The concept of denial has been an integral part of the psychological and disability studies bodies of literature for over 100 years.Yet, denial is a highly elusive concept and has been associated with mixed, indeed conflicting theoretical perspectives, clinical strategies, and empirical findings. In part II the author reviews empirical findings, measurement strategies, and clinical approaches associated with denial, with particular emphasis on rehabilitation-specific findings and implications. It focuses on empirical findings linking the use of denial to a number of psychosocial outcomes, measures that have been employed in the assessment of denial and, intervention strategies to manage denial. Part II concludes with a brief discussion of the implications generated by the current understanding of denial to rehabilitation practitioners and researchers.
Aikens, J.E., Fischer, J.S., Namey, M., & Rudick, R.A. ( 1997). A replicated prospective investigation of life stress, coping, and depressive symptoms in multiple sclerosis. Journal of Behavioral Medicine, 20, 433-445.
2.
Allen, H.A. ( 1985). The Gestalt perspective. Journal of Applied Rehabilitation Counseling, 16(3), 21-25.
3.
Arnett, P.A., Higginson, C.I., Voss, W.D., Randolph, J.J., & Grandey, A.A. ( 2002). Relationship between coping, cognitive dysfunction and depression in multiple sclerosis. The Clinical Neuropsychologist , 16, 341-355.
4.
Behen, J.M., & Rodrigue, J.R. (1994). Predictors of coping strategies among adults with cancer. Psychological Reports, 74, 43-58.
5.
Billings, E., Lindell, B., Sederholm, M., & Theorell, T. ( 1980). Denial, anxiety, and depression following myocardial infarction. Psychosomatics, 21, 639-645.
6.
Bracken, M.B., & Bernstein, M.B. (1980). Adaptation to and coping with disability one year after spinal cord injury: An epidemiological study . Social Psychiatry, 15, 33-41.
Buetow, S., Goodyear-Smith, F., & Coster, G. ( 2001). Coping strategies in the self-management of chronic heart failure. Family Practice, 18, 117-122.
11.
Caplan, B., & Shechter, J. ( 1987). Denial and depression in disabling illness. In B. Caplan (Ed.), Rehabilitation psychology desk reference (pp. 133-170). Baltimore, MD: Aspen.
12.
Carver, C.S., Pozo, C., Harris, S.D., Noriega, V., Scheier, M.F., Robinson, D.S., et al. (1993). How coping mediates the effect of optimism on distress: A study of women with early stage breast cancer. Journal of Personality and Social Psychology, 65, 375-390.
13.
Carver, C.S., Scheier, M.F., & Weintraub, J.K. (1989). Assessing coping strategies: A theoretically based approach. Journal of Personality and Social Psychology, 56, 267-283.
14.
Connor, S.R. ( 1986). Measurement of denial in the terminally ill: A critical review. The Hospice Journal, 2, 51-68.
15.
Coven, A.B. ( 1977a). The Gestalt approach to rehabilitation counseling. Rehabilitation Counseling Bulletin, 20, 167-174.
16.
Coven, A.B. ( 1977b). Using Gestalt psychodrama experiments in rehabilitation counseling. Personnel and Guidance Journal, 56, 143-147.
17.
Croog, S. H., Shapiro, D. S., & Levine, S. (1971). Denial among male heart patients. Psychosomatic Medicine, 33, 385-397. de Ridder, D., Fournier, M., & Bensing, J. (2004). Does optimism affect symptom report in chronic disease? What are its consequences for self-care behavior and physical functioning? Journal of Psychosomatic Research, 56, 341-350.
18.
Deaton, A.V. ( 1986). Denial in the aftermath of traumatic head injury: Its manifestations, measurement, and treatment. Rehabilitation Psychology, 31, 231-240.
19.
Dimsdale, J.E., & Hackett, T.P. ( 1982). Effect of denial on cardiac health and psychological assessment. American Journal of Psychiatry, 139, 1477-1480.
20.
Dougherty, K., Templer, D.T., & Brown, R. ( 1986). Psychological states in terminal cancer patients as measured over time. Journal of Counseling Psychology, 23, 357-359.
21.
Dunkel-Schetter, C., Feinstein, L.G., Taylor, S.E., & Falke, R.L. ( 1992). Patterns of coping with cancer. Health Psychology, 11, 79-87.
22.
Dunn, M.E. ( 1975). Psychological intervention in a spinal cord injury center: An introduction. Rehabilitation Psychology, 22, 165-178.
23.
Esteve, G.L., Valdes, M., Riesco, N., Jodar, I., & De Flores, T. ( 1992). Denial mechanisms in myocardial infarction: Their relations with psychological variables and short-term outcome. Journal of Psychosomatic Research, 36, 491-496.
24.
Ferraro, J., Barreto, M.P., & Toledo, M. ( 1994). Mental adjustment to cancer and quality of life in breast cancer: An exploratory study. Psycho-Oncology, 3, 223-232.
25.
Finset, A., & Andersson, S. (2000). Coping strategies in patients with acquired brain injury: Relationships between coping, apathy, depression and lesion location. Brain Injury, 14, 887-905. Folkman, S., & Lazarus, R. S. (1985). If it changes it must be a process: A study of emotion and coping during three stages of a college examination. Journal of Personality and Social Psychology, 48, 150-170.
26.
Folks, D.G., Freeman, A.M., Sokol, R.S., & Thurstin, A.H. (1988). Denial: Predictor of outcome following coronary bypass surgery. International Journal of Psychiatry in Medicine, 18, 57-66.
27.
Fowers, B.J. ( 1992). The Cardiac Denial of Impact Scale: A brief, self-report research measure. Journal of Psychosomatic Research, 36, 469-475.
28.
Friedman, L.C., Baer, P.E., Nelson, D.V., Lane, M., Smith, F.E., & Dworkin, R.J. ( 1988). Women with breast cancer: Perception of family functioning and adjustment to illness. Psychosomatic Medicine, 50, 529-540.
29.
Friedman, L.C., Nelson, D.V., Baer, P.E., Lane, M., & Smith, F.E. ( 1990). Adjustment to breast cancer: A replication study. Journal of Psychosocial Oncology, 8, 27-40.
30.
Friedman, L.C., Nelson, D.V., Baer, P.E., Lane, M., Smith, F.E., & Dworkin, R.J. ( 1992). The relationship of dispositional optimism, daily life stress, and domestic environment to coping methods used by cancer patients . Journal of Behavioral Medicine, 15, 127-141.
31.
Froese, A.P., Cassem, N.H., Hackett, T.P., & Silverberg, E.L. (1975). Galvanic skin potential as a predictor of mental status, anxiety, depression and denial in acute coronary patients. Journal of Psychosomatic Research, 19, 1-9.
32.
Froese, A.P., Hackett, T.P., Cassem, N.H., & Silverberg, E.L. (1974). Trajectories of anxiety and depression in denying and nondenying acute myocardial infarction patients during hospitalization. Journal of Psychosomatic Research , 18, 413-420.
33.
Gainotti, G. ( 1993). Emotional and psychosocial problems after brain injury . Neuropsychological Rehabilitation, 3, 259-277.
34.
Gentry, W.D., Foster, S., & Haney, T. ( 1972). Denial as a determinant of anxiety and perceived health status in the coronary care unit. Psychosomatic Medicine, 34, 39-44.
35.
Gentry, W.D., & Haney, T. ( 1975). Emotional and behavioral reaction to acute myocardial infarction. Heart & Lung, 4, 738-745.
36.
Gleser, G.C., & Ihilevich, D. ( 1969). An objective instrument for measuring defense mechanisms . Journal of Consulting and Clinical Psychology, 33, 51-60.
37.
Goldbeck, R. ( 1997). Denial in physical illness. Journal of Psychosomatic Research, 43, 575-593.
38.
Gottschalk, L.A., & Hoigaard-Martin, J. (1986). The emotional impact of mastectomy. Psychiatry Research, 17, 153-167.
39.
Greer, S. ( 1992). The management of denial in cancer patients. Oncology, 6, 33-40.
40.
Greer, S., Moorey, S., & Watson, M. ( 1989). Patients’ adjustment to cancer: The Mental Adjustment of Cancer (MAC) Scale vs. clinical ratings. Journal of Psychosomatic Research, 33, 373-377.
41.
Greer, S., Morris, T., Pettingale, K.W., & Haybittle, J.L. (1990). Psychological response to breast cancer and 15-year outcome. Lancet, 335, 49-50.
42.
Greer, S., & Watson, M. ( 1987). Mental adjustment to cancer: Its measurement and prognostic importance. Cancer Surveys, 6, 439-453.
43.
Hackett, T.P., & Cassem, N.H. ( 1974). Development of a quantitative rating scale to assess denial. Journal of Psychosomatic Research, 18, 93-100.
44.
Hackett, T.P., Cassem, N.H., & Wishnie, H.A. ( 1968). The coronary care unit: An appraisal of its psychological hazards. New England Journal of Medicine, 279, 1365-1370.
45.
Hackett, T.P., & Weisman, A.D. ( 1969). Denial as a factor in patients with heart disease and cancer. Annals of the New York Academy of Sciences, 164, 802-817.
46.
Hanson, S., Buckelew, S.P., Hewett, J., & O’Neal, G. (1993). The relationship between coping and an adjustment after spinal cord injury: A 5-year follow-up study . Rehabilitation Psychology, 38, 41-52.
47.
Havik, O.E., & Maeland, J.G. ( 1986). Dimensions of verbal denial in myocardial infarction . Scandinavian Journal of Psychology, 27, 326-339.
48.
Havik, O.E., & Maeland, J.G. ( 1988). Verbal denial and outcome in myocardial infarction patients . Journal of Psychosomatic Research, 32, 145-157.
49.
Heim, E., Valach, L., & Schaffner, L. (1997). Coping and psychological adaptation: Longitudinal effects over time and stages in breast cancer. Psychosomatic Medicine, 59, 408-418. Hill, A., Niven, C. A., & Knussen, C. (1995). The role of coping in adjustment to phantom limb pain. Pain, 62, 79-86.
50.
Jacobsen, B.S., & Lowery, B.J. ( 1992). Further analysis of the psychometric properties of the Levine Denial of Illness Scale. Psychosomatic Medicine, 54, 372-381.
51.
Kennedy, P., Lowe, R., Grey, N., & Short, E. ( 1995). Traumatic spinal cord injury and psychological impact: A cross-sectional analysis of coping strategies. British Journal of Clinical Psychology, 34, 627-639.
52.
Kennedy, P., Marsh, N., Lowe, R., Grey, N., Short, E., & Rogers, B. ( 2000). A longitudinal analysis of psychological impact and coping strategies following spinal cord injury. British Journal of Health Psychology, 5, 157-172.
53.
Kneier, A.W., & Temoshok, L. ( 1984). Repressive coping reactions in patients with malignant melanoma as compared to cardiovascular disease patients. Journal of Psychosomatic Research, 28, 145-155.
54.
Kortte, K.B., & Wegener, S.T. ( 2004). Denial of illness in medical rehabilitation populations: Theory, research, and definition. Rehabilitation Psychology , 49, 187-199.
55.
Kortte, K.B., Wegener, S.T., & Chwalisz, K. ( 2003). Anosognosia and denial: Their relationship to coping and depression in acquired brain injury. Rehabilitation Psychology , 48, 131-136.
56.
Krakow, K., Buhler, K.E., & Haltenhof, H. ( 1999). Coping with refractory epilepsy. Seizure , 8, 111-115.
57.
Kunkel, E.J., Woods, C.M., Rodgers, C., & Myers, R.E. ( 1997). Consultations for maladaptive denial of illness in patients with cancer: Psychiatric disorders that result in noncompliance. Psycho-Oncology, 6, 139-149.
58.
Kvam, S.H., & Lyons, J.S. ( 1991). Assessment of coping strategies, social support, and general health status in individuals with diabetes mellitus. Psychological Reports, 68, 623-632.
59.
Langer, K.G. ( 1994). Depression and denial in psychotherapy of persons with disabilities. American Journal of Psychotherapy, 48, 181-194.
60.
Levine, J., Warrenburg, S., Kerns, R., Schwartz, G., Delaney, R., Fontana, A., et al. (1987). The role of denial in recovery from coronary heart disease. Journal of Psychosomatic Medicine, 49, 109-117.
61.
Livneh, H. ( 1986). A unified approach to existing models of adaptation to disability. Part II: Intervention strategies. Journal of Applied Rehabilitation Counseling, 17(2), 6-10.
62.
Livneh, H., & Antonak, R.F. ( 1991). Temporal structure of adaptation to disability. Rehabilitation Counseling Bulletin, 34, 298-319.
63.
Livneh, H., Antonak, R.F., & Gerhardt, J. ( 1999). Psychosocial adaptation to amputation: The role of sociodemographic variables, disability-related factors and coping strategies. International Journal of Rehabilitation Research, 22, 21-31.
64.
Livneh, H., Martz, E., & Wilson, L. M. (2001). Denial and perceived visibility as predictors of adaptation to disability among college students. Journal of Vocational Rehabilitation, 16, 227-234. Lowery, B. J. (1991). Psychological stress, denial and myocardial infarction outcomes. Image, 23, 51-55.
65.
Lynch, S.G., Kroencke, D.C., & Denney, D.R. ( 2001). The relationship between disability and depression in multiple sclerosis: The role of uncertainty, coping, and hope. Multiple Sclerosis, 7, 411-416.
66.
Marshak, L.E., & Seligman, M. ( 1993). Counseling persons with physical disabilities: Theoretical and clinical perspectives. Austin, TX: Pro-Ed.
67.
Martz, E., & Livneh, H. ( 2007). Do posttraumatic reactions predict future time perspective among people with insulin-dependent diabetes mellitus? Rehabilitation Counseling Bulletin, 50, 87-98.
68.
Martz, E., Livneh, H., Priebe, M., Wuermser, L.A., & Ottomanelli, L. (2005). Predictors of psychosocial reactions to disability among individuals with spinal cord injuries. Archives of Physical Medicine and Rehabilitation, 86, 1182-1192.
69.
McCabe, M.P., McKern, S., & McDonald, E. ( 2004). Coping and psychological adjustment among people with multiple sclerosis. Journal of Psychosomatic Research, 56, 355-361.
70.
Meyerowitz, B.E. ( 1983). Post mastectomy coping strategies and quality of life . Health Psychology, 2, 117-132.
71.
Miller, D.L., Manne, S.L., Taylor, K., Keates, J., & Dougherty, J. ( 1996). Psychological distress and well-being in advanced cancer: The effects of optimism and coping. Journal of Clinical Psychology in Medical Settings, 3, 115-130.
72.
Mohr, D.C., Goodkin, D.E., Gatto, N., & Van der Wende, J. (1997). Depression, coping and level of neurological impairment in multiple sclerosis. Multiple Sclerosis, 3, 54-58.
73.
Moore, A.D., & Stambrook, M. ( 1994). Coping following traumatic brain injury (TBI): Derivation and validation of TBI sample Ways of Coping-Revised Subscales. Canadian Journal of Rehabilitation, 7, 193-200.
74.
Moore, A.D., Stambrook, M., & Peters, L.C. ( 1989). Coping strategies and adjustment after closed-head injury: A cluster analytic approach. Brain Injury, 3, 171-175.
75.
Moyer, A., & Levine, E.G. ( 1998). Clarification of the conceptualization and measurement of denial in psychosocial oncology research. Annals of Behavioral Medicine, 20, 149-160.
76.
Naugle, R.I. ( 1988). Denial in rehabilitation: Its genesis, consequences, and clinical management. Rehabilitation Counseling Bulletin , 31, 218-231.
77.
Nelson, D.V., Friedman, L.C., Baer, P.E., Lane, M., & Smith, F.E. ( 1989). Attitudes to cancer: Psychometric properties of fighting spirit and denial. Journal of Behavioral Medicine, 12, 341-355.
78.
Nelson, D.V., Friedman, L.C., Baer, P.E., Lane, M., & Smith, F.E. ( 1994). Subtypes of psychological adjustment to breast cancer . Journal of Behavioral Medicine, 17, 127-141.
79.
Nockelby, D.M., & Deaton, A.V. ( 1987). Denial versus distress: Coping patterns in post head trauma patients. International Journal of Clinical Neuropsychology , 9, 145-148.
80.
O’Brien, M.T. ( 1993). Multiple sclerosis: The relationship among self-esteem, social support, and coping behavior. Applied Nursing Research , 6, 54-63.
81.
Olney, M. F., Kennedy, J., Brockelman, K. F., & Newsom, M. A. (2004). Do you have a disability? A population-based test of acceptance, denial, and adjustment among adults with disabilities in the U.S. Journal of Rehabilitation, 70, 4-9.
82.
Ostby, S.S. ( 1985). A rational-emotive perspective. Journal of Applied Rehabilitation Counseling, 16(3), 30-33.
83.
Ownsworth, T.L., McFarland, K., & Young, R.M. ( 2002). The investigation of factors underlying deficits in self-awareness and self-regulation. Brain Injury, 16, 291-309.
84.
Pakenham, K.I. ( 2001). Coping with multiple sclerosis: Development of a measure . Psychology, Health, & Medicine, 6, 411-428.
85.
Pilowsky, I., & Spence, N.D. ( 1983). Manual for the Illness Behavior Questionnaire (IBQ) (2nd ed.). Adelaide, Australia: University of Adelaide.
86.
Prigatano, G.P., & Klonoff, P.S. ( 1998). A clinician’s rating scale for evaluating impaired self-awareness and denial of disability after brain injury. The Clinical Neuropsychologist, 12, 56-67.
87.
Prince, R., Frasure-Smith, N., & Rolicz-Woloszyk, E. (1982). Life stress, denial, and outcome in ischemic heart disease patients. Journal of Psychosomatic Research, 26, 23-31.
88.
Quinn, M.E., Fontana, A.F., & Reznikoff, M. ( 1986). Psychological distress in reaction to lung cancer as a function of spousal support and coping strategy. Journal of Psychosocial Oncology, 4, 79-90.
89.
Radley, A., & Green, R. ( 1985). Styles of adjustment to coronary graft surgery. Social and Science Medicine, 20, 461-472.
90.
Rodin, G., Craven, J., & Littlefield, C. (1991). Depression in the medically ill: An integrated approach. New York: Brunner/Mazel .
91.
Rodrigue, J.R., Boggs, S.R., Weiner, R.S., & Behen, J.M. ( 1993). Mood, coping style, and personality functioning among adult bone marrow transplant candidates. Psychosomatics, 34, 159-165.
92.
Schwartz, C.E., Daltroy, L.H., Brandt, V., Friedman, R., & Stolbach, L. ( 1992). A psychometric analysis of the Mental Adjustment to Cancer Scale. Psychological Medicine, 22, 203-210.
93.
Soloff, P.H. ( 1980). Effects of denial on mood, compliance, and quality of functioning after cardiovascular rehabilitation. General Hospital Psychiatry, 2, 134-140.
94.
Soloff, P.H., & Bartel, A.G. ( 1979). Effects of denial on mood and performance in cardiovascular rehabilitation. Journal of Chronic Disease, 32, 307-313.
95.
Stanton, A.L., & Snider, P.R. ( 1993). Coping with a breast cancer diagnosis: A prospective study. Health Psychology, 12, 16-23.
96.
Starkstein, S.E., Fedoroff, J.P., Price, T.R., & Robinson, R.G. (1993). Denial of Illness Scale: A reliability and validity study. Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 6, 93-97.
97.
Stern, M.J., Pascale, L., & McLoone, J.B. ( 1976). Psychosocial adaptation following an acute myocardial infarction. Journal of Chronic Disease, 29, 513-526.
98.
Thomas, S.A., Sappington, E., Gross, H.S., Noctor, M., Friedmann, E., & Lynch, J.J. ( 1983). Denial in coronary care patients-An objective reassessment . Heart & Lung, 12, 74-80.
99.
Turnbull, O.H., Jones, K., & Reed-Screen, J. (2002). Implicit awareness of deficit in anosognosia? An emotion-based account of denial of deficit. Neuro-Psychoanalysis, 4, 69-86.
100.
Upton, D., & Thompson, P.J. (1992). Effectiveness of coping strategies employed by people with chronic epilepsy. Journal of Epilepsy, 5, 119-127.
101.
Vandereycken, W. ( 2005). Denial of illness: A concept in search of refinement . Advances in Psychology Research, 37, 63-95.
102.
Warrenburg, S., Levine, J., Schwartz, G.E., Fontana, A.F., Kerns, R.D., Delaney, R., & Mattson, R. ( 1989). Defensive coping and blood pressure reactivity in medical patients. Journal of Behavioral Medicine, 12, 407-424.
103.
Watson, M., Greer, S., Blake, S., & Shrapnell, K. ( 1984). Reactions to a diagnosis of breast cancer: Relationship between denial, delay and rates of psychological morbidity. Cancer, 53, 2008-2012.
104.
Watson, M., Law, M., dos Santos, M., Greer, S., Baruch, J., & Bliss, J. ( 1994). The Mini-MAC: Further development of the Mental Adjustment to Cancer Scale. Journal of Psychosocial Oncology, 12, 33-46.
105.
Weiss, D.S., Horowitz, M.J., & Wilner, N. ( 1984). The Stress Response Rating Scale: A clinician’s measure for rating the response to serious life-events. British Journal of Clinical Psychology, 23, 202-215.
106.
Weller, D.J., & Miller, P.M. ( 1977). Emotional reactions of patient, family, and staff in acute-care period of spinal cord injury: Part 1. Social Work in Health Care, 2, 369-377.
107.
Wheeler, S., & Lord, L. ( 1999). Denial: A conceptual analysis. Archives of Psychiatric Nursing, 13, 311-320.
108.
Wool, M.S. ( 1986). Extreme denial in breast cancer patients and capacity for object relations. Psychotherapy and Psychosomatics, 46, 196-204.
Zeidner, M., & Saklofske, D. ( 1996). Adaptive and maladaptive coping. In M. Zeidner & N. S. Endler (Eds.), Handbook of coping: Theory, research, applications (pp. 505-531). New York: John Wiley.
