Using Denial Effectively

A number of 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.

THE TRICK

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:

1. 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).
2. Find someone else who needs support. Nothing distracts us from our own misery better than trying to help someone with theirs.
3. 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.
4. 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.