledge a painful fact—what I consider to be willful ignorance—represents denial only at its most extreme. In a less severe form, denial can actually be quite adaptive.
What I recommended to my patient wasn’t willful ignorance of the possibility the lesion in his liver could be cancer. I recommended a form of denial I call controlled distraction. He needed to cease ruminating over a possibility that he knew might be in store for him. Yes, the liver lesion could have been cancer, but in between the time the biopsy was scheduled and the time it was performed the only kind of waiting available to him was passive waiting. That is, no amount of thinking about his situation would provide him any course of action he could take to affect the outcome. All his thinking did was make him anxious.
He’d already wisely decided to have the biopsy so willful ignorance was clearly not preventing him from taking the action he needed to ensure he had the best chance for a good outcome. So I suggested he work to focus his attention on something else while he waited. By not thinking about the liver lesion, I told him, he’d be able to avoid feeling anxious.
This kind of denial does, in fact, work—if you can actually find a way to stop thinking about what’s triggering your anxiety. My patient needed a little help to do this—the Valium—but he still found the suggestions I made about how to focus his attention elsewhere helpful:
- Find something pleasurable to do. One reason some people drink or use drugs or buy things when they’re anxious or depressed is because pleasure is distracting. Far from recommending you overdose on potentially harmful pleasure, I suggest finding an innocuous one that you enjoy. Read an engrossing book. Watch a funny movie. Build a model airplane (motor tasks are particularly distracting—if not a model airplane, build something).
- Find someone else who needs support. Nothing distracts us from our own misery better than trying to help someone with theirs.
- Recognize when you’re ruminating. With a little training, you can draw your attention to the process of rumination itself and recognize when your thoughts are doing nothing but circling the worst possibility for your future. With a little practice, then, you can choose to turn your thoughts to something else (a task you have to complete or, even better, something you’re actually looking forward to). Psychologists call this thought stopping (where you consciously turn your attention away from ruminating) and it can be extremely effective (as long as you don’t try to suppress negative thoughts but rather distract yourself from them. Research suggests suppressing thoughts paradoxically makes them harder to ignore). In recent years, behavioral activation has garnered support in the literature. Rather than try to control your thoughts, get out and do something enjoyable. Let your environment distract you. Studies suggest this is as effective in some cases for treating depression as cognitive therapy.
- Focus on the likelihood of a good outcome. Whatever that likelihood is, allow yourself to bask in it. Indulge yourself in imagining how relieved you’ll feel when you hear the good news you want. Don’t be afraid to embrace hope; don’t imagine the pain of being disappointed if you’re wrong will make hearing bad news that much worse. It might briefly, but then there will only be the bad news itself for you to manage. I’m not arguing here for the pursuit of false hope. Just for focusing on whatever real hope exists.
After a difficult week, my patient had his biopsy. A day later the pathology came back. It was a benign liver adenoma. He had his lung cancer removed and three years later remains disease free.
Next Week: Analysis Of The Health Care Law
Good advice, Alex. I suggest to my patients that they “rest their minds” in reasonable hope for something like this, and invite them to join me in imagining how relieved we will be together when we meet. They understand it’s not a promise, but rather an affirmation of what is still possible when the result could go either way. At least it’s an easier place to live while waiting.
This one is relevant for me this week. I actually think that denial is much under-rated. At least if you know it’s denial. Why dwell on the worst possible aspects or possibilities of a bad situation? And a prescription for Valium and denial—it sounds like a joke, but makes a whole lot of sense. We have a choice in what we pay attention to after all.
Excellent argument for the case of “polite denial” as I’ve always called it. I run a support group for folks w/bipolar disorder which is a real tough diagnosis as it’s equated by society with “being crazy.” I always tell newly diagnosed members to simply take their medicine and forget about the diagnosis, that it took me years before my brain could accept it. Recently I was diagnosed with chronic kidney disease from years of taking lithium. The thought of going on dialysis was so horrific my defenses quickly set in and I forgot about it while, behind the scenes, my brain readied itself for acceptance and maintaining a strict diet to postpone the inevitable.
Such a useful strategy and one I think that shows our adaptability. My father is dying and I use books, funny movies and making things (jewelery, sewing), to keep my mind busy. Doesn’t work all the time, of course, but it’s a lot better than dwelling on the inevitable. Thank you for the reassurance that I’m not “running away” from the inevitable.
The topic of this blog is very timely for me, and very helpful. I have Chronic Fatigue Syndrome and spend a lot of time at home alone, especially when I don’t feel well from post-exertional relapses. Yesterday I attended the SGI Nichiren Buddhism Sunday meeting and this morning I can feel the physical effects. When I have misunderstandings with other people, especially those who have been very supportive, I’m quite unhappy. Because of their past support, I’m able to support others and called them. I read on Saturday something similar to what you mention from a book on acceptance and commitment therapy. Your comments reinforce those ideas and are very helpful. Thanks.
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Rumination is “crazy,” that’s what’s crazy! What is it, really, and how come it has the power to take hold and not let go, no matter what the issue . . . ? I can be drifting off, nearly asleep, and all of a sudden—BOOM—I’m ruminating and wide awake with the anxiety produced by ruminating. Out of the blue! (Then, of course, to add to the sleeplessness, anger will take over, anger about my vulnerability to rumination!) Grrrr!
“Don’t try to suppress negative thoughts but rather distract yourself from them.”
I was always a worrywart, fearing I had failed tests (esp. math!) in school. My mother said, “It is what it is—you will fail, or not. Why worry?” Truth! Unless you believe in magic, you will not affect an outcome which has already occurred, or is imminent.
You can only move forward from this day; all the rest is rolling the film forward, and you haven’t even written the script, yet! As Mark Twain said, “I’ve lived a long life and seen a lot of hard times…most of which never happened.”
I love how you’ve turned denial into a compassion practice, Alex. Wise denial of course, but denial still. I’m adding it to my bag of tools for coping with chronic illness.
I’ve used this approach before in my life but I wouldn’t call it denial; it’s more waiting for an outcome. As in the case of your friend I would say “don’t worry until you know there is a reason to worry.” This is not so much denial but just waiting for the facts and not dwelling on the worst case scenario. Especially true re medical tests. Easier said than done, I know. Glad your friend is OK. Love your blog—thanks for taking the time to write it every week!
This is good practical advice. I’ve had to tell patients that their cancer has been there awhile, it wasn’t going to change significantly in a few days, and they could take the time to discuss their options with their families, do a little research, ask some questions, and decide on the best approach for them and their situations.
That little bit of time helps to distill the essence of what it means to be alive, to feel gratitude, and to be loved and supported. The “waiting time” can be a gift, if properly framed.
Really good advice, Alex. I used this some time ago while awaiting the results of a medical test. Found myself some valium to enable me to get through the next few days and to sleep…and plopped myself down at the piano and practiced for four days which absorbed my total concentration. It definitely got me through that weekend. Thanks for all your good advice.
Very useful column! As I have been dealing with minor cancer, almost the hardest thing has been submitting to numerous tests (it feels like a full-time job) and then waiting for results. I keep reminding myself of what a friend in AA says, “Worry is the interest you pay on a debt you may never incur.”
The concept of denial bothers me. I won’t deny it. So does the idea of waiting, although that will require a bit more explanation. Your discussion of denial, however, is not exactly that, or at least not entirely that. Denial, in any form, is delusional. It is refusal to see, to hear, to taste. Your illustration refers to the future, and the future does not yet exist, so denying future news is refusing to recognize tomorrow, which also does not exist, and so is a waste of time and energy. So, denial of a possibility is not nearly as useful as acceptance of a possibility, which eliminates the need to maintain fear. Moving on to tomorrow is much less involved than rejecting its possibility. Waiting is similar but another perspective on the same thing. Living right now does not require waiting for later. Again, later does not yet exist, but right now does. Rather than deny and wait, live only in the present, being held by the here and now. It takes practice. Otherwise, life continues to be conditional and the immediate takes a back seat to tomorrow which, when it comes, we will greet and bravely accommodate, because we are capable of that. Our fear of the future need not be reinforced while our ability to live right now should be. Does any of this make any sense?
Thanks Alex for your clarification. Accepting the possibility of pain while attending to other things is way different from denying and distracting oneself from the possibility of pain. The former is actually what you described, which is a healthier way of living. And while it is true that we are born to focus on the shadows beyond the campfire, looking for mountain lions and other threats, we are able to train ourselves to know when that attention is unnecessary and even harmful. Thanks.
I am not well-versed in Buddhist principles, but my understanding is that you are supposed to “allow” distractions, pictures running through your mind, perhaps even rumination(s) and anxiety, to march from right to left, and then practice neutrality towards those unbidden distractions. Just acknowledge them and let them go their way . . . To me, this means that on day #1, or initially, upon hearing a scary diagnosis, I am quite disquieted, but it is my job to let something that is really scary (threat to my life/health) march through my mind.
I allow myself to go through the stages of letting go—perhaps acceptance comes before letting go. As I said I am not well-versed in Buddhist principles, so I don’t really know the order of the stages . . . And then, on day #2, and beyond, figuratively, I calmly watch those marching distractions and anxieties with their unruly attendant emotions of alarm, fear, anger, etc.
For myself, it would only be something quite physical, like a brutal workout at the Tae Kwon Do do jang, or an amazingly gripping book, that would distract me. Denial would not be a possibility to get me through to days #3, #4, #5. Only physical or intellectual distraction would work for me.
Alex, I especially liked your answer to Chris regarding how Nichiren Buddhism helps with leveraging negative emotions as a springboard for growth, uncovering wisdom to win over obstacles. I’d appreciate hearing more about this.
What if a catastrophic diagnosis is not a possibility but a confirmed fact?
I think that is when denial is really useful. Do whatever you can to deal with it, take whatever treatments are available, etc. Then stop ruminating. Put those thoughts away on a shelf at the back of your mind. Get on with other things. Don’t anticipate the grief and troubles that are on their way.
First, I want to thank you for your website, your insight, & all the helpful information you provide for all of us.
Next, a nit to pick. Trick #3, first sentence should be “your” thinking, not “you’re.” You mentioned last week that you hate this sort of slip. I spent many years editing papers for engineers, & have been unable to “turn off” that part of my brain since retiring. No offense meant!
I do appreciate all your posts, and have learned many useful things by reading them. Thanks again.
Thanks for your answer to my question. I didn’t see it until today, 7-15, when I was looking for another answer. I did receive an email response with the typo comment, which made me laugh, because I’m an editor also.
Zen has a very direct approach. Die before you die, Adyashanti says. Why not take the fearful opportunity (with the help of drugs or not) to face the ego’s fear of death…a beautiful surrender and awakening is possible with this juicy, real life fear. Whether this is the final blow or not, it can be a practice run for the inevitable.
Hi there! I came upon your blog today and have enjoyed all the food for thought that you’ve laid out here. Great work; I commend you on finding the time to write all these posts despite of having a busy physician schedule. I have always been a fan of the Asian philosophies and its great to see you try to put them to work in real life situations. Thanks again for a great read!
I’m pondering this right now, whether denial or even optimism is the best course if it keeps one from making decisions that promote the best course in a really bad situation (i.e., choosing an alternative that provides for more comfort if the cancer follows the statistically likely scenario), rather than ignoring that possibility, thus perhaps making the end stage less comfortable.