After my grandfather Sam had a major stroke at the age of 80, his mind was strangely altered. My brother and I would sit next to him during our visits, and he’d tell us rambling stories in a raspy voice about how he’d boxed and beaten Muhammad Ali the night before. This was weird and frightening, but it was my grandmother’s reaction that struck me as even odder. She would observe this scene of her teenage grandsons listening to their beloved Pop Pop with a wide smile on her face. Didn’t she hear, I wondered, the bizarre things her husband was saying? Or was she choosing to ignore his blatant confusion?
Reflecting on those visits four decades later, I’m certain my grandmother was using a form of denial to cope with the situation. Many patients and family caregivers do, I’ve learned. It wasn’t that she was pretending that Pop Pop hadn’t had a stroke or that it hadn’t greatly affected him. Instead, she was minimizing her recognition of the full extent of its impact, and seeing love, not incoherence, in his baffling tall tales.
As a way to cope, denial has a mixed reputation. Psychologists view it as a common means of self-preservation that keeps the denier from being emotionally overwhelmed by illness, disability and other difficult circumstances. But adult children who are responsible for their parents’ well-being often regard the elders’ denial as dangerous wishful thinking, especially if their parents insist on driving when unsafe or if they resist moving from multistory homes when at risk for tumbling down the stairs. Indeed, one of the harshest put-downs that frustrated health care and social service professionals say to one another about balky patients and family members who won’t follow clinical recommendations is that they’re “in denial” — that is, out of touch with reality.
When are denial and minimization helpful techniques for family caregivers? And how should you respond to denial that seems to be destructive refusal to accept change? Here are some ideas.
Respect the good that denial can do — for now. Most patients and family caregivers who under-react to an emerging medical crisis aren’t engaging in make-believe. They are dealing with a bad situation as much as they can handle, without feeling a panicked sense that their lives are out of control. In these instances, downplaying the catastrophes ahead may not lull them into false security, but instead shield them just enough to maintain confidence and hope in order to keep trying as hard as they can.
Acknowledging the extent of my grandfather’s cognitive decline would have served no purpose other than to alarm, demoralize and probably depress my grandmother. But perceiving her Sam as the same old entrancing conversationalist he’d always been gave her the comfort that he was still partly himself and that their loving relationship hadn’t changed.
Don’t force a confrontation. Sometimes, professionals and family members try to run roughshod over a caregiver’s denial by making her squarely face (“for her own good”) the grim situation at hand. But in my clinical experience, confrontation often produces one of two harmful effects — either the caregiver, suddenly stripped of all illusions, becomes despondent or she avoids what she’s not ready to face by shunning the confronter. With either result, nothing will have been accomplished except for a decrease in morale and support.
A better strategy is to gently pose “what if” questions over time that make the caregiver gradually begin to consider all the coming challenges and possible ways of grappling with them. For example, I might have asked my grandmother, “What would you do if Pop Pop becomes too confused to make decisions for himself?” She might have become annoyed with me, pooh-poohing the question. But she likely would have started musing to herself what her options were, such as making sure there was always someone with him, discussing with him any decisions he’d be asked to make or even making all decisions for him.
Compromise on what can and should be handled. Few of us are such dry-eyed realists that we are immediately ready to contend with all that caregiving throws at us. We confront the bad realities if and when we can psychologically handle them. Using a little denial may even help us keep the past alive. In my grandmother’s eyes, my grandfather was all sweetness to the day he died, no matter how many imaginary boxing matches he thought he had won. There is sweetness for me now in that memory of the two of them enjoying each other’s company as they always had.
Barry J. Jacobs, a clinical psychologist, family therapist and healthcare consultant, is the co-author of Love and Meaning After 50: The 10 Challenges to Great Relationships — and How to Overcome Them and AARP Meditations for Caregivers (Da Capo, 2016). Follow him on Twitter and Facebook.