Being the Best Bearer of Bad Tidings - CiteSeerX

Being the Best Bearer of Bad Tidings

Kate Sweeny and James A. ShepperdUniversity of Florida

Giving bad news is an unpleasant task, and the medical literature provides numerousguidelines for giving bad news well. However, what people mean by “giving bad newswell” is less clear. What should be the goal when communicating bad news? Theauthors suggest that the goal of news-givers should be to guide recipients toward adesired response and the authors propose a theoretical framework, the Bad NewsResponse Model, for delivering bad news that draws from research in health and socialpsychology. The model is applicable to all forms of bad news and specifies that threecharacteristics of the news (controllability, likelihood, and severity) influence whichresponse (Watchful Waiting, Active Change, or Acceptance) will most often lead to thebest quality of life for the recipient.

Keywords: bad news, communication, coping, situational factors

God grant me the serenity to accept the things I cannotchange, courage to change the things I can, and wis-dom to know the difference.

Serenity Prayer, source uncertain

In the book The Anatomy of Hope (Groopman,2004), an oncologist recounts the stories of twopatients whose prognoses permitted little hope.The first patient’s physician repeatedly misled herinto thinking that a cure was likely rather thanproviding more accurate information about herinevitable fate. When the cancer was about to takeher life, the patient expressed dismay at the falsehope promoted by her trusted physician. In con-trast, the second patient’s physician conveyed thegravity of her situation at each step of the cancer’sprogression. This patient lived her last moments tothe fullest and died with little regret or dismay.Although the two diagnoses were equally dire, thepatients’ experiences were decidedly different.Such stories emphasize the role of those chargedwith giving bad news in providing the recipientswith wisdom to know when their situation can be

changed and when the situation simply calls forserene acceptance. These anecdotes suggest theneed for a systematic model of giving and re-sponding to bad news.

Giving bad news is an unpleasant task (Rosen& Tesser, 1970). Unfortunately, most peoplemust transmit bad news at some point in theirlives. They may have to break up with a lover ortell a student about a failing grade. Moreover,many professions entail bad news transmissionas part of the job description. Health care em-ployees must convey diagnoses, military per-sonnel must deliver news of wartime casualties,and managers must occasionally hand out pinkslips. Although giving bad news is uncomfort-able for the giver, the opening medical exam-ples point to the importance of giving bad news“well”. A number of researchers in the medicalfield have provided guidelines to help those whomust give bad news, but what people mean by“giving bad news well” is less clear. Evaluatingthe success of a bad news transmission requiresthat news-givers have a goal in mind whengiving bad news and compare the outcomes oftheir transmission to that goal. Some research-ers focus on the goal of providing hope to therecipient of the news, others focus on makingthe transmission easier and less painful for thenews-giver, and others focus on increasing re-cipients’ satisfaction with the bad news trans-mission. What should be the primary goal whencommunicating bad news?

Kate Sweeny and James A. Shepperd, Department ofPsychology, University of Florida.

We thank J. T. Ptacek, Kevin McCaul, Marie Helweg-Larsen, Michael Weigold, Barry Schlenker, and GregNeimeyer for their helpful comments on earlier versionsof this article.

Correspondence concerning this article should be addressedto Kate Sweeny or James Shepperd at the Department ofPsychology, P.O. Box 112250, University of Florida, Gaines-ville, FL 32611-2250. E-mail: [email protected] [email protected]

Review of General Psychology Copyright 2007 by the American Psychological Association2007, Vol. 11, No. 3, 235–257 1089-2680/07/$12.00 DOI: 10.1037/1089-2680.11.3.235

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The purpose of this review is to investigatehow to give bad news well. Central to the notionof “giving bad news well” is having a clearunderstanding of the goal of bad news transmis-sion. We critically evaluate six goals suggestedby prior research and propose a broader, morecomprehensive goal for giving bad news. Wethen offer a theoretical framework, the BadNews Response Model, which draws from re-search in health and social psychology and isdesigned to maximize positive long-term out-comes for news-recipients. The model specifiesfour possible responses to bad news and threesituational factors that influence the responsechoice. Finally, we discuss future directions forresearch.

The goals of this review are, by necessity,limited in scope. We do not address specificaspects of bad news transmission, such as toneof voice, setting, eye contact, and amount ofinformation. Although many studies have ad-dressed these issues (e.g., Holland, 1989; Loge,Kaasa, & Hytten, 1997; Ptacek & Eberhardt,1996; Ptacek & Ptacek, 2001), and these aspectsof the communication can affect how peoplerespond to bad news, they fall outside of thescope of this article. Furthermore, we do notaddress the process by which people respond tobad news. The literature on coping focuses onhow people appraise and respond to bad news(see Snyder, 1999 for a review). We focus onthe goals people have when giving bad news.Finally, we do not attempt to predict with cer-tainty the best responses to bad news. The BadNews Response Model predicts how situationalfactors might affect responding, but the modeldoes not stipulate how people “should” respond.

Giving Bad News Well

A review of the medical literature reveals arich yet disorganized picture of how to give badnews well. Some consensus exists as to thestages of the bad news transmission process andthe important aspects of the situation and themessage itself (see Fallowfield & Jenkins, 2004;Faulkner, 1998; Ptacek & Eberhardt, 1996), butlittle consensus exists about the goals these sug-gestions are designed to achieve, and often nogoal is mentioned at all. The medical literaturesuggests six possible goals of a bad news com-munication: (a) decreasing news-givers’ dis-comfort, (b) providing sufficient information to

recipients, (c) promoting recipients’ satisfactionwith the transmission, (d) improving news-recipients’ memory for and understanding ofthe news, (e) reducing recipients’ distress inresponse to the news, and (f) promoting hope.We briefly review the evidence supporting eachof these goals and then offer a new, alternativegoal that incorporates the positive aspects of theother six goals. Although we treat these goals asdistinct for the purpose of this review, it isnoteworthy that a news-giver may simulta-neously pursue multiple goals during a badnews communication.

Decreasing the News-Giver’s Discomfort

One goal of bad news-givers is to decreasethe discomfort they feel about giving bad news.Giving bad news is often extremely unpleasantfor the news-giver. Physicians and nurses reportdiscomfort with giving bad news because oflack of training, fear of patients’ emotional re-actions, fear of their own emotional reactions,fear of being blamed for the bad news, fear ofthe patients’ suffering and dying, personal fearof illness and death, and uncertainty associatedwith not knowing all the answers (Ambuel &Mazzone, 2001; Buckman, 1984). Reducingnews-givers’ discomfort is an important goalbecause discomfort with giving bad news canproduce negative consequences for both news-givers and recipients. One study found thatburnout and poor mental health are commonamong physicians who must frequently givebad news, and that physicians who felt insuffi-ciently trained in giving bad news experiencedthe greatest distress (Ramirez et al., 1995). Fur-thermore, research shows that physicians whoare more comfortable and confident with givingbad news are perceived as more trustworthy bypatients, and patients who trust their physiciansare more likely to comply with treatment rec-ommendations (Holland, 1989).

With the importance of this goal in mind,several training programs for health care pro-fessionals aim to decrease discomfort and in-crease confidence and skills with giving badnews (Baile et al., 1999; Parathian & Taylor,1993; Unger, Alperin, Amiel, Beharier, & Reis,2001). In addition to formal training programs, anumber of professionals suggest strategies tomake the job of giving bad news easier (e.g., Clark& LaBeff, 1982; Eggly et al., 1997; McClenahen

236 SWEENY AND SHEPPERD

& Lofland, 1976; Radziewicz & Baile, 2001). Forexample, one paper describes five strategies tosmooth the process of giving news of death andsuggests that the best method of communicationdepends on several situational factors (the type ofdeath, the age at death, the place of death, and theoccupation and experience of the news-giver)(Clark & LaBeff, 1982).

Helping people to feel comfortable givingbad news is clearly important. However, thegoal of decreasing news-givers’ discomfort isproblematic for several reasons. First, makingnews-givers as comfortable as possible maymean that they portray the news in a morepositive light than is warranted, omitting nega-tive information in an attempt to avoid elicitingnegative responses from the receiver. Second,this goal relegates to secondary importance theneeds of the news-recipient. An appropriategoal for bad news transmission should accountfor the needs of both the news-giver and newsrecipient.

Providing Sufficient Information

A second goal for giving bad news describedin the medical literature is to provide news-recipients with sufficient information about thenews. Researchers who address the ethics ofgiving medical bad news primarily focus onhow much information people should receiveabout diagnoses and prognoses. In medical set-tings, ethical treatment requires that patientsreceive clear, honest information because it al-lows the patients to accept the situation andmake plans for the future (Fallowfield, Jenkins,& Beveridge, 2002; Girgis, Sanson-Fisher, &Schofield, 1999; Goldie, 1982; Ward, 1992).The information provided should also be con-sistent among patients and their family mem-bers to avoid distrust and suspicion (Doyle &O’Connell, 1996). Furthermore, cultural, fam-ily, and personal preferences affect the amountof information patients wish to receive, and it isthe physician’s responsibility to consider thesepreferences (Sabbioni, 1997).

However, personal comfort with disclosingbad news often determines what and how muchinformation many physicians disclose. Givingand receiving bad news are both unpleasantexperiences, and physicians and patients may beeager to avoid the experience at all costs. In onestudy, 40% of physicians admitted to giving

patients inaccurate life expectancy estimates,mostly in an optimistic direction (Lamont &Chisakis, 2001). Although some people may notbe prepared to hear the full truth about an un-desirable diagnosis (Bor et al., 1993; Goldie,1982; Greer, Morris, & Perringale, 1979;Lubinsky, 1994; Michaels, 1983; Radziewicz &Baile, 2001), evidence suggests that patientswith serious conditions often suspect that theywill hear bad news (Fallowfield, Jenkins, &Beveridge, 2002). Knowing how much infor-mation to disclose is difficult, leading some torecommend that physicians repeatedly ask pa-tients how much they want to know, thus allow-ing the patients to determine the level of infor-mation conveyed (Freedman, 1993).

Providing sufficient information is clearly anecessary goal in medical interactions, includ-ing bad news communication. Patients who donot receive sufficient or accurate informationare unable to make informed decisions as tohow they want to respond to their diagnosis.However, this goal is insufficient for guidingbad news-givers. The ethical guideline of pro-viding clear, complete information to patients isa means to an end, not an end in itself; it is onlya starting point for guiding bad news transmis-sion.

Promoting Recipient Satisfaction

A third goal for bad news-givers is to give thenews in a way that satisfies recipients. A pre-dominant belief in the medical literature is thatpatients should be satisfied with the way theyreceive bad news and that they should have theirneeds met in the communication experience.One review of the literature concluded that,when giving bad news, the patients’ desires andneeds are far more important than the physi-cians’ (Ptacek & Eberhardt, 1996). Many stud-ies reinforce this idea by asking patients howthey want to hear bad news and then using theirresponses to design bad news communicationstrategies (e.g., Ambuel & Mazzone, 2001;Back & Curtis, 2002; Butow et al., 1996; Girgiset al., 1999; Hagerty et al., 2005; Randall &Wearn, 2005; Salander, 2002). Other studiesmeasure patients’ satisfaction with their experi-ence receiving bad news to assess the competenceof bad news-givers (e.g., Damian & Tattersall,1991; Derdiarian, 1989; Dunn et al., 1993; Ellis &Tattersall, 1999; Gillotti, Thompson, & McNeilis,

237BEING THE BEST BEARER

2002; Hurwitz, Duncan, & Wolfe, 2004; Mast,Kindlimann, & Langewitz, 2005; Ptacek &Ptacek, 2001; Reynolds, Sanson-Fisher, Poole,Harker, & Byrne, 1981). Such studies typicallyfind that the needs patients express are in linewith established guidelines for giving bad news(Girgis et al., 1999; Ptacek & Ptacek, 2001;Randall & Wearn, 2005).

However, some differences arise when com-paring patients’ needs and the ways physicianstypically give bad news. For example, patientsrate information about treatment and future out-comes as more important to them than diagnos-tic information (Back & Curtis, 2002; Butow etal., 1996; Salander, 2002). Patients also viewthe experience of receiving bad news as anongoing process throughout their treatment, notas a one-time conversation with their physician(Randall & Wearn, 2005). Finally, a number ofstudies find that small talk and general expres-sions of support, not in-depth conversationabout diagnoses or prognoses, are most helpfulto patients receiving bad news (Dean, 2002;Gillotti et al., 2002).

Increasing patient satisfaction with bad newscommunication is a worthy goal for bad news-givers. However, asking patients how they wantto hear bad news assumes that patients canobjectively and accurately evaluate their ownemotions and the reasons for them. People aregenerally poor at accurate introspection and thuspoor at understanding the reasons behind theiremotional and cognitive responses (Nisbett &Wilson, 1977). For example, patients reportingthat their physicians are unskilled at presentingbad news may be unaware of the effects that theirlocation, mood, and relationship with the physi-cian have on their feelings about the news trans-mission. In this light, it seems that patients’ opin-ions, although important and valid, may be asomewhat inaccurate source of suggestions forhow to give bad news. Finally, satisfaction with abad news communication is undoubtedly influ-enced to some extent by the content of the com-munication. Other things being equal, the worsethe news, the less satisfied people will be with thecommunication. Although the medical literaturedoes not speak to this point, it seems likely that afocus on promoting recipient satisfaction with thecommunication creates the possibility that news-givers will alter or water down the bad news.

Improving Memory and Understanding

A fourth goal for giving bad news is to ensurethat recipients understand and remember infor-mation about the bad news and its implications.People receiving bad news often find it difficultto understand and remember the informationthey receive. For example, a patient may hearthe word “cancer” during a diagnostic conver-sation and fail to process any information there-after. Presenting information in a way that pa-tients can understand is crucial in bad news com-munication because it can improve patients’outcomes, avoid confusion and distress, and in-crease patients’ satisfaction with the communica-tion (Baile et al., 2000; Ellis & Tattersall, 1999;Fallowfield & Jenkins, 2004; Loge et al., 1997;Quill, 1991).

A number of researchers suggest that whenbad news is complicated or difficult to under-stand, bad news-givers should be careful to clar-ify, check for understanding, and summarize theinformation presented (Dias, Chabner, Lynch,& Penson, 2003). Furthermore, a number ofcommunication skills of the news-giver, such asself-confidence, warmth, and honesty, can helpthe patient to process bad news (Myers, 1983).Finally, providing recall aids (e.g., informa-tional handouts, audiotapes of the bad newscommunication) often improves patients’ mem-ory and understanding, and may reduce patientanxiety (Back & Curtis, 2002; Hogbin, Jenkins,& Parkin, 1992; McHugh et al., 1995; Reynoldset al., 1981).

Improving news-recipients’ memory and un-derstanding of the information they receive isclearly an important goal for bad news-givers.People who fail to comprehend the bad newsthey receive may be unable to cope with thenews and may make unwise decisions in re-sponse. On the other hand, news-recipients needmore than memory and understanding of thefacts to cope and respond effectively. For ex-ample, even if a breast cancer patient hears,understands, and remembers the details of herdiagnosis, she is unlikely to know much aboutthe implications of the diagnosis or what courseof action she should take. As such, improvingmemory and understanding represents an im-portant intermediate goal for bad news commu-nication, but is insufficient as an overarchingprinciple for guiding news-givers.


Reducing Recipients’ Distress

A fifth goal for bad news-givers is to mini-mize recipients’ distress in response to thenews. People receiving unexpected or traumaticnews may be emotionally paralyzed by the expe-rience, and poor communication by news-giverscan exacerbate recipients’ distress (Lerman et al.,1993). Many physicians and researchers recognizethe importance of reducing emotional trauma aftera bad news communication (Baile & Aaron,2005; Boyd, 2001; Brewin, 1991; Fallowfield &Jenkins, 2004; Ptacek & Eberhardt, 1996; Quill,1991; Rabow & McPhee, 1999; Shields, 1998).Emotional distress may particularly involve fearof death when bad news is health related(Penson et al., 2005), but all types of bad newsare capable of producing distress.

Researchers have noted that news-recipients’distress is most severe during and just after abad news communication, whereas the news-giver’s distress is most severe just before andduring (Ptacek & Eberhardt, 1996). A conse-quence of this incongruity is that news-giversmay be insensitive to recipients’ distress fol-lowing the communication of bad news. In re-sponse to this problem, the medical literatureprovides a number of suggestions for increasingsensitivity to patients’ distress. For example,physicians should prepare in advance for thecommunication (Holland, 1989; Michaels,1983; Shields, 1998), demonstrate empathy,sensitivity, and compassion (Boyd, 2001;Brewin, 1991; Fogarty et al., 1999; Mast et al.,2005; Penson et al., 2005; Rabow & McPhee,1999), allow patients to express their emotions(Boyd, 2001; Penson et al., 2005; Rabow &McPhee, 1999), take sufficient time in the badnews communication (Boyd, 2001; Penson etal., 2005), and help patients put the situation inperspective (Lalos, 1999). In addition, physi-cians shouldn’t simply reassure the patient andmove on; instead, they should acknowledge pa-tients’ distress, determine the sources of dis-tress, and check the patients’ needs before mov-ing on to reassurance (Maguire, 1998).

Although news-givers are in part responsiblefor managing recipients’ distress, this goal isnot an end in itself and thus is an insufficientgoal for bad news communication. Much likethe goal of improving memory and understand-ing, the goal of reducing recipients’ distress isan intermediate goal that makes it possible for

recipients to move on to the greater goal ofcoping and responding to the bad news. Even ifthe breast cancer patient described earlier un-derstands and remembers her diagnosis and alsomaintains a manageable level of distress afterhearing the news, she may nevertheless lack theresources to move forward and respond. Fi-nally, as with promoting recipient satisfaction,focusing on reducing distress may inadvertentlyinfluence the content of the communication.The worse the news, the more likely the recip-ients will be distressed by the communication.Thus, similar to the goal of promoting recipientsatisfaction, attending to recipient distress maylead news-givers to alter or water down the badnews.

Promoting Hope

A sixth goal for giving bad news is to pro-mote hope or optimism in recipients, an ideathat has received considerable attention in themedical literature (Bor et al., 1993; Bruhn,1984; Charlton, 1992; Clayton, Butow, Arnold,& Tattersall, 2005; Groopman, 2004; Yates,1993). Hope can be defined as a combination ofdesires for the future, values and goals aboutfuture outcomes, and action to bring abouthoped for outcomes (Simpson, 2004). The goalof promoting hope is supported by the findingthat hope may be a powerful force in predictingpositive health outcomes, such as better adjust-ment to breast cancer (Taylor, Lichtman, &Wood, 1984), lower incidence of hypertension(Richman et al., 2005), better immune function-ing (Segerstrom, Taylor, Kemeny, & Fahey,1998), and faster recovery from a number ofillnesses (Groopman, 2004).

A number of factors increase the likelihoodof promoting hope in a bad news communica-tion. For example, fostering a good relationshipbetween patient and physician (Bruhn, 1984;Salander, 2002), focusing on the potential forsuccessful treatment (Bruhn, 1984; Clayton etal., 2005; Peteet, Abrams, Ross, & Stearns,1991; Sardell & Trierweiller, 1993), and dis-cussing the effects of the news on day-to-dayliving (Clayton et al., 2005) promote hope inpatients receiving bad news.

Promoting hope as a goal for news-givers issomewhat problematic. Although hope maylead to positive outcomes in many cases, it mustbe balanced with honesty and realistic goals


(Clayton et al., 2005; Groopman, 2004; Links &Kramer, 1994). This balance is particularly im-portant when there is a possibility that hope maybe shattered at some point down the road, as isoften the case during the course of an illness.Shattered hopes can lead to disappointment anddistrust of those who initially communicatedhopefulness (Peteet et al., 1991; van Dijk,Zeelenberg, & van der Pligt, 1999). On theother hand, hope can always be directed towardthe possibility of improving outcomes down theroad or having a productive life despite the badnews (Links & Kramer, 1994; Peteet et al.,1991; Yates, 1993), making hope a worthwhilegoal for bad news-givers.

However, providing hope is not the same asproviding news-recipients with the informationthey need to cope and respond to negative lifeevents. The breast cancer patient gains strengthand other positive outcomes as a result of herphysician promoting hopefulness, but she needsmore than hope to know which course of treat-ment to undergo. Hope may be a necessarycomponent of coping with bad news, but news-givers must also help recipients engage in re-sponses that will lead to the best long-termoutcomes. Thus, promoting hope, along withimproving memory and understanding and re-ducing distress, is an intermediate step in thegreater goal of promoting effective responses tobad news.

Guiding Recipients Toward DesiredResponses

The six goals for bad news-givers just de-scribed (reducing news-givers discomfort, pro-viding sufficient information, promoting recip-ients’ satisfaction, improving memory and un-derstanding, reducing distress, and promotinghope) suggest different interpretations of what itmeans to give bad news well. However, thesegoals are means to an end, not ends in them-selves. The six goals described are intermediategoals that may ultimately lead to positive out-comes for the recipient of the news but do notspecify how these positive outcomes can beachieved. Furthermore, these goals were devel-oped for use in medical settings and may bedifficult to apply to other types of bad news.

We suggest an alternative, broader goal fornews-givers that incorporates aspects of each ofthe other goals. We propose that giving bad

news well is defined as guiding news-recipientstoward desired responses—responses thatnews-givers believe will result in the best long-term outcomes for recipients. Although we laterprovide suggestions as to which responses maybe most effective, a desired response refers tothe response deemed best by the news-giver.

To illustrate, imagine a physician givingnews of cancer. The physician must convey thediagnosis honestly and clearly, but ultimatelythe physician must encourage the patient to seekthe most effective course of treatment or per-haps choose no treatment, depending on thesituation. With this goal in mind, news-giverscan provide sufficient information and feel con-fident in their ability to give bad news well.Furthermore, numerous studies suggest that afocus on options for the future increases satis-faction with the communication, reduces dis-tress, and promotes hope (Back & Curtis, 2002;Clayton et al., 2005; Peteet et al., 1991; Salander,2002; Schofield et al., 2003). Finally, guidingnews-recipients toward the most effective courseof action (or inaction) maximizes their chances ofexperiencing positive long-term outcomes andquality of life, although the definition of the bestoutcomes varies greatly across situations. In gen-eral, successful bad news transmission shouldprompt the recipient to respond in a way thatmaximizes quality of life and minimizes negativelife outcomes. These outcomes include financialstability, physical, mental, and emotional health,and general well-being.

A handful of studies have examined positivelong-term outcomes associated with communi-cating bad news and reveal that a variety offactors can directly influence outcomes such aspsychological adjustment to an illness and psy-chological and emotional health. Findings sug-gest that strategies such as expressing empathy,allowing sufficient time for the bad news com-munication, and engaging the patient in treat-ment decisions, among others, predict betteradjustment to breast cancer (Butow et al., 1996;Roberts, Cox, Reintgen, Baile, & Gibertini,1994). Another study of breast cancer patientsfound that perceptions of caring and emotionalsupportiveness during the bad news communi-cation predicted fewer cancer-related PTSDsymptoms, less depression, and less general dis-tress (Mager & Andrykowski, 2002). In addi-tion, physicians’ personal manner, communica-tion skills, technical skills, and overall care pre-


dicted emotional health in breast cancer patients(Silliman et al., 1998).

Yet the studies just described do not indicatehow various aspects of the bad news communi-cation lead to positive or negative health out-comes. For example, how does emotional sup-portiveness by physicians lead to better emo-tional outcomes in patients? It may be the casethat supportiveness leads to better treatment de-cisions, or any number of positive behaviors,which then lead to better long-term outcomes.The researchers typically offer no explanationof how factors such as perceptions of caring,emotional supportiveness, the physician’s per-sonal manner, communication skills or techni-cal skills produce beneficial outcomes. More-over, because these studies are largely correla-tional and rely almost entirely on patients’retrospective reports about how they receivedtheir diagnoses, the specific mechanisms aredifficult to pin down. Thus, we propose thatguiding recipients toward desired responsesrepresents the mechanism by which news-givers can promote positive long-term out-comes.

The medical literature supports the goal ofguiding patients toward the best course of actionduring bad news communications. A number ofphysicians note that patients want to focus onthe future, toward treatment and long-term out-comes, rather than just on the diagnosis (Back& Curtis, 2002; Baile & Aaron, 2005; Baile etal., 2000; Bor et al., 1993). Other physiciansdescribe methods for giving bad news with thestated purpose of improving coping and deci-sion-making (Boyd, 2001; Clayton et al., 2005;Epstein, Alper, & Quill, 2004; Fogarty et al.,1999; Lalos, 1999). Finally, several physiciansdiscuss various possible responses to bad newsand the outcomes of engaging in different re-sponses (De Haes & Koedoot, 2003; Greer etal., 1979).

The goal of guiding recipients toward themost effective responses prompts two ques-tions. First, what are the different ways peoplecan respond to bad news? Second, which re-sponses should bad news-givers suggest? Wedeveloped the Bad News Response Model toanswer these two questions. We propose that allresponses to bad news fall into one of fourcategories: Watchful Waiting, Active Change,Acceptance, and Non-Responding. We furthersuggest that three factors of the outcomes of bad

news (controllability, likelihood, and severity)indicate which response is likely to be effective(see Figure 1).

The Bad News Response Model

The Bad News Response Model suggests thatgiving bad news well involves guiding news-recipients toward a desired response. Thus, themodel is aimed both at the person who mustgive bad news and at the recipient of the news.Ultimately, the goal of the Bad News ResponseModel is to elicit a desired response from therecipient of bad news, but bad news-givers mustevaluate the characteristics of the possible badoutcome that determine what the desired re-sponse should be. Bad news-givers can thentailor their communication of bad news to en-courage the desired response from the recipient.In addition, recipients of bad news can individ-ually evaluate their situation and determine themost effective response to the news. It is im-portant to note that the Bad News ResponseModel does not attempt to precisely predict theresponse that will lead to the best quality of life.The model provides guidance for bad news-givers as to which responses may be best underdifferent circumstances, but the model ad-dresses a wide spectrum of bad news and mustmake generalizations based on situational fac-tors. Bad news-givers and recipients shouldchoose the response that is most likely to resultin the best outcomes, given their assessment ofthe situational factors.

In addition, the Bad News Response Modelfocuses on what lies in the future as a result ofthe bad news and not on the event that haspassed. The model addresses responses to badnews and the outcomes of those responses onthe future. Thus, the situational factors in themodel do not pertain to the event that is beingdisclosed, but rather to the possible results ofthat event. These results include both directoutcomes of the bad news and indirect effects ofthe news on other parts of life. For example, aprofessor who must tell a student about a failingexam grade (the past event) should consider theimpact of that exam on the student’s final gradein the course (a direct future outcome) and onthe student’s overall academic status (an indi-rect future outcome) when determining the beststrategy for bad news transmission.


How Can People Respond to Bad News?

The Bad News Response Model suggests thatpeople can respond to bad news in one of fourways: (a) Watchful Waiting, (b) Active Change,(c) Acceptance, and (d) Nonresponding. Theseresponse categories broadly apply to manykinds of bad news, although the specific natureof each response may differ across domains. Forexample, a patient who responds to a diagnosisof cancer with Active Change will engage indifferent specific behaviors than will a studentwho responds to a failed exam with ActiveChange. However, we suggest that these tworesponses will be similar in fundamental ways.

As evident in Table 1, we anticipate that thefour response categories will each elicit aunique pattern of characteristics in terms ofanxiety, affect and activity level. Anxiety levelrefers to feelings of worry, concern, or fear.Affect refers to general positive or negativemoods and emotions, such as happiness or sad-ness. Activity level refers to the extent to whichenergy is directed toward changing the out-comes of the bad news. Of note, the character-istics described may be present with all fourresponses to varying degrees, but we suggestthat they are more likely to occur with theirrespective response.

The characteristics in Table 1 may be causes,consequences, or concomitants of each responsechoice. For example, people who experiencehigh levels of anxiety in response to bad newsmay be more likely to see the need to takeaction, in which case anxiety serves as a cause.However, people may also deliberately chooseto respond to bad news in a certain way, whichcan then lead to a variety of consequentialthoughts and feelings. Finally, certain kinds ofbad news may prompt both a particular responseand particular thoughts and feelings indepen-dently. Within the present model, we simplydiscuss the dimensions in Table 1 as character-izing a given response category.

Figure 1. The Bad News Response Model.

Table 1Characteristics of the Three Response Categories

WatchfulWaiting

ActiveChange Acceptance Nonresponding

Anxiety Low High Moderate LowPositive

affect Moderate Low Low HighNegative

affect Low High High LowActivity

level Low High Moderate Low


Watchful Waiting. The first category repre-sents a relatively passive form of responding.The medical literature has employed the term“watchful waiting” as a specific contrast to ag-gressive treatment options (e.g., De Haes &Koedoot, 2003). Here, Watchful Waiting indi-cates a more general “wait and see” mentalityregarding the bad news. The term “watchful”emphasizes that people engaged in this responseare aware that they are facing a possible threatand are vigilant to changes in their situation.However, they maintain the status quo ratherthan take action. To illustrate, consider a mandiagnosed with prostate cancer. The man is inhis late 80s, a widower, and has few financialresponsibilities. Although this man registers andaccepts his diagnosis of cancer, he may choosenot to get a second opinion or undergo treatmentbut instead go on with his life largely as ifnothing had changed. He may make annual ap-pointments to reassess his response, but other-wise his life remains as it was before his diag-nosis.

Watchful Waiting bears similarity to the gen-eral conceptualization of emotion-focused cop-ing (Folkman & Lazarus, 1980), although thespecific characterization of emotion-focusedcoping differs widely between studies (Carver,Scheier, & Weintraub, 1989). The similarityresides in the fact that both Watchful Waitingand emotion-focused coping focus on distrac-tion and emotional regulation. Emotion-focusedcoping entails to directing energy toward man-aging anxiety and other negative emotions aris-ing from a stressful situation rather than engag-ing in active intervention. People in the Watch-ful Waiting category may engage in activitiesthat distract them from the bad news. Behaviorsthat are designed to take one’s mind off of athreat may be beneficial if no actions will makea difference, or if action would be too costly orif dwelling on the threat is counterproductive(Lazarus, 1985).

However, Watchful Waiting differs fromemotion-focused coping in a fundamental way.Emotion-focused coping is not mutually exclu-sive with other more active forms of respond-ing, and in fact, people may engage in emotion-focused coping in all four-response categoriesof the Bad News Response Model. Emotion-focused coping complements all forms of re-sponding by reducing the intensity of stressfulemotions and allowing people to gain perspec-

tive on their situation (Folkman & Lazarus,1980). In contrast, Watchful Waiting involves aspecific set of behaviors and emotions that rep-resent one way of responding to bad news.

It seems likely that Watchful Waiting in-volves low anxiety, high general positive affect,and low activity level. Each of these character-istics results from distraction from the bad newsand attention toward other, presumably positiveaspects of life. Excessive focus on the bad newswould increase anxious thoughts and feelings,induce sadness and distress, and lead to highactivity levels in an effort to mobilize actiontoward change. People engaged in WatchfulWaiting avoid this process by distracting them-selves from the bad news.

Active Change. Active Change representsthe most vigorous, engaged form of responding.Unlike the distraction or irrelevant activity char-acterizing Watchful Waiting, Active Change in-volves specific responses directed toward ad-dressing the bad news. Active Change alignsmost clearly with traditional views of produc-tive coping strategies, such as problem-focusedcoping, that directly address the negative situa-tion. Problem-focused coping in part involvestaking action to solve a problem or change anegative situation (Carver et al., 1989; Folkman& Lazarus, 1980, 1985).

Active Change includes three types of behav-ior: information seeking, prevention, and treat-ment. Information seeking serves two purposes.First, information seeking provides recipients ofbad news with the information they need tomake decisions about how to respond. Second,information seeking serves to connect recipientswith others who have dealt with similar expe-riences and provides a network of support. Ofnote, other researchers have discussed theseroles of information seeking as part of problem-focused or active coping (Aldwin & Revenson,1987; Lazarus, 1981; Lazarus & Launier, 1978).

The terms “prevention” and “treatment” havemedical connotations, but in this context theybroadly refer to behaviors directed toward pre-venting the situation from deteriorating (main-tenance) and treating an undesirable situationthat has emerged (improvement). To illustrate,consider a different man diagnosed with pros-tate cancer. This man is in his late 40s, has awife and several children, and is the primarybreadwinner for the family. Unlike the man inhis 80s who chooses Watchful Waiting, the


second man may be very willing to undergochemotherapy and radiation in hopes that it willeradicate the cancer and allow him to live a fulland long life with his family. He should activelyinvestigate his condition, perhaps seeking a sec-ond opinion or researching prostate cancer on-line or at the library, and undergo preventativeand/or aggressive measures to prolong his life.Active Change also involves high anxiety andhigh activity levels. The high levels of anxietyresult from acknowledgment that a negativeevent is likely to occur and/or that the conse-quences are severe. The high activity levelsresults from mobilization of energy toward ac-tive responses.

Acceptance. Acceptance is the third andmost complex form of responding. This re-sponse is similar to previous conceptualizationsof acceptance in the literatures on aging, dis-ability, and death. Previous theories discuss ac-ceptance as a last stage in coping with loss orimpending death that comes after a process ofdenial (Gamliel, 2000; Kubler-Ross, 1969).Many theorists assert that acceptance is a posi-tive coping strategy in uncontrollable circum-stances. People who come to accept their cir-cumstances are able to seek meaning in theirloss, reduce their dread over what lies ahead,and seek social support to cope (Gamliel, 2000).On the other hand, other researchers have foundlittle support for the assertion that acceptance isan adaptive coping strategy, and some studieseven suggest that realistic acceptance might bepredictive of negative outcomes (Greer et al.,1979; Reed, Kemeny, Taylor, Wang, & Visscher,1994; Wortman & Silver, 1989).

We view Acceptance as action toward accep-tance rather than passive resignation. Peoplewho respond to bad news with Acceptance donot necessarily collapse in a heap, although thisresponse may be unavoidable at first. Instead,they eventually direct their energy toward mov-ing forward and addressing any consequencesof the bad news. Acceptance involves lookingbeyond the negative outcomes to the possibilityfor hope that lies in the future. Even in the caseof imminent death, people can find hope inliving life to the fullest during their remainingtime and dying with dignity (Dean, 2002). Al-though this response is similar in many ways toprevious conceptualizations of acceptance, itavoids the sense of passivity and hopelessnessthat may lead to negative outcomes. In addition,

Acceptance is not a final, static state of resig-nation; instead, it involves an ongoing positiveprocess of making the best of a bad situation.

Acceptance combines aspects of WatchfulWaiting and Active Change to most effectivelyaddress situations in which a lack of engage-ment is inappropriate yet the person cannotchange the outcome. People can direct theirenergy toward changing their lives rather thanchanging the negative event. This responsebears similarity to the concept of secondarycontrol, in which people change themselves tofit a situation rather than changing the situationto fit the self (i.e., primary control) (Rothbaum,Weisz, & Snyder, 1982). Secondary control rep-resents an important form of control over one’semotional responses, but it does not involveengaging effort toward changing the situation.

Acceptance involves two types of behavior:information sharing and accommodation. Infor-mation sharing involves telling others about thenegative event, although the extent of sharingwith others may vary depending on the news.For example, certain types of bad news, such astesting HIV-positive, may stigmatize the indi-vidual, and people may want to limit their in-formation sharing to close friends and family.Furthermore, the effectiveness of informationsharing depends in part on the receptiveness ofthe listener (Harber & Pennebaker, 1992; Kelly& McKillop, 1996).

Information-sharing serves three purposes.First, information sharing helps people acceptthe negative event by making the event part oftheir social reality. People who keep negativeevents, such as a disease or a job loss, a secretfrom friends and family may be in denial thatthe event has occurred. Information sharing isboth a step toward acceptance and a sign thatsuch acceptance has begun. Second, informa-tion sharing elicits social support from friendsand family. Researchers have distinguished be-tween seeking social support for emotional rea-sons versus seeking social support for practicalreasons (advice, assistance, etc.) (Carver et al.,1989). Acceptance focuses more on the emo-tional side of social support, rather than the moreactive, change-focused practical side. Third, infor-mation sharing seems to serve an important func-tion in an end unto itself (Pennebaker, 1988;Pennebaker, Zech, & Rime, 2001). Research findsthat people who talk (or write) more about atraumatic event ruminate less (Pennebaker &


O’Heeron, 1984), experience less anxiety(Pennebaker, Colder, & Sharp, 1990), havefewer negative health outcomes (Pennebaker &O’Heeron, 1984), and have better quality of life(Spera, Buhrfeind, & Pennebaker, 1994), evenwhen the expressions are private.

Accommodation involves making changes,not to affect the news-specific outcome, butrather to incorporate the negative event intoone’s life. When a negative outcome is uncon-trollable, accommodation focuses people’s en-ergy on productive activity rather than futileefforts to change the outcome. For example, inmost cases a woman who receives a rejectionletter from her first choice graduate schoolshould consider alternative schools or careerplans rather than continuing to pursue admis-sion at the school that rejected her. Accommo-dation often involves behavioral changes suchas cutting back on strenuous activities in thecase of a debilitating disease or putting away alost loved one’s personal items in the case of adeath in the family. It often also involves cog-nitive changes that entail looking for reasonswhy the tragedy occurred (sense making) andfocusing on positive changes resulting fromthe tragedy (benefit finding) (Davis, Nolen-Hoeksema, & Larson, 1998; Rabow & McPhee,1999). Of note, other researchers have used theterm accommodation differently, referring to apassive means of coping with old age that in-volves weakened aspirations and lowered stan-dards of living (Brandtstadter, Dirk, & Werner,1993). Here, we use accommodation to refer toan active process of reordering priorities andadjusting to the new situation.

In addition, the response of Acceptance in-volves general negative affect (including sad-ness, regret, guilt, etc.) and moderate activitylevel. People are likely to experience particu-larly negative feelings when a severe negativeevent occurs and they are helpless to change theoutcomes. The specific types of negative affectpeople experience depend on the details of thebad news. For example, people may feel guiltand regret when they feel that they could havechanged the outcome, as in the case of failing aclass, but people are more likely to experiencesadness and grief when they believe they couldnot have changed the outcome, as in the case ofan unavoidable death. Regarding activity level,Acceptance does not involve the same level of

energy mobilization as Active Change, butsome effort is required to adapt to the negativeevent. People must direct their energy towardunderstanding and accepting the situation cre-ated by the bad news and dealing with theconsequences, rather than taking active stepstoward making significant life changes in aneffort to change the outcomes of the bad news.

Nonresponding. The fourth category of re-sponding captures a number of responses.Lubinsky (1994) distinguishes between fourforms of nonresponding: denial, disbelief, de-ferral, and dismissal. Although the four mayappear similar, their sources differ. Denial isform of repression brought on as a defensemechanism. It involves vehement disagreementwith any disliked information, even when evi-dence makes it clear that the information iscorrect, and is a relatively rare response to badnews. Disbelief is marked by confusion ratherthan rejection of bad news and may result froma desire to maintain hope for longer than iswarranted. Deferral is marked by avoidance ofinformation about bad news as a result of inad-equate resources to cope with the situation. Peo-ple responding with deferral may accept thebasis for bad news (e.g., results of a medicaltest) but reject or ignore the implications ofthose findings (i.e., the necessity of lifestylechanges or treatment). Finally, dismissal ismarked by anger at the bad news-giver anddenial of the news-giver’s competence or legit-imacy. These four reactions, though different insignificant ways, all fall into the response cate-gory of Nonresponding.

Nonresponding is distinct from WatchfulWaiting. Nonresponding is not an attempt toreduce anxiety about bad news while acknowl-edging it, but rather an attempt to pretend noth-ing has happened or “wish away” the bad news.Furthermore, Nonresponding may be mostlikely to occur in situations when Acceptance iscalled for. Both Watchful Waiting and ActiveChange are somewhat attractive responses: oneallows people to monitor the news and deferaction until it is appropriate, and the other in-volves taking action to change things for thebetter (De Haes & Koedoot, 2003). Acceptance,in contrast, requires people to face the newshead-on and does not offer the hope that thingswill turn out well. Although Acceptance is nec-essary when a very bad outcome is unavoidable,


people may prefer to embrace Nonrespondinginstead. Nonresponding can feel good for ashort time because it allows people to pretendthat nothing has changed for the worse, butpeople eventually must face negative outcomes,such as the death of a loved one or a terminalillness, and cope with the consequences.

On the other hand, nonresponding may be anacceptable response in the short-term. A num-ber of researchers and physicians note that de-nial is a necessary response for some peopleunder certain circumstances, and a number oftheorists have argued that news-givers shouldnot force recipients to face bad news before theyare ready (Bor et al., 1993; Faulkner, 1998;Greer et al., 1979; Radziewicz & Baile, 2001).As indicated in Figure 1, the Bad News Re-sponse Model indicates that Nonresponding is alegitimate but generally undesired response.News-givers may recognize that recipients arelikely to engage in nonresponding at first, butthe Bad News Response Model suggests that thegoal of the news-giver is to guide people towardthe response that will lead to the best long-termoutcomes. Although Nonresponding may befunctional at first, people must eventually facebad news and choose a different response.

How can people respond? Summary and con-clusions. The Bad News Response Modelsuggests that people can respond to bad news inone of four ways: (a) Watchful Waiting, (b)Active Change, (c) Acceptance, and (d) Nonre-sponding. Watchful Waiting represents a rela-tively inactive response characterized by dis-traction activities and managing anxiety. ActiveChange is a highly active response primarilycharacterized by direct attempts to change thesituation. Acceptance involves activity directedtoward changing one’s life to incorporate badnews rather than attempting to change the out-comes of the news. Nonresponding involvesunproductive (at least in the long-term) avoid-ance or denial of bad news.

Although, thus far, we have discussed thefour response categories as though they weremutually exclusive and as though selecting oneresponse means rejecting other responses, peo-ple may display (or appear to display) multipleresponses. Multiple responding can manifest inseveral ways. First, people may engage in mul-tiple responses simultaneously. By so doing,people hedge their bets by putting some efforttoward one response (e.g., trusting that things

will go well, as in Watchful Waiting) while alsorecognizing and preparing for alternative possi-bilities (e.g., by taking measures to encourage apositive outcome, as in Active Change). Forexample, someone who learns of upcoming lay-offs can engage in Watchful Waiting by delay-ing the search for a new job while also engagingin Active Change by delaying large purchases.This form of multiple responding recognizesthat the future is uncertain and that what aperson expects to occur may not occur. AsMohammed, the Muslim spiritual leader said,“trust in God, but tie your camel first” (Cleary,2001).

People who seem to be engaging in multiple,simultaneous responses may also be respondingto multiple levels of abstraction of the badnews. A single news event may include morethan one form of bad news. A young man wholearns that he failed a major project in a classrelevant to a desired career has essentially re-ceived two pieces of news. First, he must dealwith the possibility that he will fail the course.Second, he must deal with the implications ofhis failure on his qualifications to enter hisdesired career. He may respond with ActiveChange in regards to his course grade whilesimultaneously responding with Acceptance inregards to his career path. Alternatively, he mayrespond with Acceptance in regards to hiscourse grade but take active measures to ensurethat he performs well on other career-relevantcriteria.

Finally, people may respond in differentways to one situation across time. For example,imagine that a physician finds a lump in a pa-tient’s breast. The physician may initially en-courage Watchful Waiting, suggesting that thepatient proceed with life as usual until the bi-opsy results come in. If the biopsy reveals ma-lignancy, the physician might then recommendActive Change. Finally, if subsequent tests re-veal that the cancer is resistant to treatment, thephysician may suggest Acceptance. Thus, onebroad situation may involve multiple newsevents, therefore allowing for the possibility ofmultiple responses. The Bad News ResponseModel can account for longitudinal events ifnews-givers and recipients reevaluate the situa-tion at each point when new information isavailable (see Figure 1).


Which Responses Should News-GiversSuggest?

The Bad News Model suggests that badnews-givers should guide recipients toward de-sired responses; the model does not attempt topredict with certainty the best responses to badnews. The model ultimately relies on news-givers to determine the response that will lead tothe best outcomes for recipients and then guidethe recipients toward that response. However,bad news varies on a number of predictabledimensions, and research suggests that certaindimensions may lead one response to be moreeffective than others, depending on the situa-tion. Specifically, examination of the vast liter-ature on risk perception, health behavior, andcoping reveals three factors that repeatedlyemerge as playing a particularly important rolein people’s responses to the possibility of badnews and other stressful situations: the control-lability of negative outcomes, the likelihood ofnegative outcomes, and the severity of negativeoutcomes.

Table 2 presents a summary of the responsesthat may be most effective for each combinationof high and low controllability, likelihood, andseverity. These suggestions represent the re-sponses that seem most likely to be effectiveunder different circumstances, in light of exist-ing research on both responses to bad news andsituational factors of the news. In general, wesuggest that people should engage in ActiveChange when two or three of the situationalfactors are high (high control, high likelihood,and/or high severity) and Watchful Waitingwhen two or three of the situational factors arelow (low control, low likelihood, and/or lowseverity). The only exception occurs when like-lihood and severity are high but control is low.Under these circumstances, when severe nega-

tive outcomes are highly likely and little ornothing can be done to change the outcomes, wesuggest that Acceptance is the best response.

It is noteworthy that perceptions of control-lability, likelihood, and severity are somewhatsubjective. Numerous studies demonstrate thatpeople often function under an illusion of con-trol when, in fact, chance determines their fate(Crocker, 1982; Langer, 1975; Langer & Roth,1975). In addition, people misperceive the like-lihood of events because of 64 misunderstand-ings of objective probabilities (Kahneman &Tversky, 1982; Tversky & Kahneman, 1974),undue focus on salient examples (MacLeod &Campbell, 1992; Slovic, Fischoff, & Lichtenstein,1982), and a desire to avoid disappointment orregret (Carroll, Sweeny, & Shepperd, 2006;Sweeny & Shepperd, 2007). Finally, people oftenbase their perceptions of severity on misleadinginformation, such as prevalence, personal rele-vance, or illness stereotypes (Croyle & Williams,1991; Jemmott, Ditto, & Croyle, 1986). Oneprominent model of coping suggests that peopleengage in an appraisal process to determinewhether a stressful situation demands coping re-sources (Folkman & Lazarus, 1980; Lazarus,1966; Lazarus & Folkman, 1984), and this ap-praisal process is subject to the many biases thatcolor judgments. Thus, news-recipients undoubt-edly choose responses that reflect misperceptionsof bad news.

Although people’s natural responses may bebiased, the most effective response to bad newsdepends more on the actual controllability, like-lihood, and severity of potential negative out-comes than on subjective perceptions of thesefactors. For example, a patient who misper-ceives the severity of his or her condition be-cause of lack of knowledge or inaccurate un-derstanding will not benefit from, and may evenbe hurt by, pursuing treatment based on thismisperception. The purpose of this section is todiscuss situational factors that may predict theeffectiveness of responses to bad news. As such,objective levels of controllability, likelihood,and severity are more important for our pur-poses than subjective appraisals of these factorsby news-recipients.

Controllability. The first factor that may in-fluence effective responding to bad news is thecontrollability of the negative outcomes thatmay result from bad news. The ability to controlthe outcomes of bad news varies greatly across

Table 2Impact of Situational Factors on Responding

Low likelihood High likelihood

Low severityLow control Watchful Waiting Watchful WaitingHigh control Watchful Waiting Active Change

High severityLow control Watchful Waiting AcceptanceHigh control Active Change Active Change


different situations. For example, a student whodiscovers he or she is failing a course severalweeks before the semester’s end may be able toimprove his or her grade by completing extracredit assignments, getting help from the pro-fessor, or studying long and hard for the finalexam. However, as the semester draws to aclose, control over the course grade diminishes,and once final course grades are turned in, theremay be no remaining avenues to affect the out-come of the course.

Controllability plays a significant role in pre-dicting people’s responses to threat. The HealthBelief Model (Becker, 1974; Janz & Becker,1984; Kirscht, 1988) and Protection MotivationTheory (Floyd, Prentice-Dunn, & Rogers, 2000;Maddux & Rogers, 1983; Rogers, 1983) includemeasures of controllability (response efficacyand/or self-efficacy) as factors that predictwhether people engage in preventative healthbehaviors, and the proactive coping model(Aspinwall & Taylor, 1997) indicates that per-ceived control plays a role in people’s attemptsto prevent negative events. Research on copingshows that the controllability of a stressful sit-uation affects the strategies people choose toadopt when coping with stressful situations(Folkman & Lazarus, 1980). When people per-ceive event controllability to be high, they tendto adopt active coping strategies; when peopleperceive event controllability to be low, theytend to adopt strategies directed toward manag-ing their emotions (Aldwin, 1991; Carver,Scheier, & Weintraub, 1989). Other studies findthat the effectiveness of various coping strate-gies depends in large part on the controllabilityof the stressful situation, with active strategiesproving most beneficial when the situation iscontrollable (Aldwin & Park, 2004; Park, 2001;Park, Armeli, & Tennen, 2004).

Likelihood. The second factor in determin-ing the appropriate response to bad news is thelikelihood of possible negative outcomes. Badnews does not always indicate a guaranteednegative outcome. For example, a boss mayhave to inform employees that the companymust downsize without knowing who will losetheir jobs. Physicians frequently give bad newsthat indicates the possibility of illness or injurybased on initial evidence without the ability todiagnose a problem with complete certainty.

For the purposes of the model, “likelihood”refers to how likely negative outcomes are to

occur if the news recipient does not act to pre-vent them. For example, the likelihood that asuspicious lump indicates cancer should beevaluated irrespective of treatment options orthe patient’s intentions to seek treatment. Assuch, likelihood is distinct from controllability.People may reduce the likelihood of negativeoutcomes by their response to bad news, but theinitial evaluation of likelihood is separate fromcontrollability.

Likelihood influences responding in twoways. First, and most intuitive, people considerthe likelihood of a negative outcome in weigh-ing the costs and benefits of an effortful andcostly response. Several models include likeli-hood (or perceived vulnerability) as a predictorof health behavior (Becker, 1974; Rogers,1983) and preventative behavior in general (seeTheory of Reasoned Action, Ajzen & Fishbein,1980; and Subjective Expected Utility Theory,Edwards, 1954).

Second, and less intuitive, the initial percep-tion of likelihood of a negative outcome influ-ences later affective reactions should the worstactually occur. Expectations about future out-comes play a role in how bad a bad outcomefeels. Negative outcomes are unpleasant in theirown right, but they are particularly unpleasantwhen they are unexpected (Shepperd & McNulty,2002; van Dijk & van der Pligt, 1997). Peoplewho respond as if a negative outcome is unlikelyto occur may have a particularly unpleasant expe-rience if the outcome does occur, more so than ifthey had expected the worst. This finding suggeststhat people may benefit not only in terms of literalpreparation, but also in terms of affective prepa-ration by engaging in responses that are moreactive if the negative outcome is likely to occur.

Severity. The third factor in determining theappropriate response to bad news is the severityof the possible negative event. Bad news variesin terms of how important or consequential thepossible negative outcome is. Clearly, a womanwho learns that she is at risk for heartburn ishearing very different news than a woman wholearns that she is at risk for a heart attack, andboth the news-giver and the recipient of thenews should proceed differently in these twosituations. Of course, even news that has rela-tively nonsevere consequences can be bad. Thewoman who learns she has a high risk for heart-burn may have to make significant dietary andother lifestyle changes. However, her response


will differ in many ways from the woman learn-ing of her risk for heart attack, and the peoplegiving the news to these women should alsoproceed differently.

The consequences or severity of bad newsmay differ based on a characteristic of the out-come (e.g., financial impact, life expectancy,effect on emotional well-being) or characteris-tics of the individual. The earlier examples ofthe two men diagnosed with prostate cancerillustrate how characteristics of the individualsuch as age, family circumstances, financial sta-bility, and responsibilities can influence theconsequences of bad news.

People naturally account for the severity ofpotential negative outcomes when they antici-pate and respond to bad news. The severity ofpotential health outcomes predict whether peo-ple will engage in preventative health behavior(Becker, 1974; Rogers, 1983), and research oncoping finds that people choose active copingstrategies when they judge the event to behighly stressful or important (Anderson, 1977;Parkes, 1986; Terry, 1991). In addition, re-search on bracing for bad news finds that peopleonly embrace a negative outlook for outcomesor consequences that are important (Shepperd,Findley-Klein, Kwavnick, Walker, & Perez,2000). People brace less for outcomes that areunimportant because such outcomes are lessconsequential for them. For example, partici-pants in one study who anticipated soon learn-ing their test results for a medical conditionshifted from optimism in their risk estimatesonly when the consequences of testing positivewere severe. If the consequences were not se-vere, their predictions remained unchanged(Taylor & Shepperd, 1998). If possible negativeoutcomes are inconsequential or nonsevere,news-recipients gain more from choosing rela-tively passive responses (Watchful Waiting)than from engaging in physically or emotionallyactive responses (Active Change or Accep-tance).

Communicating Desired Responses

Although the goal of the Bad News ResponseModel is not to elucidate specific details of thecommunication of bad news, the model sug-gests that the bad news-giver direct the recipienttoward desired responses and offers insightsinto which responses may be most effective in

different situations. The direction on behalf ofthe bad news-giver can encourage people torespond in the most effective way even in theface of problems with comprehension, arousal,education, and so forth

When preparing to give bad news, the com-municator can evaluate the news situation interms of the likelihood, severity, and controlla-bility of negative outcomes and direct the com-munication toward encouraging the recipient toengage in the response that is most likely to beeffective. The details of such direction will dif-fer greatly depending on the specific topic andnature of the bad news, but these broad gener-alizations should be effective across a variety ofdomains and situations. It is important to notethat the Bad News Response Model does notrecommend that bad news-givers manipulatethe recipient into responding in a particular wayusing whatever means necessary. Rather, news-givers should present all possible responses andthe costs and benefits of each, and then givetheir opinion regarding the best possible re-sponse (Epstein, Alper, & Quill, 2006).

At first glance, the suggestion that news-givers should evaluate multiple aspects of therecipient’s situation to give the bad news in thebest way may seem impractical. In many cases,news-givers may know little about the recipientor the circumstances surrounding the bad newsthey must disclose. However, the model’s sug-gestions represent an improvement over leavingbad news-givers to their own devices. News-givers who attempt to evaluate the bad news andguide recipients toward responses that are mostlikely to be effective, as suggested by the BadNews Response Model, will likely do a greaterservice for the recipients than would a news-giver with little or no guidance. Without guid-ance, news-givers often fall victim to personalconcerns, such as not wanting to upset the re-cipient or be blamed for the news, that oftentrump concern for the best interest of the recip-ient (Buckman, 1984). Furthermore, recipientsof bad news can use the model to evaluate theirnews and choose the best response when thenews-giver is unable to guide them appropri-ately.

Summary, Critique, and Future Directions

The medical literature suggests a number ofgoals to help people give bad news well: new-


givers should reduce their own discomfort, pro-vide sufficient information, promote recipientsatisfaction, improve memory and understand-ing, reduce recipients’ distress, and promotehope. However, none of these goals providessufficient information or a broad enough objec-tive to adequately guide people in giving badnews. We propose that giving bad news wellshould instead be defined as guiding news-recipients toward desired responses—responsesthat news-givers believe will result in the bestlong-term outcomes for recipients. The BadNews Response Model suggests that news-givers can look to situational factors (controlla-bility, likelihood, and severity) to determinewhich of three responses (Watchful Waiting,Active Change, and Acceptance) is most likelyto be effective.

Strengths of the Model

The Bad News Response Model has a num-ber of strengths that improve previous attemptsin the medical literature to study the processesof giving bad news. First, the model is applica-ble to a broad set of situations and domains,including academic performance, professionalnews, interpersonal news, medical diagnoses,and news of death, among others. Second, themodel addresses the roles of both the bad news-giver and the recipient of the news by makingsuggestions for transmission based on the de-sired response. Third, the model systematicallyaddresses different types of bad news in termsof the likelihood, severity, and controllability ofpossible negative outcomes of the news. Al-though the model draws on the strengths ofprevious research, it represents the first compre-hensive model of giving and responding to badnews.

The Bad News Response Model can serveseveral important purposes. First, the model canassist bad news-givers who otherwise must relyon their own limited experience or personalmotivations when giving bad news. The BadNews Response Model provides a goal for badnews transmission that can reduce the impact ofthe news-giver’s concerns on their news-givingstrategies by guiding them toward recipient-focused strategies.

Second, bad news-givers can use the modelto evaluate their transmission of news after thefact. If news-givers observe recipients making

an undesired response, they can examine theirtransmission strategy in light of the model. Thenews-giver may have incorrectly assessed oneor more of the situational factors, or the sugges-tion of the best response may have been inef-fective. For example, physicians may be un-aware of their patients’ financial circumstances,and this lack of information could result inmisjudgment of the severity and/or controllabil-ity of patients’ medical conditions. Physiciansmight assume that expensive treatments are fea-sible when in fact the patient does not haveinsurance or the means to pay for the treat-ments, making the prognosis relatively uncon-trollable. Even when physicians perfectly assessthe situational factors, patients often mishear orforget information conveyed in a diagnosticcommunication (Croyle, Loftus, Klinger, &Smith, 1993). The best efforts of news-givers toprompt desired responding can be lost if therecipient tunes out the transmission. Bad news-givers who notice seemingly ineffective re-sponding by recipients can seek additional in-formation to better judge the situational factorsor reevaluate the bad news transmission forsigns of lack of attention or misunderstandingon the part of the recipient.

Third, bad news recipients can use the modelto evaluate their responses to bad news, apartfrom the giver. After receiving bad news, recip-ients can use the model to determine the mostappropriate response by evaluating the likeli-hood, severity, and controllability of the possi-ble outcomes. For example, a woman wholearns of upcoming layoffs at work can considerthe likelihood that she will lose her job, howbad the consequences of a job loss would be,and if she has control over whether she is laidoff. Having evaluated the situation, she mayhave a better sense of the most effective re-sponse. This process may help people to over-ride responses based solely on anxiety or fear.In addition, recipients who find that their re-sponse to some news is ineffective can reexam-ine the situational factors involved and possiblyadjust their responses accordingly. If thewoman facing a possible job loss responds withActive Change and then finds that she is makingno progress toward keeping her job, she maydecide to shift toward Acceptance by checkingthe want ads and telling her family about thelayoffs.


Limitations of the Model

Although the Bad News Response Model isbased on research from psychology, medicineand health, the model is largely speculative andremains untested. In addition, the model makesbroad suggestions to allow the greatest breadthof application. This focus on the functionality ofthe model leads to an emphasis on generalityover detail. As a result, the Bad News Responsemodel may be imperfect in certain specific sit-uations, while making suggestions that lead tothe best outcomes overall. People often makemiracle recoveries from medical conditions thatwere, by all accounts, beyond hope. Althoughthe model would recommend Acceptance inthese cases, people can choose to take risks andpursue unlikely cures in hopes of such a mira-cle. However, the model plays the odds bysuggesting the response that will most oftenresult in the best outcomes.

The model does not provide specific sugges-tions regarding how news-givers should com-municate their suggestion of the best responsein a way that insures recipients will respond asdesired. Other researchers have addressed tech-niques of news transmission in both the medicalliterature and in the literatures on persuasionand communication, but future research may berequired to determine the specific application ofthat research to the goal of guiding news-recipients toward desired responses. One strat-egy that may prove successful is for news-givers to help recipients reach accurate conclu-sions about the controllability, likelihood, andseverity of potential negative outcomes of badnews. The research reviewed earlier suggeststhat people naturally respond to bad news inlight of these situational factors, but their as-sessment of these factors may be inaccurate orbiased. News-givers can provide recipients withmore objective information about the bad news,thus making desired responding more likely.

Finally, the model does not specify preciselyhow people should evaluate the three situationalfactors, or how to determine whether the factorsare “high” or “low”. The situational factors fallon a continuum, and the distinction betweenhigh versus low is relative. For example, badnews that is low in severity may be significantlymore severe than neutral news, but it is low inseverity compared to other types of bad news.Research examining people’s perceptions of

various events, as well as the most effectiveresponses to these events, will address the ques-tion of how to evaluate the situational factors ofbad news.

Future Directions

The first step for future research is to test theeffectiveness of the Bad News Response Modelas a model for giving bad news well. Fourquestions deserve attention. First, are the fourresponses in the model exhaustive, or are thereother possible responses? Second, do the re-sponses suggested in the model, which derivefrom the three situational factors, produce thebest quality of life? Third, how do people nat-urally respond to bad news under various cir-cumstances, and can bad news-givers improvethe likelihood that people will make the desiredresponses? Fourth, how can news-givers bestguide recipients toward a desired response oncethe desired response is determined? The modelmakes predictions for each of these questions,and studies are currently underway to test thesepredictions.

A second direction for future research is toexamine the specific characteristics of the fourresponses to bad news. Table 1 makes predic-tions regarding the cognitive, emotional, andbehavioral characteristics of each response. Forexample, we suggest that Watchful Waiting ischaracterized by low anxiety, high general pos-itive affect, and low arousal. Studies examiningpeople’s emotional states and activity levelwhile engaging in Watchful Waiting, and like-wise Active Change and Acceptance, can exam-ine these characteristics.

A third area for future research is the influ-ence of individual differences on people’s re-sponses to bad news. The model attempts tomake predictions that generalize across peopleand circumstances. However, individual differ-ences may affect responding in two ways. First,individual differences likely affect people’s nat-ural responses to bad news. For example, self-efficacy could increase the likelihood of choos-ing Active Change over the other response cat-egories. Second, individual differences likelyinfluence both the actual and perceived experi-ences of the likelihood, severity, and controlla-bility of negative outcomes. The 80- and 40-year-old men with prostate cancer describedearlier provide one example of how differences


such as age, priorities, and resources affect thebest response to bad news. For example, thesame disease with the same prognosis has moresevere consequences for the man with respon-sibilities to his family than for the man with fewresponsibilities. Although the disease may beequally severe for the two men, the conse-quences of the disease on other areas of theirlives are likely to differ in severity.

Finally, future studies can examine the appli-cation of the Bad News Response Model todifferent cultures and developmental stages. Sev-eral studies find that people give medical badnews differently in different cultures (Searight &Gafford, 2005). For example, patients in Chinaoften receive less information about their diag-noses than patients in the United States (Tse,Chong, & Fok, 2003), and cancer patients inEngland report that their doctors used the word“cancer” much less frequently than patients inthe United States (Newall et al., 1987). Thesefindings suggest that the Bad News ResponseModel may apply across cultures, but it is pos-sible that cultural values and traditions mayaffect the way in which some aspects of themodel are applied. As such, culture may act asan individual difference variable that affectsnatural responses to bad news. For example,differences in personal agency between Easternand Western cultures may lead people to re-spond with Active Change more in the Westthan in the East, and this difference would affectthe ease with which news-givers are able toguide people toward the three responses in dif-ferent cultures.

Furthermore, although people of all ages re-ceive bad news, the cognitive and emotionalresponses of children are likely not comparableto those of late-adolescents or adults. Youngchildren and adolescents may have a difficulttime expressing complex emotional reactions andmaking complex decisions (Inhelder & Piaget,1958). The Bad News Response Model may beapplicable to all ages, but the nature of its appli-cability likely differs across developmental stages.For example, the model may apply better to theprimary caregiver than to the child diagnosed witha severe illness, or better to the adult child than tothe senile parent given news of failing health. TheBad News Response Model assumes that recipi-ents of bad news are in a position to choosebetween different possible responses. In the casesjust described, the family member, not the primary

recipient of the news, will make decisions abouttreatment options.

Coda

The medical literature provides many usefulsuggestions for giving bad news but falls shortof providing an overarching goal for bad news-givers. The Bad News Response Model repre-sents an improvement over the existing work ongiving bad news by providing a framework thatincludes all types of bad news, incorporates anumber of valuable goals for bad news trans-mission, and addresses the role of both thenews-giver and the recipient. A comprehensiveand systematic model of bad news transmissionbenefits not only people who must give badnews, but also those receiving the news. Peoplereceiving bad news must not only address thesubject of the news itself, but also their emo-tional reactions to the news. Poor coping canlead to depression, anxiety, and other mentalhealth concerns. The Bad News ResponseModel strives to provide bad news-givers thetools they need to improve the recipient’s abilityto respond effectively to the situation at hand.

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Received August 31, 2006Accepted December 20, 2006 �


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