Proposal of a revised model

These results suggest that there may be two separate denial-like processes occurring in two different groups o f people with dementia.

1. Pre-morbid personality does appear to relate to the coping strategies employed by individuals in managing the threat o f dementia. In particular, stoical and reserved attitudes towards emotional expression are predictive o f an increased use o f avoidant behavioural coping strategies.

Salander & Windahl (1999) categorise denial-like processes into avoidance, disavowal and denial. They refer to avoidance as the conscious behavioural act of avoiding information. Interestingly, avoidant behavioural coping in this study was not linked to unawareness. This provides support for Salander & Windhal’s assertion that avoidant behavioural coping is conscious despite being a denial-like process, and as such might not be expected to be associated with unawareness o f current functioning. Indeed, it seems likely that an individual would need to be aware o f their difficulties in order to consciously implement avoidant coping strategies and to be able to report their use o f these strategies. Therefore, this group o f dementia patients are individuals who have pre-morbidly tended to hold negative attitudes towards emotional expression. They are consciously aware of their difficulties and they tend to consciously employ avoidant coping strategies in a motivated attempt to manage their illness.

2. It seems that there are another group o f individuals who are less aware o f their condition and who were pre-morbidly conscientious individuals. This is in line with Weinstein’s (1994) suggestion that highly conscientious individuals are more likely to manage the threat o f dementia using defensive denial. It seems that in

ChaptCT4: Discussion

this group the process is more one o f denial in the traditional psychoanalytic sense. As Salander & Windhal (1999) suggest:

“Denial, when conceptualised in the traditional psychoanalytic sense (Kernberg, 1994) is a forceful unconscious defensive act in the perceptual process that leaves the basics o f the threat outside the patient. It is an ‘unconscious selective perceptual blindness to the unpleasant fa c ts ’ (Page, 1975). It is not a distortion o f meaning, it is a repudiation o f meaning. ” (1999, p. 276)

Although the contribution o f organic factors to unawareness always needs to be kept in mind, it seems likely that aspects o f unawareness in this group o f patients are the outcome o f unconscious defensive denial. If this preconscious defence is effective then the patient is unaware o f their difficulties and does not perceive a problem, therefore there is possibly less o f a need to employ conscious behavioural avoidant coping strategies.

The proposed pattern o f relationships in these two processes is represented diagrammatically in Figure 4.1.

These two distinct processes have important implications for the assessment o f unawareness. It seems possible that studies which assess awareness through clinical observation and judgement may incorrectly classify some people who cope through avoidance as being unaware. If we consider some o f the avoidant coping strategies

included on the Ways o f Coping checklist (e.g. went on as i f nothing had happened; kept my feelings to myself; kept others from knowing how bad things were), it seems possible that an observer might interpret these signs as an indication o f unawareness. This highlights the importance o f including self-report measures which consider patients’ perception o f their current situation when assessing awareness. These two different processes also have implications for clinicians working with people with dementia which will be discussed later in detail.

Figure 4.1: Proposal o f a revised model regarding the relationship o f psychological factors and unawareness.

Pre-morbid negative attitudes towards emotional expression'' Patient aware of his/her difficulties

Increased use of conscious -► behavioural avoidant

coping strategies to manage the threat of dementia

Patient may appear unaware to the casual observer; however accurate self-report reveals that they are aware of their difficulties

Pre-morbidly very conscientious

“► Increased use of ---- unconscious defensive denial to mange the threat of dementia

Patient unaware of his/her difficulties, therefore does not report difficulties on self-report measures

Further research into this proposed model may need to be based on more than clinical observations or self-report questionnaires. For example, it may be possible to uncover a deeper understanding o f these processes through an in-depth

Chapter 4: Discussion

interview. Alternatively, an indirect implicit task paradigm may be better equipped to assess covert unconscious processes such as defensive denial.

Overall, it appears that there may be a small effect o f psychological variables, in particular self-rated conscientiousness, on level o f awareness which was not detectable in the regression analysis once control variables had been included in the model. Indeed, the number o f participants in the study meant that there was sufficient power to detect a large effect size but not a small effect. It could be argued that if a study with relatively lower power detects a significant result then there is a good possibility that it is robust. Therefore, the small effect o f psychological variables on level of awareness, which was detected in this study, can be regarded as relevant and clinically significant.