Opening Case Study
When John’s ophthalmologist, Dr. Aldrich, told him that he had glaucoma, he didn’t have an immediate response other than to look down at the floor and slowly shake his head back and forth.
Dr. Aldrich, who had given this diagnosis many times and was comfortable with talking with his patients about their emotions, waited for a few moments before continuing. He knew that John needed time to let the news ‘sink in’ before talking further.
Keep in Mind: Are you comfortable with silence? If the patient remained unable to communicate after leaving the doctor’s office, could you also sit with a patient in silence for a few moments or would you feel like you needed to intervene? What about the silence would make you feel like an intervention on your part was needed?
After a few moments of silence, Dr. Aldrich said to John:
“I know this is unexpected. It must be a shock to you.”
John nodded his head in agreement.
“Do you have any questions?” Dr. Aldrich asked.
“Not now,” John answered. “I think this is probably all I need to know at this point.”
“I’d like to get you started on a medication,” Dr. Aldrich continued. “You will need to take it every day to keep the pressure down. Other patients have responded well to this treatment and I don’t see any reason why you won’t.”
“Okay,” John answered. “Whatever you say.”
Keep in Mind: In this situation, would you expect a patient to have questions about their diagnosis and its treatment? If not, would you be able to accept that the patient wasn’t ready to talk further or would your initial inclination be to emphasize the importance of understanding the diagnosis and treatment plan as soon as possible?
Dr. Aldrich wanted to talk with John further about his condition and his treatment, but could see that he wasn’t going to be able to make any further progress at that moment. John was clearly too closed down emotionally to go further. He handed John a prescription, and briefly explained what a diagnosis of glaucoma might mean in the future, especially if left untreated, and then explained the treatment plan.
John mumbled a few words about following up and then walked out of Dr. Aldrich’s office.
Michael, an optometric technician, took note of John’s state of mind and decided to catch up with him before he left. Michael knew that John was going to be told about his diagnosis.
Keep in Mind: What would you consider to be your role with a patient who is clearly in emotional shock after hearing a medical diagnosis? Would you feel it was your responsibility to reach out to them on an emotional level or do you think it would be more professional to give the patient space to deal with this in their own way?
“John,” Michael said. “Anything I can help you with?”
“Not right now,” he answered.
Michael’s experience working in an optometric technician role with newly-diagnosed patients had taught him that John would need his own time to move past the initial sense of shock and process his emotional reaction. And he knew that, while John was dealing with the initial sense of shock, he wasn’t able to articulate his thoughts or feelings beyond a sense of ‘numbness.’
However, Michael also knew that, from a medical standpoint, it was important for John to acknowledge his diagnosis, understand his condition, and get started on a treatment regimen to prevent any further damage to his eyes. Michael knew that Dr. Aldrich would have made all of this clear to John, including the presenting the possibility that, without treating his condition, he could ultimately lose his sight. From John’s demeanor, Michael knew he hadn’t been ready to hear all of this.
He was concerned that, if John was not able face the emotions around his diagnosis, and become proactive about his health, he might be at risk for not taking responsibility for his treatment. Michael knew that once the initial shock wore off, John would have a reaction to his diagnosis that was similar to the way human beings deal with other traumatic events: flight, freeze, or fight. He also knew that John’s reaction would have implications for what kind of a patient he would be, and the kinds of help he would need, going forward with his treatment.
“John, do you mind if I give you a call in a couple of days?” Michael asked.
Introduction
“Suddenly, it was like time stood still.”
Receiving a medical diagnosis is a stressful event. Regardless of the specific diagnosis, or how severe the patient perceives it, they feel an immediate sense of uncertainty – life may never be quite the same. And like other stressful events, our minds and bodies are hardwired by nature to react. The initial reaction is shock, as our conscious minds essentially shut down while, subconsciously, this information is processed.
As the shock fades away, it gives way to one of three reactions that are occur in response to stress. These reactions are commonly known as flight, freeze, and fight. The Flight response is primarily an emotional reaction, and patients may be so caught up in their emotions that they may have not be able to make objective decisions regarding their condition and its treatment. On the other hand, those having a Freeze response may be unable to acknowledge their feelings at all or may have a fatalistic view, either of which may result in inaction. Ideally, those in Fight response have access to their emotions as well as their logical resources, and are able to harness both as they face their illness. Most important, patients can be taught how to be Fighters.
These basic reactions, in turn, impact the kinds of emotions that newly-diagnosed patients experience, and how they cope with these emotions, as well as how they deal with their diagnosis from a rational standpoint, e.g. including information gathering. For better or worse, how patients cope during those first few days and weeks after receiving the diagnosis will have implications throughout their treatment process – from treatment decision making to coping with the treatment to ongoing recovery and life management.
For healthcare professionals, understanding and recognizing how patients are reacting to their diagnosis can be of mutual benefit to them and their patients. For example, while patients experience a range of emotions in reaction to their diagnosis, understanding whether a patient is having a Flight, Freeze, or Fight will guide healthcare professionals in gauging readiness to receive information, so that it is presented in manner to which patients will most likely be receptive: Those in Flight reaction may need some additional emotional support while those in Freeze reaction may need some coaching on interpreting what they read and hear with a sense of optimism. Fighters may ask a lot of questions for which the team needs to be prepared. And going forward with treatment and recovery, patients who don’t become Fighters may continuously erect barriers to compliance and life management.
Keep in Mind: Think about a moment in your life when you unexpectedly read or experienced something that was so unpleasant that you momentarily were thrown off guard. How did you react? Receiving a medical diagnosis is a stressful event, and patients react to their diagnosis as they would to any other stressful event.
The First Reaction: No Reaction
When healthcare professionals are sitting with a patient who has been newly diagnosed with a health condition, whether catastrophic or chronic, almost invariably the patient describes his or her reaction with one word: shock, or related terms like numbness, in a trance, or simply, ‘no feeling at all.’ The experience of shock is often associated with disbelief or a sense that their emotions might be so strong that they should be held at bay for fear that they might be overwhelming. There are of course exceptions. For example, when a condition from the past is recurring, or when symptoms over time have rendered the diagnosis inevitable, patients may report an initial feeling that ‘the other shoe has finally dropped’ or that they are about to go down a road that that they have previously been on. Still, it is only human nature to cling to that possibility that “it won’t happen to me.” This belief is mainly unconscious; after all, most of us spend our time assessing our chances of getting hit by a medical diagnosis.
Carole described her reaction when she was first diagnosed with cancer.
It was like the world suddenly stood still. I mean, all I could hear was my own breathing, and the thumping of my heartbeat. At first, I was completely numb, and I wasn’t thinking anything. And then I started saying the word ‘cancer’ over and over. Still, no feelings. But deep inside, I realized that, no matter what, my life was never going to be the same.
The initial shock may last a moments, hours, days, or may continue on, as the patient’s emotional and rational sides are both struggling with the news. If you have been through the experience of a diagnosis, you might remember how you first reacted, or didn’t react, to the news, or maybe you have seen someone else go through it and felt your own helplessness as you watched them struggle.
In a way, being faced with a diagnosis, while not usually a death sentence, is similar to hearing about a death. As Carole, in the example above described her diagnosis, nothing will ever be quite the same. Newly-diagnosed patients are left with the knowledge that, yes, bad things can happen. They realize that they weren’t really aren’t invincible after all. And the diagnosis – whether it requires extensive treatment that essentially interrupts normal life for months or longer, or whether it requires medication and alterations in diet and lifestyle – will at some point require the patient’s acknowledgement and full attention. Know that this looms ahead can also be initially overwhelming for the patient.
During this time of initial shock, patients are often not open to more information, nor willing to discuss their diagnosis and what it means. This presents challenges to the healthcare providers who may need to begin a medication regimen and/or a decision on a path of treatment. If is difficult with to communicate with patients who may feel as if they unable to hear or comprehend what they are being told.
Some patience is needed at this time. The newly-diagnosed patient may need some time and space to sit with this news. If the healthcare professional pushes them too hard to discuss the treatment plan or to make a treatment decision during this time, the patient may become defensive and refuse to talk further, potentially becoming even more resistant. Human beings can’t be forced to take in more information than they can process at that moment.
As discussed in Chapter One, it is recommended that patients be provided with some time to sit with their diagnosis. Clearly, sensitivity to how the patient is responding must be balanced with the level of urgency in taking any necessary action. However, it may be useful to schedule a follow-up appointment to provide the patient with some time to react to the diagnosis and formulate his/her questions, or to call the patient in a day or two to either schedule an appointment or to remind the patient to make sure they don’t avoid their follow-up appointment.
After the First Shock
Ironically, accepting that life is going to change is the first step toward coping with the emotional impact of the diagnosis and making decisions.
Newly-diagnosed patients all come to this realization at the same time and in the same way, and some unfortunately do not face it at all. What is consistent among newly-diagnosed patients is that each individual goes through their own process in terms of how they deal with this news and how they move forward. Still, patients’ reactions can be categorized as Flight, Freeze, or Fight.
These three terms are rooted in the earliest days of the human race when, anthropologists tell us, a predatory beast might appear at any moment. In the 1920’s, psychologists began using the term “flight or fight” to discuss how humans react to a threat, and when stress emerged as a concern in the 1970’s and 1980’s, a third reaction – freeze – came into use.
These three basic reactions – flight, freeze, and fight – are also relevant in describing how we react to medical diagnoses.
Figure 2-__
Initial Shock at Diagnosis
Flight Freeze Fight
Positive thinking Isolation Empowerment
Rigidity Helplessness Emotional coping skills
Rational thinking
Flight: Charging Forward, but Blindly?
The best way to introduce the Flight response is through a case example of a newly-diagnosed patient who will be referred to as Dave. An active man, without a history of health problems, his diagnosis of a heart condition took him totally by surprise. His physician presented him with what she thought was the best recommendation, which was a triple bypass, and then suggested that Dave go home and do some thinking before making a decision.
Dave later reported that the sense of shock continued not only that evening, but for a couple of days afterward. He couldn’t believe that he, of all people, was being told that he was in anything but top condition. And his heart? Not a chance. He told his wife only that his doctor was watching his heart, but that he was absolutely fine, which of course she was skeptical of but knew better than to push if Dave wasn’t ready to talk. Dave describes the next few days like this:
Once the numbness started to wear off, I kind of went into a panic mode. It was like I had this thing around my heart and I wanted it cut out as soon as possible. I was afraid to think because I was afraid I might talk myself into doing nothing, or that I might put too much strain on my heart. I imagined my doctor as my savior. I wanted to put all of my faith and trust in her and have her direct my path. I was in such a rush, I asked her to call the cardiologist she had recommend to try and influence him to schedule me for surgery as soon as possible.
While Dave is placing all of his trust in the first physician he encounters, he is also running toward the treatment that feels most expedient. He is not considering the implications of the treatment, in terms of factors such as side effects, recovery, and ongoing lifestyle management. As a result, he may later discover that this is not a treatment that he was prepared to deal with, which has implications for ongoing compliance as well as dissatisfaction with his healthcare provider.
The Flight reaction has other implications as well. Individuals with this reaction may – out of a sense of panic – run toward unproven alternative treatments with potentially alarming results. They may also be susceptible to the recommendations of healthcare providers with whom they feel comfortable with emotionally but who may not offer the best treatment option. For example, patients in Flight reaction may profess to ‘love’ their practitioners. Like falling head-over-heels in love, the Flight reaction doesn’t leave room for obtaining a second opinion on the diagnosis, investigating treatment options, and at least checking into the credentials and track record of the physician. Patients in Flight reaction may also attach themselves to an unproven, non-medical treatment with potentially alarming consequences.
On the other hand, the Flight reaction can result in a strong emotional response such that patients are unable to move beyond their emotions such that they cannot access into their logical side. Excessive crying, expressions of anger, giving in to fearfulness… these responses signify that a patient is also in Flight – not toward the first available treatment or the most loved practitioner but instead running away from their diagnosis.
Freeze: Don’t React and Maybe the Diagnosis Will Go Away
Not all patients ‘take flight’ toward the first available treatment. Some don’t take flight at all. Instead, the initial shock gives way to they sit and stare into space, literally and figuratively, waiting for the nightmare to pass, or for someone, often a family member, to step in and take charge. This is understandable. After all, between the shock of the diagnosis, and their perception that they are unprepared to make the decisions that are suddenly thrust upon them, or that they have no hope, they are essentially immobilized.
When in Freeze mode, the emotions appear to stop working, not because they are broken but because they are being tightly held in place. And while this might be an opportunity for the rational side to kick in and take charge of the situation, logic without emotion is not necessarily going to result in rational thinking, as evidenced by John.
I just sat there when the doctor told me, and I guess I’m still just sitting still. I can hardly get out of the chair, to tell you the truth. I kind of decided to be philosophical about it. I don’t know much about this but I do know that statistically, the numbers are against me. I mean, what can I do when fate isn’t on my side?
John is using the defense that individuals in Freeze reaction often adopt: refusing to react emotionally. Not getting actively involved in learning about the condition and its treatment. Unfortunately, this also means giving up.
Essentially, the Freeze reaction is an extension of the original feeling of shock, but with some key differences. Shock is the mind’s way of shutting down the emotions, and allowing the brain to process the information, before reaction. Patients in Freeze reaction are consciously suppressing – holding down – their emotions. Instead, they are giving in to rational thinking, based on their view of the facts. But there are risks involved when the logical mind is operating without the emotions.
Patients in Freeze reaction, because they are operating without their emotional side, may be at risk for adopting an attitude of hopelessness and helplessness. First, they are not allowing themselves to work through the initial emotions, like anger and fear, which patients generally experience when they are initially diagnosed. They are missing that experience. Often patients in Freeze reaction refuse to discuss their condition any more than absolutely necessary with their healthcare professionals, and may avoid telling family members as long as possible. And while patients in Flight reaction may have completely given themselves over to their emotions, at the expense of rational thinking, patients in Freeze have not acknowledged their emotions, which leaves them stuck in avoidance and isolation.
One characteristic common among patients in Freeze mode is an unwillingness to make decisions about their treatment. They rely on their physicians, possibly working with family members, to make these decisions. Basically, they decide not to decide.
Keep in Mind: Have you ever been in a situation where you were afraid that, if you really let yourself react emotionally, you might lose control? Patients in Freeze mode have shut down emotionally. As a result, they may fall into a helpless role, and refuse to be involved in their own healthcare.
Fight: Striking a Balance Between Emotion and Logic
Being open to emotions can result in a inner sense of optimism and hope. If this optimism is balanced with rational thinking, patients are in the best position to make treatment decisions, deal effectively with treatment and lifestyle changes, and otherwise cope with the changes and challenges that may arise as they face the future. Again referring to the standard reactions to a stressful situation, these individuals are in Fight reaction.
Fight doesn’t necessarily imply fighting in the sense of taking up arms and, in fact, sometimes clients resist this word because of that association. Being a fighter means being empowered in terms of understanding the diagnosis, the options for treatment, and what lifestyle adjustments need to be made in the near future, and beyond. Being empowered is about arming oneself with emotional coping skills as well as rational thinking.
Fighters have acknowledged the feelings that arose as a result of hearing the diagnosis and continue to honor their own emotions. It would even be reasonable to say that dealing with the emotional aspects of a diagnosis opens the door to rational decision making. Fear may, realistically, never fade away. The anger and disappointment may flare up at times. But emotions like fear and anger, when they are acknowledged and experienced, may also give way to hope, optimism, and a renewed passion for life.
Marie said it this way:
I sat and cried and asked ‘why me?’ for quite awhile, maybe a few days. And then I stood up and said, ‘I am going to fight this beast. I’m not going to let it beat me down.’ The next day I made a list of who I needed to talk to, where I needed to go for information, and what I needed to start planning for. That doesn’t mean I don’t feel overwhelmed sometimes, because I still do. But I’m also in active mode.
Marie didn’t hold back on her emotions but, instead, faced her disappointment and fear. She sat alone with her emotions and, in her case, had a good cry. She also discussed her emotional reactions with a member of the healthcare team, who was comfortable being a ‘listening ear.’ Had she not taken the time to experience how she was feeling, she would have forced to sit with a large block of emotion, and it would have essentially taken all of her mental energy to hold it down. By doing so, she was able to start asking questions and making decisions.
Patients in Fight reaction are more prepared to take action with their condition. By working through their emotional reactions – feeling their feelings and expressing them to supportive listeners – they are not running from their feelings, nor are they so overwhelmed by them that they can’t – or don’t have to – think. The result is a sense of self confidence that comes from being aware of, and open to, emotions. Fighters also have access to their rational minds. This doesn’t mean that they are in perfect balance every day, or that they don’t have bad days when nothing seems to go right.
Fighters are able to search for, and process, information. They are more likely to ask questions and to evaluate alternatives. They take more control over their treatment decisions and the ongoing lifestyle adjustments that they need to make.
Their balance of emotions and logic results in an attitude of empowerment toward their healthcare and the individuals who deliver it. For some patients, the Fight attitude comes naturally; it is simply how they react they adopt toward their diagnosis, once they move beyond the initial shock. These individuals will sometimes present challenges to their healthcare team, because they believe that the ultimate decisions regarding, for example, sources of information, treatment alternatives, and lifestyle adjustments, lies in their own hands. However, as described in future chapters, they are also more likely than those in Flight and Freeze mode, to have successful outcomes. And, also described in future chapters, are methods that the healthcare team can employ to create and enhance Fighter attitudes in patients having Flight and Freeze reactions.
Keep in Mind: How have you faced some of the unexpected twists and turns in your own life? Have there been times when you didn’t think you could face a challenge that came your way, and just hoped that if you ignored it, it would go away? Or did you find yourself want to ‘latch onto’ a quick solution with the hope that you could ‘fix it’ as soon as possible? A Fighter might first sit down and have a good cry, and then talk to a friend to sort out their feelings. A Fighter would also face the reality of the situation and arm him or herself with the facts, and develop a strategy for moving forward.
Recognizing a Patient’s Reaction
The healthcare team can greatly benefit from recognizing the type of reaction that individual patients are having to their diagnoses. As discussed, patients in Flight, Freeze, and Fight reaction have widely different orientations toward their condition and their perception of control as a patient and their willingness to be in control. If the healthcare team is sensitive to the implications of these reactions for patients, time and energy can be focused in ways that leverage the patient’s strengths as well as weaknesses in how they approach their diagnosis and treatment. Understanding the reaction can be useful in guiding how to:
- Present information on the condition and its treatment
- Coach patients through the treatment process
- Make recommendations on lifestyle management
- Encourage patients to seek support with activities of daily living
- Monitor ongoing compliance
Figure 2-__
A photo of a patient with a fearful expression.
Rx: Working with Patients in Each of the Three Reactions
Case Study: A Patient in Flight Reaction
Dave, the patient whose situation was briefly described under the discussion of the Flight reaction, at the beginning of this chapter, had a discussion with Tom, a member of the healthcare team who, fortunately, recognized his Flight reaction and conducted the conversation in a way that would not cause Dave to be defensive but would instead promote effective communications.
Tom: How are you doing, Dave?
Dave: How am I doing? How do you think I’m doing? I’ve just been told I’m going to die if I don’t get some help right away. How would you be doing if you were me?
Tom: Sounds like you’re feeling pretty scared about your diagnosis, Dave. I can understand why you’d be scared.
Dave: Of course I’m scared. I’ve got to get this thing fixed before it kills me.
Tom: Okay, Dave. You have a lot of highly-skilled professionals here who are watching over you closely.
Dave: Don’t I know that! I really love Dr. Benson! She has taken good care of me for the last ten years. She’s sending me to a Dr. Jacobs, a cardiologist who is one of the best in the country. I know this is soon going to be behind me.
Tom: Wow, one of the best cardiologists in the country?
Dave: I can’t imagine that Dr. Benson would send me to someone who wasn’t the absolute best in her field.
Tom: So it sounds like you have a lot confidence in Dr. Jacobs. What’s the next step?
Dave: I meet with Dr. Jacobs next week. I know he’ll want to operate right away and that’s what I want, too. I expect to be full back to my life in a month or so.
Tom: What’s Dr. Benson told you?
Dave: I told you already. Dr. Jacobs is an excellent cardiologist. I know she’ll give him a call and have him push up my surgery. I wouldn’t be surprised if I ended up going in for it later next week. No time like the present, I’ve always said. And if I don’t have faith in the people who are helping me, then I may as well give up.
Tom: So Dr. Benson is referring you to someone she trusts, Dr. Jacobs, and you’re anxious to get going. Is that right?
Dave: Exactly. Only losers think negative.
Tom: You’ve really got a positive attitude here, Dave. I’m certainly not going to argue that with you. And like I mentioned before, you’ve got some very good people on your case. But I was wondering if it might be useful to sit down and talk about the process that people generally go through who have your diagnosis, you know, like how cardiologists generally work with their patients and the recovery process after surgery. Would that be useful?
Dave: I’m not expecting anything less than a miracle! That’s the only way I can get through this. That’s why I’m so excited about getting started.
Tom: I’m not suggesting you won’t have a good outcome, Dave. I just wanted to suggest that we might go over a few things so that you’ll have a better idea about how this process usually works.
Dave: Well… I guess we could talk a little bit. But I’m only allowing positive people to come through my door today.
Tom: You can count on me as a member of the positive team!
Figure 2-__
A Patient in Flight Reaction
Overarching Theme: Caught up in emotions
- Running Toward: Positive thinking, but blinded to reality
“This is my only hope.”
Consequences: Avoidance of information or recommendations that are perceived
as threatening the chosen path
Over-expectation regarding the treatment experience and its
Benefits, which can result in extreme disappointment, or denial,
when treatment doesn’t meet unrealistic expectations
Behaviors: Elation bordering on ‘mania’ regarding ‘miracle’ course of action
Refusal to listen to alternatives
Anger when others are perceived as ‘being negative’
- Running Away: Descent into emotions bordering on irrationality
“Please leave me alone. I can’t face this.”
Consequence: Refusal to accept the diagnosis and embark on a beneficial
treatment path
Emotional distress may further contribute to physical symptoms
Behaviors Extreme sadness, crying, heaviness similar to inconsolable grief
Avoidance of others that may lead to isolation
Working with Patients in Flight Reaction
Essentially, the Flight reaction is recognizable based on the presence of pronounced emotionality. While it is important for patients to express their emotional reactions in a way that is consistent with their personal style and comfort level, patients in Flight reaction have basically become ‘stuck’ in their emotions.
Patients in Flight reaction provide a range of challenges for the healthcare team. These patients are often so caught up their emotions that they essentially have made themselves ‘deaf.’ Patients whose emotional reactions have resulted in a singular focus on their course of treatment can initially be easier to work with from the perspective of having a motivated attitude and being compliant. However, this single-mindedness can also result in a rigid attitude, such that any information or recommendations that are interpreted to their chosen course of action are rejected. Furthermore, patients in Flight may be less open about considering the next option if the chosen course of treatment is not working, or if an adjustment is needs to made. In fact, their disappointment may so profound that they become discouraged and, given their emotional state, may be come irrational as a result of their disappointment.
Patients in Flight reaction who are simply overcome by their emotions and not able to cope with the reality of their condition also present challenges to the healthcare team. They may become so overwrought that they are, at least temporarily, unreachable. Any suggestion from the healthcare team regarding the value of understanding their diagnosis or considering treatment options may be met with a wall of emotion. When patients Flight reaction takes them in this extreme direction, healthcare professionals may be at least temporarily unable to establish communications.
This is not to imply that patients in Flight reaction will invariably not choose the best treatment alternative and be compliant patients. This emotional energy can be channeled into a positive force that can result in an enthusiastic attitude toward treatment. The key is to gently encourage a sense of reality – so that expectations remain realistic – to avoid the extreme disappointment that can result when patients in Flight reaction don’t experience what they expected from their treatment.
Keys to Communicating with Patients in Flight Reaction
Acknowledge emotions
Patients in Flight reaction are receptive to acknowledgement of their emotions. Using feeling words – frustrated, angry, excited, positive – will signal that you are attuned to how they are feeling and open to knowing more.
Examples:
“So you are really upset about this.”
“You are pretty excited about getting started.”
“You aren’t sure where to turn right now.”
Paraphrase
Paraphrasing what you hear the patient saying. This strengthens your connection with the patient and deepens your understanding. Make it clear to the patient that your paraphrases are tentative, and that you aren’t attempting to tell them how they should think or feel. Connect your paraphrases to feeling words.
Examples:
“It sounds like you have talked with your doctor about the potential treatment options, and it all sounds depressing.”
“So your understanding is that you will see results quickly, and you won’t experience any side effects. Is that right?”
“This is all feeling so bleak to you that you don’t even want to talk about it.”
Explore expectations
Patients in Flight reaction are highly sensitive to any suggestion that they may not be heading in the right direction in terms of their treatment, outcome, and ongoing lifestyle management. Any questions or comments contrary to their chosen position is likely to be viewed as ‘negative’ or argumentative which, in turn increases their defensiveness. Ask questions in an open, non-judgmental manner.
Examples:
“What’s ahead for you at this point?”
“How do you see this treatment working?”
“What’s your doctor telling you?”
Offer consistent and gentle references to reality
Patients in Flight reaction can benefit from gentle references to realistic treatment expectations and outcomes, but with their high level of attachment to their emotional reactions, they will be become resistant if they perceive that their feelings are not being acknowledged and respected. It can be helpful if references to reality are presented as suggestions, rather than dictated in any way. It can also be helpful to ask the patient if they are interested in stories about how other patients have experienced their condition and its treatment.
Examples:
“I have worked with a lot of other patients who have felt like you about their condition. Would you be interested in hearing about some of their experiences?”
“I know you are feeling totally alone here. But I can tell you about some of the options that you have.”
“It is certainly understandable that you would be hopeful. That attitude is really going to help you to get through your treatment. I have a couple of ideas you might want to consider.”
Figure 2-__
Photo of a patient who is expressionless.
Case Study: A Patient in Freeze Reaction
John, the patient quoted in the description of the Freeze Reaction earlier in this chapter, was so overwhelmed at the news of his condition that he had basically given up on his treatment before he even got started. Michael, a member of the healthcare team, sat down with John and talked with him about his diagnosis.
Michael: Hey John. I hear the doctor gave you had some news this morning. How are you doing?
John: How am I doing or what am I doing? The answer is about the same for both questions. I’m a complete zero.
Michael: What does that mean?
John: It means what it sounds like. The stats are against me.
Michael: What did the doctor say about next steps?
John: I don’t really remember if we talked about that. But the key point here is that I have a condition that is life-threatening any way you want to look at it. I’m not stupid, and I’m not going to sit and wring my hands over it. I know the deal here.
Michael: Sounds like you have done some research on your own. Have you done that?
John: I don’t need to do a bunch of research. Anybody knows what my diagnosis means. It means death.
Michael: So you are kind of familiar with your condition, and have an idea of what your diagnosis means.
John: That’s exactly right. So let’s not sit here and complain about it.
Michael: How are you feeling about all of this?
John: It’s like I told you. I’m not going to weep and wail about reality.
Michael: Okay, John. I understand your thinking here. Do you want to talk about next steps?
John: I don’t think there is a lot to discuss, like I’ve been trying to explain to you. The doctor is going to recommend what he’s going to recommend.
Michael: So you are not thinking you have a lot of options here.
John: Really, I don’t want to deal with this by doing a lot of talking. What’s going to happen is going to happen. It’s not about what I want.
Michael: Well, like I said, John, you have a right to your opinions. But I can tell you that there are some options here, as the doctor outlined for you. With your permission, I’d like to go over them with you. I know you don’t want to think about this a lot but it might be helpful to get a clearer picture of what’s available to you in terms of treatment.
John: My doctor will tell me what to do.
Michael: I’m sure he can recommend a best course of action. But maybe I can help you get ready for that discussion.
John: I don’t know…
Michael: You don’t have to talk to me about this if you don’t want to, John. But I wanted to let you know I’m around.
John: Okay, I’ll think about it.
Figure 2-__
A Patient in Freeze Reaction
Overarching Theme: Emotionally shut down, fatalistic
- Intellectualizing: Avoidance of discussing ‘the condition’ with anyone, perhaps
Limited discussions with the physician
“I’m not going to sit around and wring my hands about this.”
Consequences: Lack of information-seeking behaviors
Holding in emotions, which further hampers the ability to come
to terms with the diagnosis
Lack of emotional support
Behaviors: Refusal to discuss the diagnosis
Citing statistics and/or limited medical facts, usually in support of
the futility of treatment and a negative outcome
Using ‘I think’ to the exclusion of ‘I feel’
- Hopelessness Immobilized by the prospect of having the condition
“I can’t deal with this.”
Consequences: Avoidance of discussion about the condition
Passively allows the physician or family members to step in
and make decisions
May not be compliant with treatment due to lack of
optimism or motivation
Behaviors: Emotionally disconnected or flat
Refuses to participate in discussion about the diagnosis
May cease other activities and essentially shut down
Working with Patients in Freeze Reaction
When you witness a patient who seems to have no emotional response at all to their diagnosis, they may be having a Freeze reaction. It is not that they are incapable of expressing emotions. To the contrary, they are most likely suppressing their emotions – holding them back – out of a fear that if they did react emotionally, they would be overwhelmed by their feelings and somehow lose control. And they fear where this loss of emotional control might lead.
Patients in Freeze reaction are difficult to reach for two key reasons. First, they are not open to discussing their condition, which can result in frustration for members of the healthcare team who are responsible for treatment planning and monitoring compliance. Second, they have such a low level of optimism toward their treatment that they most likely don’t see a need to participate or, if they do participate, do so minimally and without motivation.
Patients in Freeze reaction may intellectualize about their condition. While they might be reachable through a discussion of the facts, they are unfortunately often only willing to consider their situation from their own limited viewpoint. This viewpoint is most likely based less on information and more on an avoidance of information, and is consequently expressed in terms of a bleak outlook, or an outlook over which the patient has no control, and therefore no reason to be involved. This results in an uphill journey for the healthcare team, because the patient is resisting coming to grips with their diagnosis – the first step toward working with their healthcare team is to develop and put into place an optimal treatment strategy – through suppressing their emotions and avoiding involvement.
Patients for whom the Freeze reaction has led to a retreat into hopelessness are equally hard to reach. Rather than intellectualize, they essentially have shut down and are waiting for someone else to step in and take charge. These patients may stubbornly refuse to take any kind of role in decision-making and ongoing treatment, and instead adopt a victim role. Out of their sense of helplessness, the patients may also resist the assistance of family members. The family, in turn, may ask the healthcare team to act as mediators, which is an uncomfortable role and not likely to be productive.
Keys to Communicating with Patients in Freeze Reaction
Use ‘Think’ words
Patients in Freeze reaction are emotionally shut down. Therefore, use of the word ‘feel’ and references to feelings will be met with resistance. Consequently, using the word ‘think’ when discussing the patient’s condition will be less likely to met with resistance.
Examples:
“What do you think are your options?”
“What are you thinking as I talk about this approach to your treatment?”
“Can you give me some of your thoughts?”
Paraphrase
When used with a patient in Freeze reaction, a paraphrase demonstrates that you are listening and acknowledging their struggle to express themselves, and that you are open to whatever they have to say. Honoring their statements about how they perceive their situation may provide subtle encouragement to open up more. Also, paraphrasing may over time help the patient to see how they are avoiding their feelings and taking a limited view of the potential for treating their condition.
Examples:
“At this point, you don’t see any reason to think you can be treated effectively.”
“So you are telling me you don’t want to be involved in making decisions about how you might modify your lifestyle.”
“You remember reading about your condition a few years ago and what you read about the treatment wasn’t so encouraging.”
Model the use of feeling words.
While patients in Freeze reaction are suppressing their own feelings, often out of a fear of losing control, they may be reached by hearing feeling words in another context. For example, the healthcare professional can express how she might be feeling in a similar situation. Telling stories about how other patients have reacted emotionally, and how they coped, can also subtly communicate that patients do have emotional reactions to their diagnosis and they do effectively cope with these feelings. Hearing about how others have coped emotionally can help the patient to see that emotions are normal. If using this technique, it is important to be sensitive to resistance on the part of the patient and not to push too hard on emotions.
Examples:
“I know this must all feel really overwhelming, at least that’s how I would be feeling at this point.”
“I have another patient who had the same diagnosis at your age. He was really freaked out – scared and angry – but he reached out and got a lot of support, and he’s doing well right now with his treatment.”
“Sometimes people just want to sit and feel sad for awhile. That’s normal.”
Offer gentle invitations to talk about feelings.
Patients in Freeze reaction may need to give themselves permission to feel their emotions. If they perceive that professionals with whom they come into contact are comfortable with emotions, and open to discussing them, then they may gradually decide that they can safely open up without fear of being labeled in some way, e.g. as weak or neurotic. It can also be useful to let these patients know that you can refer them for additional mental health assistance if they do indeed feel overwhelmed.
Examples:
“Do you want to talk to me about how this is affecting you emotionally?”
“I want to reassure you that it is normal to have a lot of feelings when someone is going through a situation like this. And if you want to talk about how you feel, I am ready to listen.”
“If at any time you feel overwhelmed by your feelings, I can get you in contact with someone who is trained to help you.”
Keep in Mind: Tread gently and stay open. Patients who are having trouble getting in touch with their emotions, or thinking rationally, don’t respond well to being told how they should be reacting, regardless of how well-meaning the intention. Use your instincts, and the skills you learn in this chapter, as you approach patients who are in crisis over a medical diagnosis. Make suggestions, but be ready to retreat when patients are resistant. Avoid approaching patients with expectations regarding how they might, or should, be reacting to their diagnosis. Don’t assume anything. Be open and, as you learn from patients you will, in turn, be able to better reach them.
Case Study: A Patient in Fight Reaction
Marie, the patient quoted in the description of the Fight Reaction earlier in the chapter, returned to her physician’s office a few days after her diagnosis to begin discussing her treatment. While there, she met with Jonelle, a member of the healthcare team, to discuss how they would work together once her treatment began.
Jonelle: Marie, how are you doing?
Marie: Today, not so bad. Over the weekend, not so good.
Jonelle: I was concerned about you when you left the office last week. I knew your diagnosis had hit you like a ton of bricks and that you weren’t sure what to feel or think. How did the weekend go?
Marie: I called in sick on Friday and cancelled all of my weekend plans with a lame excuse that I had to bring home work from the office. I sat and stared into space for a couple of days. I didn’t even turn the TV on. On Saturday afternoon, I had a good long cry, and beat on a pillow for awhile. I just felt so sad that this was happening to me, and then mad about how unfair it was.
Jonelle: So you really let yourself have your feelings. Was that helpful?
Marie: You bet it was. Afterwards, I felt like I could take a deep breath again. And I said to myself: “I am going to stomp this beast. I gonna fight back.” I called my brother and told him the news. I listened to him cry for a few minutes, and then I said the same thing to him. And he said: “How can I help you?”
Jonelle: Fantastic. You powered yourself up. And you reached out for support. Those are all good things!
Marie: Well, I’m not telling you I’ve turned into superwoman or anything. I woke up on Sunday morning with this dull ache in my stomach and the thought that I have a whole lot to deal with and I’m not sure how I’m going to do it. I laid in bed and stared at the ceiling for awhile and felt sorry for myself. And then I answered that question, too. I’m going to do it one day at a time. I got out of bed and sat in front of the computer and got busy.
Jonelle: It’s normal to have some dips in your feelings. And as you experienced, you can have your feelings and then pick yourself up and move forward. So you did some research.
Marie: Yes, I did. I had a whole list of questions for the doctor and now I have a whole list for you. I am going to take some notes while we talk and then do some more research, and talk to some other experts. I have a lot of work ahead of me.
Jonelle: Sounds good to me. Let the fact-finding begin!
Figure 2-__
A Patient in Fight Reaction
Overarching Theme: Empowerment through a balance between emotions and logic
Ongoing Coping: Good days and bad days, but staying focused on the future
“I am going to do what I have to do to get through this.”
Consequences: In touch with emotions and able to express them
Active information-gatherer
Self-perception as the final decision-maker and responsible
for ongoing lifestyle management
Attitude of independence may at times be unproductive –
may not ask for needed support and may insist on a treatment
path that may conflict with the recommendations of the primary
physician
Behaviors Emotionally expressive
Brings questions and Web hardcopy to appointments
Insists that healthcare providers support their recommendations
Working with Patients in Fight Reaction
Healthcare professionals describe patients in Fight reaction as a joy and inspiration. They are informed, motivated, and willing to take responsibility for their treatment.
From this perspective, the Fight reaction is a mentally healthy reaction to a medical diagnosis. For the healthcare team, this means patients who have access to their emotions and are willing and able to talk about feelings. Healthcare professionals, in turn, will need to feel comfortable with emotions such that they can have these discussions. Fighters have a lot of questions about their treatment, and may also have suggestions for alternate medications and remedies, e.g. for supportive care. They may have their own ideas, also based on research, about the best way for them to make changes in day-to-day lifestyle. As these questions and suggestions arise, members of the healthcare team will need to answer these questions and, most likely, provide reasons behind their answers. Fighters are often highly educated, and this can result in defensiveness on the part of their healthcare providers if they don’t feel prepared to respond or if they are not comfortable with assertive patients.
If there is a negative side to the Fight reaction is that Fighters can at times become somewhat over-confident. They may assume they know so much about their condition and its treatment that they don’t need to rely on the medical experts, or may demand supportive evidence that is not readily available. This can cause frustration for their healthcare providers, as well as result in unnecessary delays. Fighters may develop a ‘go it alone’ mentality that can result in isolating themselves from support that might be helpful in completing day-to-day tasks. Without adequate support, Fighters can take too much on and, consequently, not have as much energy to heal. They may also develop their own ideas about how to make lifestyle changes, which can be frustrating for the nursing team.
Keys to Communicating with Patients in Fight Reaction
Acknowledge that they are in control.
Fighters pride themselves on taking responsibility for their healthcare and they expect their healthcare providers to respect their role. While this attitude can sometimes lead to frustration on the part of healthcare providers, and some conflict, it is recommended that this position not be directly challenged. After all, the benefits of working with empowered patients greatly outweighs the occasional control issues that may arise.
Examples:
“You’re in charge here.”
“The decision is ultimately up to you.”
Don’t think you always have to have the answers.
Fighters may be all over the Web, including the Websites of support groups offering discussion boards in which the latest, often experimental treatment, is discussed. Because they are so heavily involved in researching their condition and its treatment, they may encounter information that their healthcare providers have not yet been exposed to. Or they may have questions about their treatment that their healthcare providers simply haven’t encountered before. As these questions arise, don’t hesitate to say that you don’t have an answer. Offer to take a look at the information that the patient is referring to and/or use your own sources to find the answer, or direct the patient to a resource that can offer the information the patient needs.
Examples:
“I haven’t been asked that question before and I don’t want to answer it until I have given it some thought. I will follow up with you.”
“Where did you see that information? Why don’t you give me the resource and I will read through it and give you my thoughts.”
“I don’t have that answer but I can recommend a good resource that I have used myself and also recommend to patients with these kinds of questions.”
Offer to make suggestions.
Given that Fighters want to feel that they are in control, they may be resistant to any implication that the nursing team is telling them what they have to do. Remind yourself that patients who require a directive approach, as it is with those in Freeze reaction, can require a lot of extra time and energy. Instead, where possible, offer suggestions to Fighters and let them make their own choices. Even if you have only one option to offer, make it clear that that there is more than one possible outcome, depending on whether the patient accepts the suggestion or not.
Examples:
“I can’t tell you what to do here, but I would like to give you some ideas for your to consider.”
“I can tell you about some of the experiences of other patients in your situation.”
“You have the ultimate decision here, but I would like to suggest what might occur if you decide to say no.”
Don’t be afraid to identify your concerns.
While they are assertive in communicating with healthcare professionals, Fighters generally also accept assertive behavior as well. If you sense that a Fighter patient is going down the wrong path, don’t hesitate to tell them so. Be ready to support your assertion with information and, if possible, evidence. They will appreciate that not all aspects of their treatment and ongoing care is negotiable.
Examples:
“I have to be honest with you. I don’t think this is the best decision. I’ll tell you why.”
“The alternative you’re talking about just doesn’t make any sense to me based on my experiences with other patients.
“Can we talk about this? I want to share some concerns with you.”
Encourage Fighters to ask for help when they need it.
Fighters can sometimes become independent to an extreme, such that they don’t always ask for practical or emotional support when they need it. For example, Fighters may attempt to perform daily tasks like housework while recovering from treatment, thinking they will be energized by staying active, or will be an example to others of what it means to be in charge. Members of the healthcare team can be instrumental in gently suggesting the value of obtaining adequate support during treatment and recover, and offering to brainstorm on options.
Examples:
“You’re really taking a lot on when your body needs time for rest and recovery. Don’t you think you could use some temporary help here?”
“I know you are managing all of this really well. But I also think it would be helpful to sit down and talk to someone on a regular basis, just to help you let off some steam.”
“I know you aren’t an invalid. Maybe we could come up with some ideas to get the yardwork handled by someone else while your body mends.”
Keep in Mind: Do you believe that patients in Fight reaction are born Fighters? Certainly, this reaction comes naturally to some patients just as do the Flight and Freeze reactions. Nonetheless, Fighter skills can be taught to patients. This is essentially the overarching goal of this book. Guidelines and suggestions for bringing out the Fighter in patients – and using Fighter skills to enhance the relationship between patients and the healthcare team – will be provided in the chapters that follow.
Introducing: Body Language
Humans experience their emotions in various ways. They may attempt to hold their emotions inside, out of a desire to prevent others from knowing how they feel, or because they are uncomfortable with their feelings. On the other hand, they may discuss their feelings openly. They also demonstrate their feelings, through facial expressions, the gestures that they make with their hands, and by their posture. This outward demonstration of emotions is referred to as body language. For example, a person who is sad may cry, hold their hands up to their face, and hang their head. An angry person will have an angry expression, stand straight, and place their hands on their hips. Going forward in the book, body language will be discussed in each chapter.
Patients in Flight, Freeze, or Fight reaction to their diagnoses may show their emotions through their body language, as follows:
Flight Reaction
- Crying, rubbing eyes
- Holding their hands up to their face, or limply at their sides
- Agitated, nervous gestures
- Rubbing hands
Freeze Reaction
- Sitting with legs, arms crossed
- Shoulders hunched
- Head resting in hands, looking downward
- Rigid
- No facial expression
Fight Reaction
- Straight, rigid posture
- Making eye contact with others
- Standing with hands on hips
- Sitting with legs apart
Summary
Patients need their own time to experience the initial shock of receiving the diagnosis. They move from shock to a reaction that is consistent with how humans react to stressful events: Flight, Freeze, or Fight. Recognizing how patients are reacting, and understanding what this means for ongoing coping, can revolutionize the communications process between patients and the nursing team. Based on the reaction, members of the healthcare team can gauge how to present information to patients, how to make recommendations, and how to react when they encounter resistance to ongoing compliance and lifestyle management.