Coping with serious illness: Clinicians often are challenged when patients seem disconnected in their prognostic awareness. How should we talk to the patient with a prognosis of less than 6 months who tells us they don’t want to hear any bad news in one moment and expresses concern they will not live to see their infant daughter graduate in the next? Fast Fact #508 describes the ‘dual framework’ theory to explain how patients cope with serious illness.

What is the dual framework theory?  The dual framework (also termed double awareness, dual awareness, middle knowledge (1), or multiplicity of mind (2)) is a theory that explains how people cope with overwhelming existential information. It recognizes that people often display contradictory wishes or understandings without having to reconcile them. For patients with serious illness, these orientations (or ‘parts’ as referred to by the internal family systems model) include being engaged with living (including even wildly optimistic hopes for the future) and preparing for impending death (3). Patients may seem to shift back and forth from optimism and pessimism, or may feel the need to hold their hopes and realism in a balance (4). While not directly representative of the psychological experience of patients, visualizing a pendulum swinging between moments of hope and optimism and moments of worry and understanding is a way of conceptualizing what may seem to be rapid and contradictory shifts in orientation (5).

Clinical manifestations: Clinicians only observe a snapshot of the patient’s perspective. They are not privy to the entirety of a patient’s internal thought process and therefore a patient externally may appear to swing and land at any point on the pendulum’s trajectory at a given moment. While this may lead to confusion or concern about a patient’s illness understanding, experts believe this oscillation is healthy and part of a larger emotional regulation process that allows patients to titrate their exposure to their own mortality. As patients’ prognostic awareness develops (either naturally or with clinical guidance), there may be less shifting from extremes of optimism and pessimism. Eventually, a more reliable ability to hold a simultaneous focus on living with an awareness of dying may develop: “I know that I am going to die from this cancer. Until that happens, I want to make every day count (6).”

Practical guidance for implementing the dual framework: Clinicians can help patients cope with serious illness by exploring the various internal ‘parts’ that are revealed as a patient moves about the arc of the pendulum. By helping patients to understand and accept the desires and motivations of these ‘parts’ which arise due to the stress of the illness, a more organized sense of self in relation to the illness can develop. Getting data from other inter-disciplinary team members, family, or friends can allow clinicians to get a broader picture of these parts. When patients seem stuck in one ‘part’ or psychologically distressed, clinicians should seek help from colleagues with more robust training in mental health (e.g., social workers, psychologists, chaplains).

Guiding patients through hopes, worries, and parts: The first goal should be to build a trusting relationship with the patient and encourage them to be curious about their ‘parts’. Encouraging patients to suppress or ignore anxious or overly optimistic parts typically is not helpful. All parts are valid emotional responses and should be heard (2). See the table below for examples of ways to engage patients in a conversation of learning and exploration. 

The therapeutic value of acceptance: Clinicians should normalize mixed feelings: “It sounds like you have a lot of reasonable worries, and that some days you also feel happiness, such as when you are playing with your cats.” Once understood, strongly expressed ‘parts’ often make space for other perspectives, ultimately leading to a more integrated self-focused on living well, even while acknowledging impending death. Clinicians should recognize that mixed feelings often appear up till the time of death and can impact the way patients engage in complex, value-based medical decision-making. The adage ‘hope for the best, prepare for the worst’ is a shorthand for this complex internal process.

Conclusion:  The dual framework is a theoretical psychological concept to help us understand and attend to seemingly contradictory psychological needs of patients living with serious illness.

References 

1. Weisman AD. On dying and denying: A psychiatric study of terminality. New York, NY: Behavioral Publications; 1972.
2. Schwartz RC. Moving from acceptance toward transformation with Internal Family Systems Therapy (IFS). J Clin Psychol. 2013;69(8):805-16.
3. Colosimo K, Nissim R, Pos A, et al. “Double awareness” in psychotherapy for patients living with advanced cancer. Journal of Psychotherapy Integration; 2018.
4. Curtis J, Engelberg R, Young J, et al. An approach to understanding the interaction of hope and desire for explicit prognostic information among individuals with severe chronic obstructive pulmonary disease or advanced cancer. Journal of palliative medicine. 2008;11(4).
5. Jacobsen J, Jackson V, Greer J, Temel J. What’s in the syringe? : principles of early integrated palliative care. Oxford, UK: Oxford University Press; 2021.
6. Jacobsen J, Brenner K, Greer J, et al. When a Patient Is Reluctant To Talk About It: A Dual Framework To Focus on Living Well and Tolerate the Possibility of Dying. Journal of palliative medicine. 2018;21(3).

Author Affiliations: 1Icahn School of Medicine at Mount Sinai, New York, NY; 2Harvard Medical School, Boston MA.
Conflicts of Interests: Dr. Arnold is a board member of VitalTalk and an editor for Uptodate.
Version History:  Originally edited by Sean Marks MD; first electronically published in April 2025.