Chapter 5: Communication, psychological wellbeing and safeguarding
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Denial and collusion
Definitions
Denial is a complex phenomenon (Vos and de Haes [278]) and can be considered an adaptive mechanism for slowing down and filtering the absorption of traumatic information, ‘allowing for avoidance of painful or distressing information’ (Goldbeck [107], p.586).
Collusion is when two or more parties develop a shared, sometimes secret, understanding that may involve withholding information from another person. It can be argued that collusion is consistent with some patients’ wishes (Helft [129]) and can be a necessary protection against unbearable facts and feelings (Vos and de Haes [278], p.227). However, it is important that health professionals resist invitations to collude with patients’ or relatives’ inaccurate understandings (Macdonald [160]).
Related theory
Diagnosis of any potentially life‐threatening illness is experienced in many different ways and can cause strong emotional responses. Patients are likely to feel a degree of distress and experience a wide range of emotions that may be lessened if healthcare professionals are supportive, empathetic, truthful and open with patients about their diagnosis and prognosis.
People may use denial as a way of coping when faced with frightening situations. Denial can be conscious or unconscious and is commonly recognized in cancer settings (Vos and de Haes [279]).
Literature on denial tends to be focused within the cancer field and prevalence rates are difficult to assess. Vos ([277]) found that most lung cancer patients displayed some level of denial, which increased over the course of the illness. This was considered to be a normal phenomenon and not a sign of disturbed coping (Vos [277]). Nurses can be unsettled by the presentation of denial as it creates uncertainty about levels of understanding, coping and engagement with treatment. Family members and nurses 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. Nurses need to be aware of the pitfalls of colluding with patient or family denial and consider how they may contribute to it.
As human beings, we live our lives in our own individual, unique ways and also deal with a life‐threatening diagnosis in our own way. For some people, focusing on hope and cure is the priority, while 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, and denial is not an ‘all or nothing’ phenomenon (Dein [59], p.251): a patient may accept their illness in the morning but by evening deny that they have it.
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. Nurses need to establish what information the patient has been given, before assuming that the patient is experiencing denial. They need to be sure that patients have been given adequate, digestible information, if necessary on several occasions.
It is helpful to view denial as a process (Vos and de Haes [279]) and to see its expression as falling somewhere along a continuum. This needs to be acknowledged in the assessment process. Repeated assessments of denial may aid understanding of how various factors might influence denial and how to better understand its dynamic nature.
Table 5.12 Supporting a person in denial
| Principle | Rationale |
|---|---|
| Aim to provide honest information to patients with the use of good communication skills, to the depth and detail the patient requests. | This enables patients to have control over the rate at which they absorb and integrate news and information that may have life‐threatening implications for them (Maguire [162], R ). |
| Listening, reflecting and summarizing are useful skills when interacting with individuals in denial. | These techniques will establish a supportive relationship that in the future may provide the patient with the security to acknowledge the gravity of the information they have been given. E |
| If denial is affecting a treatment regime or decisions for the future, it may need to be gently challenged. This can be done by either questioning any inconsistencies in the patient's story or asking whether at any point they have thought that their illness may be more serious. | These questions may help the patient to get closer to knowledge they may already have about the seriousness of their illness. With the right support, they might be able to face their fears and be more fully involved in decisions about future care and treatment. E |
| If the patient remains in denial, this should not be challenged any further (Dein [59]). | ‘Confrontation, if pursued in an insensitive or dismissive way or in the absence of adequate trust and support mechanisms, may increase denial, may reduce treatment compliance, or may even precipitate a complete breakdown in the healthcare professional–patient relationship’ (Goldbeck [107], p.586). |
| The delivery of bad news and information giving need to be recorded clearly. The degree to which patients will accept the information is variable and needs to be respected and carefully documented. | Good communication can help to prevent patients receiving mixed messages. Clear documentation helps other staff members to understand how the patient is coping. E |
Complications
Balancing the reality of the illness with reasonable hope is often difficult for health professionals and caregivers (Kogan et al. [145], Parker et al. [220]). When working with patients who seem to be in denial, the challenge for healthcare professionals is not so much the confrontation of denial but rather the avoidance of collusion with it (Houldin [135]), as collusion would offer the health professional an opportunity to avoid the distress.
Collusion can leave healthcare professionals, patients and relatives feeling confused. Recognizing collusion, challenging it and discussing concerns with colleagues are important. Working with the multiprofessional team helps to improve communication and ensure a collaborative approach to care. Drawing on the richness of experience of others can help.
