Common Therapist Mistakes Part 9: Challenging Denial Prematurely

I have been writing blogs about common therapist mistakes and poking fun at us therapists to some degree. I want to point out that I intentionally use the word common in the title of this series because these mistakes are the kind that we all make. And we probably make them often. I know I have. These aren't fatal mistakes. They might slow the process some but generally won't stop it. The stories I tell in these posts are the times that I was mindful enough to avoid making the mistake. I think it helps to read about these common mistakes to keep them in the forefront of our minds so that we make them less often.

Shima was a new resident in a program for eating disorders and was joining a narrative group that I was leading. I asked her if she could identify with any of the beliefs listed on a worksheet we were using (see Appendix A in my book) and how this might relate to her eating disorder. She paused and said that she didn't think she had an eating disorder. By the way, did I mention that Shima was in a residential treatment program which specialized in eating disorders? She apparently was resisting the diagnosis, although it had been thoroughly explained to her. I just said, “Oh, okay. it must be kind of awkward being here, but okay” and moved on quickly to others in the group.

Other members began identifying beliefs that they had formed previously which they thought might be related to developing or maintaining their eating disorder. Shima then reported that she related to the belief that mistakes are fatal. I leaned over and muttered, as if for her ears only, “By the way, perfectionism is linked to developing eating disorders. Not with you I’m sure …just saying.” Smiling, she responded, “Yeah, just not with me.” Then she talked about how she had interpreted some of her parents' behaviors as implying that she needed to be perfect. She began to talk more about this with the group.

At the end of the group, She was talking about how her perfectionism might be linked to body image. I asked her if she was beginning to feel crazy yet, She replied that she kind of was, and I said with a big grin, “Then my job here is done.” She laughed, but then in all seriousness I assured her that as she continued in recovery, she would actually feel less crazy and begin to know why she was struggling with certain aspects of her life.

I could have responded to her first statement regarding not having an eating disorder by talking with her about her denial of her symptoms, which would have probably made her feel defensive. I would have wanted to point out that she was in a residential program for eating disorders and to explain to her that her insurance company must believe that she had an eating disorder or they wouldn't be covering her treatment. I could even go on and say that in fact, it must be a very serious eating disorder for the insurance company to authorize this level of care. Instead, I chose to be patient, wait for an opening, and then use humor. All of this was said with a playful smile, and she responded playfully as well.

Although humor can be powerful, it can also backfire. It is important when using any therapeutic strategy that it fits you as a person and that the client is likely to interpret it as humor. I think when using this strategy, you need to genuinely be feeling affection and acceptance toward the client, and, as with any strategy, you should always use it with specific intent. Humor can be very powerful in addressing denial and avoiding resistance when people are ambivalent about getting help.

My book A Clinician’s Guide to Pathological Ambivalence: How to Be on Your Client’s Side Without Taking a Side can teach you how to avoid this and other common therapeutic mistakes by developing skills to work directly on resolving ambivalence and rewriting old narratives. I would love to hear from you. Please scroll down to the bottom of this page (past the banner of recent posts) to leave a comment.