From One Therapist to Another
Updated: Aug 2, 2019
Common Expressions of Ambivalence in Psychotherapy Part 3: Denial
It can be hard to confront denial while maintaining rapport in psychotherapy. Denial is a powerful defense mechanism which is difficult to shift even in the face of overwhelming contradictory evidence. Anais Nin was a 20th century diarist. She began what became her life-long work of art in 1914 at the age of eleven and kept writing until her death 63 years later in 1977. She wrote that "We don't see things as they are, we see things as we are."
I remember watching my precious four year old son push down a little boy who was younger than he was. Even though I had seen exactly what happened, it just did not compute with how I thought about my son. I creatively came up with other explanations for what I had seen with my own two eyes. As I sat puzzling whether the younger boy might have slipped, my son pushed him down again. It then seemed to take forever for my brain to recognize what was actually happening so that I could intervene. I later realized that it had been denial in live and living color!
Denial is another potential indicator of ambivalence. As explained in the Stages of Change model (Prochaska, DiClemente & Norcross,1994), people are unable to change until two things happen: They reach a certain level of motivation and have enough confidence that they have what it takes to make the change. The precontemplation phase is one of denial. Until a person has become aware for himself that there are risks involved by not changing, he is unlikely to begin the process. The person may be ambivalent about even beginning the conversation if he is not personally invested.
"And the day came when the risk to remain tight in a bud
was more painful than the risk it took to blossom. Life is a process of becoming,
a combination of states
we have to go through.
Where people fail is that they wish
to elect a state and remain in it.
This is a kind of death." - Anais Nin
Shima was in a narrative group that I was leading. I asked her if she could identify with any of the beliefs listed on a worksheet that we were using to help identify false scripts in narratives (worksheet can be found in my book) and how it might relate to her eating disorder. She paused and said that she wasn’t sure that she had an eating disorder. Shima was in a residential program for the treatment of eating disorders and was resisting the diagnosis although it had been thoroughly explained to her. I just said. “Oh, okay,” and moved on. Later in the group, she related to a script that "mistakes are fatal". I leaned over and muttered, with a slight grin on my face, “By the way, perfectionism is linked to developing eating disorders. Not with you I’m sure...just saying.” Smiling, she responded, "Yeah, not with me.” Then she talked about how she had interpreted some of her parent’s behavior as implying that she needed to be perfect. She began to explore this. At the end of the group, I asked her if she was beginning to identify her crazy yet. She replied that she kind of was, and I said “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 that she made sense. I could have talked with her about her denial around her symptoms, which would have probably made her feel defensive. Instead I chose to use humor. All of this was said with a playful smile and she responded playfully as well.
When a client is expressing denial, it might be advantageous to ask
"Is there any small part of you that does see a need for change?", or
"What of percentage of yourself is committed to change and what percentage is fearful of change?"
If a person responds that even a very small part or percentage is ready to change then I take this as an opportunity to point out that the person is ambivalent. If a person can be helped to move from denial to even one percent ambivalent, you've got something to work with. The the ambivalence can be harnessed as an agent of change.
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 address this and other forms of ambivalence in psychotherapy 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.