Who's in Denial? The Patient or the Therapist?
The concept of denial is used by therapists to coerce patients.
Posted Jul 08, 2019
“Patient is still in denial about the extent and severity of his problems.”
“John is in denial about his addiction and the impact it has on everybody around him.”
“Patient won’t make progress in treatment until they give up their denial.”
"Denial: It's not just a river in Egypt..."
In 1997, a colleague of mine completed their dissertation, involving a fascinating evaluation of an episode of psychotherapy treatment, from both the patient and the therapist’s perspective. One component of that evaluation stayed with me and has influenced my entire view of psychotherapy. Specifically, there was one therapist’s description of a therapeutic interaction, where the therapist said: “I confronted the patient, and on the third time, we finally broke through his denial!” But, the patient’s description of the same interaction was telling: “He [the therapist] brought this thing up three times, and I finally just agreed with him, so we could move on.”
Denial is a psychological concept first proposed as defense mechanisms, by early psychodynamic theorists, such as Freud, who proposed that denial of difficult truths was a way in which a person’s ego protected itself. Elizabeth Kubler-Ross later incorporated the concept of denial into her theory regarding stages of grief, suggesting that humans who have suffered a loss often first go through an adjustment period, including a time when they simply deny a loss that the person does not want to accept. Beck, the creator of modern cognitive behavioral therapy, adopted similar concepts, describing them as cognitive distortions, or distorted schemas, and framed them as central to explaining why people engage in unhealthy, irrational or destructive behaviors. Across many of these modern analyses of the concept of denial lies a recognition that, rather than reflecting universal psychopathology, denial may actually be healthy, normal aspects of psychological functioning.
There’s an ongoing debate about the concept of denial, as it is frequently invoked by clinicians in order to deny a patient’s perceptions or views and to compel patients to “get with the program” and admit that they have problems. Unfortunately, particularly within the addiction field, the concept of denial is often applied with a lack of attention to the contextual nature of these issues, and with a compulsory demand that the patient identifies themselves as an “addict.” For instance, Stoddard-Dare & Derigne (2009) point out that many instances of what is called denial or resistance or minimization may actually result from inappropriately aggressive approaches by clinicians which then result in a reaction from the patient. The therapist may be trying to get information when the patient doesn't yet trust them enough to admit vulnerability. In other words, when therapists try to bully a patient, they shouldn’t be surprised when the patient resists.
Recently, bio-ethicists have argued that the term denial reflects an unethical and clinically inappropriate imposition of the clinician’s views and values, onto the patient, such that the patient is coerced into agreeing with the clinician, in order to receive treatment, and that this approach ignores ways in which a patient’s perceptions may be healthy, normative or accurate (Blumenthal-Barby & Ubel 2018).
In treatment with sexual offenders, there has historically been a focus on “full disclosure.” In this, there is a belief that if a perpetrator does not offer full disclosure of all victims and criminal acts, that, the offender is never able to complete or benefit from treatment. Similar concepts are employed by many therapists who treat marital infidelity or sex addiction, and in many cases, therapists rely on the use of the polygraph as a means to force patients to “come clean” about everything.
But, there’s little evidence that “full disclosure” improves treatment or reduces future recidivism. Instead, some research finds that sex offenders who complete treatment without making “full-disclosure” are at no increased risk for recidivism. Other research suggests that denial might increase the risk of recidivism in low-risk offenders, but actually decrease risk in high-risk offenders, in a complicated, individual-specific pattern. As with so many things, the use of disclosure within sex addiction or marital treatment has no research to support it, based entirely on anecdotal evidence.
Use of the concept of denial in reference to an individual’s refusal to admit guilt when in a legal confrontation may be inappropriate, given that many attorneys specifically instruct their clients not to admit guilt or responsibility. How many of us have seen commercials by attorneys telling their prospective clients to “shut the f@#$ up!” Labeling such an individual as being in denial completely ignores the legal context of this behavior.
When a therapist claims a patient is in denial, it may say more about the therapist, than it does the patient. It says, in essence, that the therapist believes they are right, and the patient is wrong. When talking about a patient’s motivations, needs, intent, wishes, and beliefs, it is the height of clinical arrogance, for a therapist to believe they know more than the patient themselves. If your therapist tells you that you are in denial, you may want to find a different therapist who is more interested in hearing and understanding.