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with chronic illnesses to experience life as normal, denial can have negative conse-
quences if people minimize problems to the extent that they fail to take action when
it might be beneficial” (p. 668).
If you decide to address patient defenses, you must first establish a trusting rela-
tionship. Begin with primary empathy and questions to help you understand your
patient’s perspective. Then indirectly point out defenses by commenting on patient
inconsistencies between verbal and nonverbal behaviors, contradictions, omissions,
and misinformation (Clark 1991 ). (See Chap. 8 on advanced empathy and confron-
tation for examples of possible counselor statements.) Be careful about confronting
defenses head on as that may actually increase their intensity and decrease patient
trust (Clark 1991 ). Klitzman ( 2010 ) recommended “Misunderstandings might best
be reduced by addressing the emotions that may underlie them (e.g., difficulties
confronting perceived lack of control and seemingly irrevocable fate, desires to
frame genetic information positively in order to avoid despair and helplessness and
seek hope, and efforts to reduce anxiety by finding order in the face of fate and
seeming randomness). Given that emotional conflicts may not be fully conscious,
providers should proceed very carefully in addressing them” (p. 445).
Shiloh ( 2006 ) asserts that genetic counselors “...should weigh the costs and ben-
efits of changing misconceptions against the costs and benefits of keeping them for
clients’ health and well-being, before undertaking to change them. And, when they
undertake to change them, they should appreciate how difficult it may be to disabuse
someone of an attribution that may serve as a defense mechanism, and try to facili-
tate adaptation of substitute coping mechanisms” (p. 332).
9.2.4 Promoting Effective Coping
Speaking about HD, but relevant to other life-threatening genetic conditions,
Downing et al. ( 2012 ) recommended assessing “individuals’ coping strategies,
which may provide insight about their future coping abilities and whether coping is
likely to be adaptive and healthy vs. maladaptive and possibly problematic. This may
include understanding of how individuals at risk for HD and their companions use
denial as either a positive method of coping through normalization, or as a negative
method of avoidance when other coping strategies might be more effective” (p. 669).
Chaplin et al. ( 2005 ) interviewed parents with a prenatal diagnosis of spina bifida
or hydrocephalus and who decided to continue with their pregnancy. They explored
parents’ experiences of receiving the diagnosis and their coping throughout the
antenatal period. They found many parents were confident about their ability to cope
with a child with a disability, drawing “strength from their personal and professional
skills, relationships, and financial and practical resources” (p. 157). They also found
some parents coped by avoiding contact with support agencies until their child’s
diagnosis was confirmed. The researchers concluded that genetic counselors must
respect individual variation in coping strategies when parents receive unexpected
9 Patient Factors: Resistance, Coping, Affect, andfiStyles