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The Medical Implications of Nuclear War, Institute of Medicine. @) 1986 by the National Academy of Sciences. National Academy Press, Washington, D.C. Hope and the Denial of Stress in the Nuclear Age SHLOMO BREZNITZ, PH.D. Haifa University, Haifa, Israel It must be with a shared sense of frustration that we try to comprehend all the incredible things that are in store for us if nuclear war breaks out, and at the same time, to hear about the minimal level of involvement with the issues by the general population. This discrepancy, which was the focus that Susan Fiske took in her paper on adults' images of nuclear war (this volume), is very frustrating because one has the sense that not much more can be said or done to increase our awareness or stimulate action. I would like to discuss some of the key findings that have been reported, and to suggest some expla- nations for some of these disturbing discrepancies. Unfortunately, there are very few in-depth data which go beyond self- report and paper and pencil tasks, whether with children, adolescents, or adults; consequently, some of the ideas are extrapolations and specula- tions. From the papers presented in this volume I have uncovered five points that I found to be particularly important: (1) Children and adolescents do seem to be quite seriously worried. (2) They claim that they receive little information about nuclear war and the nuclear threat. (3) Adults appear to be less concerned than adolescents. (4) Considering the problem and the understanding of the information, there appears to be relatively little fear and emotion and much less action. (5) Parents and children apparently do not spend much time talking about these problems together. Let me start by making a distinction, which is a very problematic one, between the lack of concern on the one hand and active denial on the 467

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468 IMAGES AND RISKS OF NUC~F:AR WAR other. If somebody claims that he or she does understand what is at stake and at the same time does not often feel very worried or anxious about it, does this suggest that a person is not truly concerned or that there is some active denial taking place that suppresses these worries so that the person can maintain his or her life-style? This is not an easy question to answer, but it is very important because it holds very different implica- tions. Most of the findings about adults suggest that there is at least some extent of denial of a particular kind that I will describe below. The evidence presented in the papers in this volume suggests that something happens between adolescence and adulthood that makes people less worried. What can it be that makes people less worried? Did they find out something about the world that justifies their being less worried? This is unlikely. If there is evidence that up to some point there is awareness and worry and then the worry is reduced, it cannot be claimed that the person was never exposed to the information and did not reach the point of feeling worry. Something active must take place to reduce it. Among several psychological processes that can accomplish this, a particular kind of denial is probably the best candidate. There are some other "symptoms" that suggest that denial is at work, in addition to the data presented about children from both Norway and the United States. It is of some interest to note that adults exaggerate the risks of disasters from nuclear power plants, as compared with the risks of living under a dam, which could break and cause flooding, even though objective analysis of the risks suggests that the second threat is much more serious than the first one. One wonders whether people are not displacing some of their worries to something that is related to nuclear war, like nuclear power plants, and expressing their fears by focusing on a less-devastating aspect. Denial is often useful and sometimes lifesaving. There is some medical evidence that suggests that people in great trouble sometimes have a better chance of survival if they deny the enormity of what is happening to them during crises. Thus results of studies by Hackett and Cassem (1975) in a Boston hospital of patients in the intensive care unit just shortly after they have had a heart attack suggest that those patients who actively deny what is happening to them have a better chance of coming out of the hospital alive than those whose evaluations of their situation are more realistic. But denial can also be dangerous. The obvious danger is that in some situations it can lead to procrastination in seeking help or to avoidance of action that might prevent harm. Two simple illustrations can help ex- emplify this. Studies suggest that between 40 and 50 percent of patients who are subsequently diagnosed as having cancer seek medical attention much too late, not because they were not aware of any symptoms but

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HOPE AND DENIAL OF STRESS IN THE NUCLEAR AGE 469 because they were fearful to find out that it might be a serious problem. Another illustration that is quite dramatic is the story of a person who, in the midst of very severe chest pain, starts to do push-ups or to run up and down stairs to convince himself that if he can still do that, it obviously cannot be a heart attack. There is no limit to what one can do in order to achieve temporary relief from major anxiety. It used to be thought that denial is a very simple and primitive defense, but more and more it has been determined that there are many different kinds of denial, each of which seines different purposes at different stages. Forms of denial go all the way from some minor changes in perceptions to perhaps what is the most extreme form of denial, fainting. One hears some terrible news and faints; losing consciousness is a perfect time-out from threatening information. Denial cannot ever be complete, because one must process the infor- mation in order to decide whether to deny it. Thus at some level the information must infiltrate the consciousness; otherwise, denial would be totally indiscriminate. One way to look at the different kinds of denial is to view them like different stages of defense. One starts with the simple forms, and if they do not work, because there is evidence to the contrary, then there is the second level of defense, and the third, and the fourth, and so on. I believe that in the sphere of nuclear threats people are now stuck at a level of defense that is particularly difficult to alter. Research suggests that the first and easiest form of denial is the denial of personal relevance (Brez- nitz, 1983~. People think, "Sure, there are problems, but they really don't concern me. I don't have to worry." When there is evidence to the contrary, such as in the case of the threat of nuclear holocaust, it is impossible to maintain this particular posture for long. The second type of denial is often the denial of urgency: "Yes, I, too, am under danger, but there is time and there is no reason to worry now." Because emotion, particularly fear and anxiety, are always affected by temporal consider- ations, when there is time, there is no need to be anxious. One has the illusion that a lot can be done in a short time. As T. S. Eliot said, "In a minute there is time for a thousand decisions and revisions which a minute will reverse," which gives us some hope, perhaps. At the same time, one wonders whether, if T. S. Eliot knew that the warning time would be so short, he would still have made this point. The third level of denial is the denial of vulnerability. One can still maintain the belief: "Yes, it is dangerous; it is dangerous to me; it is very close, but when it comes I will be able to deal with it. I will be able to handle it." Often, there is the hyperbolic reasoning (like the person who does the push-ups in order to convince himself that the chest pains cannot be a

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470 IMAGES AND RISKS OF NUCLEAR WAR heart attack): "The very fact that I still don't do anything about it suggests that it is not so dangerous, that I can deal with it when the time comes." When denial of vulnerability is also removed, as the evidence presented in this volume clearly suggests, there comes the fourth kind of denial, and that is a particularly difficult one. This kind of denial, which is very prevalent, is the denial of responsibility. It is almost the opposite of the denial of vulnerability. Not that, "When the time comes, I will be able to deal with it," but "It doesn't matter what I do, because it wouldn't change anything." I submit that this is the stage at which most of the world's enlightened citizens really are, i.e., the stage of denial of re- sponsibility. They know the facts and are able to give information about how horrible a nuclear holocaust could be, and they estimate as one-third the probability that in their lifetime it will happen and believe that there is nothing that they can do about it. This is different from what Lifton called "resignation," a point that I will discuss below. If this analysis is true, then additional information about how terrible it is going to be is not going to overcome denial. It is only going to push people into more extreme fortes of denial, and indeed there are more extreme forms of denial, like denial of information. There has been in- formation presented about some children who do not want to hear or think about it, which is a more extreme form of denial, since it implies that the filter has already been placed at the point of information input. Therefore, I do not think that more information about how important it is to consider the nuclear threat is going to change much. Also, con- sideration should be made about how easy it is to deny the information in the case of the nuclear threat. First, there is no direct experience and there is nothing concrete on which to build one's images of subjective probability. What is it that is going to happen when there is a nuclear war? We have heard about how abstract these images are, how important a television program of a particular kind can be, precisely because it provides common images that become more concrete. On television people see faces, not numbers. It is not abstract anymore, but it is a particular family that is involved. There are other reasons that denial is very easy to maintain; one of them is that the nuclear threat is so big that it does not make sense. Even the experiences in Hiroshima and Nagasaki, which could have provided a focus for our images, are irrelevant considering that whatever could happen in a nuclear war would be on a totally different scale of magnitude. Thus, even the few images that people can still perhaps muster from a real occurrence are irrelevant. Finally, one of the main reasons that it is so easy to deny the nuclear threat and not be concerned about it on a day-to-day basis is that the world

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HOPE AND DENIAL OF STRESS IN THE NUCLEI AGE 471 is too much with us. People have other things on their minds. People are worried about interest rates and about diet. I discovered a short quotation that I found to be very illuminating. It is taken from the Beverly Hills Diet, by Judy Mazel, and it talks about the use of a scale in the morning to measure one's weight: "The scale, that little mechanical device that has more effect on us than an atom bomb. It can literally make or break our day. I have seen the most gorgeous, the most powerful, the most secure, and the most self-assured, crumble beneath its force." The nuclear threat has little social relevance, because we are all in the same boat. If some people were more threatened than others, then it could have been translated into a motivational force, but it is a great equalizer, and therefore it has very little social, interactional relevance to everyday life. At this point I would like to make a distinction between denial and its very close cousin hope. There are two ways to defend against terrible images of the future. One is to concentrate on the negative aspects and try not to see them, not to hear them, and not to think about them, resorting to the various forms of denial; the other defense consists of locating whatever positive elements are there and amplifying them. This is hope. There are different combinations of hope and denial. It is possible to have hope based on denial; this is an illusory hope that is continuously challenged by new information because it is based on false information. There is also hope that can be called mature hope, in which case a person is aware of the danger and yet maintains a level of hope. This, I believe, is related to the findings reported by Dr. Beardslee (this volume), in that those children who are more worried also have a greater sense of efficacy and think that there is greater hope to prevent the nuclear holo- caust. One must be worried in order to have hope, because by denying that which causes worry, one cannot think about it, and there is no such thing as hoping without thinking. The worst combination is when there is neither denial nor hope, which implies resignation and depression. Denial can be viewed as a vital psy- chological sign. It suggests that a person is putting up a defense, trying to protect him- or herself from something terrible. Once that is given up, there is no denial and no hope. Without hope there cannot be any action or involvement, and denial prevents that action because of anxiety-inducing reminders. Reminders often are very painful; therefore, denial prevents action that would remind a person of that which is being denied. The impact of reminders can be illustrated by patients who have had a heart attack. During recovery they must maintain a strict regimen to keep physically fit. One of the problems that often comes up in this regimen

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472 IMAGES AND RISKS OF NUCLEAR WAR is that even though the patients feel that they are in good shape, the various things that they must do constantly remind them that they are potentially at risk. This is one of the reasons that there is backsliding and a lack of adherence to their therapeutic regimen: they do not want to face these reminders all the time. I want to suggest two possible ways out of this discrepancy between action and understanding. People can be encouraged to engage in protec- tive behavior and increase the level of involvement of the general popu- lation with regard to the nuclear threat. One point refers to what is called desynchrony between action and emotion. One often finds that fear and protective behavior do not go together. At first it was thought that if people are scared, then they do something to protect themselves; this in turn reduces fear, which reduces the motivation to protect themselves. The danger then grows and fear goes up again, leading to a continuous dynamic flow between action and emo- tion. That, however, is not what seems to be the case. There is a desyn- chrony between the two. Sometimes fear does not lead to action, and sometimes action can be taken without being under the control of fear. That is the only reason that people sometimes have courage; namely, they do something in spite of their fear. There appears to be two distinct reasons for self-protection. The usual one is to reduce danger, and the other one is to reduce present worry. Nobody would be able to sell insurance if the only motivation to buy insurance would be that if something terrible happens, the family will get the money. People do not want to think about anything happening to them. They are willing to buy insurance because it makes them feel better now, not because something is going to happen tomorrow or a few years later. Therefore, if there is interest in motivating large groups of people, youngsters, adolescents, and young adults in being more concerned and more active about the nuclear threat, they cannot be motivated by the belief that they can prevent a nuclear holocaust. The only motivation that makes sense is the motivation that can work on a day-to-day basis; that is, to do something for this cause is part of a definition of being a better person today. Let me mention briefly some things about home and family. It has been stated in some of the papers in this volume that there is a problem in that children do not often speak with their parents about the nuclear threat, and in turn the parents apparently do not speak often with their children. One can understand that part of the shift from adolescence to adulthood, which has been seen in the data reported in this volume, is due to the fact that as adolescents grow up, they need to stabilize their images of the world. The image of inevitable doom does not allow one to make long

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HOPE AND DENIAL OF STRESS IN THE NUCLEAR AGE 473 term commitments in terms of a career, a family, and raising children; so perhaps it can be understood why young adults must invest more in this denial process in order to be able to move into their new roles. In addition, there might be yet another problem, which is hinted at in Beardslee's (1986) report. The problem is that adolescents might take advantage of the nuclear threat issue as something that serves as a rationale for a particular life-style. We have heard about the drugs. We have heard carpe diem, live for today, because there is no tomorrow. There is then a distinct possibility that the parents challenge this, pushing their feelings in the opposite direction from those of their children. They fry to minimize the danger of the nuclear threat and actually lose the ability to honestly discuss the issue with them. I believe that it is of tremendous importance that this one issue be removed from the intergenerational conflict. There are enough other conflicts to deal with. REFERENCES Beardslee, W. R. 1986. Children's and adolescents' perceptions of the threat of nuclear war: implications of recent studies. This volume. Breznitz, S. 1983. The Denial of Stress. New York: International Universities Press. Hackett, T. P., and N. Cassem. 1975. Psychological management of the myocardial in- farction patient. J. Human Stress 1:25-38.