Client Populations Clinical Interventions

Working with Lack of Insight: Denial

Clients with a physical or mental health condition sometimes lack insight about their problem. This often shows up clinically as denial.

By Mental Health Academy 2024-10-31 04:46:57

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Clients with a physical or mental health condition sometimes lack insight about their problem. This often shows up clinically as denial.

Related articles: Working with Lack of Insight: Anosognosia, From Resistance To Acceptance, 5 Ways Clinicians Build Resistance in Clients.

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Introduction

Our previous article discussed the frustrating situation of clients whose improvement is stymied by their lack of insight about their condition; we specifically examined anosognosia, when there is brain disorder or injury or a degenerative disease such as Alzheimer’s. We noted that insight matters for clinical, legal, and administrative reasons,  and that the unawareness can become dangerous, for the individual and others (Reddy, 2016; Rubin & Zorumski, 2016). 

The other common reason for lack of insight is when clients are in denial, which typically shows up in presenting issues such as substance use and behavioural addictions, personality disorders (such as narcissism), and eating disorders. In this second of our two-part series on working with lack of insight, we explore denial. We overview it and suggest the types of therapies that can help clients overcome the lack of insight from this source.

Overview of denial

What do we mean when we say that someone we know (perhaps we ourselves) is “in denial” about a certain issue?  We look not just at the definition, but also how it is powerful in in helping or hurting us, and what the signs, causes, and triggers are.

Definition

Denial is a defence mechanism in which an individual refuses to recognise or acknowledge objective facts or experiences; it’s typically an unconscious process that serves to protect the person from discomfort, overwhelm, or anxiety (Psychology Today, 2024b). Sigmund Freud explored it first to describe how the unconscious mind operates to protect the individual from anxiety and unacceptable thoughts. His daughter Anna expanded on it, developing the idea of defence mechanisms in general (Better Help, 2024a).

Why denial is powerful

As human beings, our survival instinct is strong, for both our physical and psychological self. So, we try to shield ourselves from distressing or overwhelming emotions or experiences by ignoring or denying reality or the consequences of reality, thereby (we hope) avoiding anxiety or discomfort. Letting in all of the truth immediately feels like more than the individual can bear, so we ignore, repress, or otherwise turn away from it. As such, denial has a powerful protector role for us. The more unpleasant the reality, the greater the protection rendered (Psychologily, 2024; Better Help, 2024a).

When we squash down unpleasant material in denial, it may be stored just out of conscious awareness, where it can be brought back to our conscious mind with relative ease, but often what happens in denial is that we repress painful emotions or memories, locking them away from conscious capacity to retrieve them. It is then that denial is most powerful, the repressed material driving our lives from “underground”. Hence, you may have heard the saying that “First we forget, and then we forget that we forgot”.

The serve and limit of denial

The serve

Denial can both help us and hurt us. It can serve in the role of Protector of the Ego, keeping us safe from looking at ourselves or addressing something around us which is too hard to bear. It offers us temporary relief and time to adjust to a new, unwelcome reality.

And the limit

Why it was so concerning to the Freuds was undoubtedly the reason modern psychologists warn against it, too; in the long term, it prevents people from acknowledging and addressing their problems. Those with substance use disorders, for example, are unable to deal effectively with that while they are unable to view it as a problem; meanwhile, their relationships, health, and job performance are all likely to go downhill. The woman with a sudden large and growing lump on her breast who says, “Oh, no need to go to the doctor. it’s probably just a lump of fat; our family doesn’t get cancer” may be setting the stage for a serious, or even unwinnable, battle with cancer later (Godman, 2023; Claney, 2024).

Signs of denial

You may have noticed clients exhibiting some of the following signs of denial:

  • Avoidance. The person finds ways to  go around or refuse to talk about, or even acknowledge, the problem.
  • Justification. The individual finds ways to justify, for example, being coercively controlled, or even beaten, by their partner: “I probably deserved it, because I disagreed with him.”
  • Blame. This is claiming, for example, that “It wasn’t my fault that I got drunk/high. My partner causes me to drink with their frequent bad moods”.  
  • Persistence. A given (maladaptive) behaviour continues despite the person experiencing negative consequences from it: continuing compulsive shopping, for instance, when the credit cards are up to their limit.  
  • Promises. The person who acknowledges that there is a problem and repeatedly states that they will address it but takes no action is a person in denial: for example, a morbidly obese person who tells the doctor they are starting a diet but has no diet or eating-change plan.
  • Distraction. Focusing on unrelated activities to avoid thinking about the problem is a form of denial. Example here? The client coming to therapy to work on their relationship who says, “Oh, I was so busy with work I just didn’t get time to do my homework about my relationship” (categories of denial adapted from Claney, 2024; Cherry, 2023; Godman, 2023). 

The causes and the triggers

The causes

In its role as protector, denial may come about as a response:

  • To stress (avoiding the overwhelm of letting in a highly stressful situation)
  • To fear (when we fear the consequences of acknowledging a problem)
  • To emotional pain (as a defence against confronting difficult emotional truths)
  • To shame (when we avoid the guilt, shame, or embarrassment we associate with certain behaviours or conditions, such as being caught in pornography addiction or being seen to be financially insolvent) (Claney, 2024).

The triggers

At a superficial level, when the above causes are in play, many situations can trigger the denial. Common ones include:

  • Abuse of any sort (mental-emotional, physical, verbal, sexual, financial, or other)
  • Grief
  • Mental health issues
  • Relational conflicts
  • Medical diagnoses or physical health issues
  • Alcohol or other substance use disorders
  • Unwanted bodily changes such as unhealthy weight gain
  • Smoking
  • Politics (adapted from Godman, 2023; Claney, 2024).

What happens when people stay stuck in denial?

Continued denial often leads to negative consequences such as:

  • Relational strain, as distance, conflict, and misunderstandings ensue in both personal and professional relationships.
  • Increased anxiety and/or depression, as the underlying issues remain unresolved and continue to affect the person in denial.
  • Delayed health treatments, as denial may prevent individuals from seeking the psychological or medical help that they need; adverse effects occur with regard to both physical and psychological health.
  • Worsening conditions, as existing problems deepen.
  • Obstructed personal growth, as individuals with denial miss opportunities to confront and work through issues; emotional development is stymied.
  • Behaviours of withdrawal (due to overwhelm) or bullying (when threats, force, or ridicule are used to exercise power over others in order to feel less lonely).
  • Self-harm behaviours increase, as they may provide short-term relief from painful feelings, even though leading the person down a more sinister path.
  • Substance use increases (Hogan, 2021; Better Help, 2024a; Claney, 2024).

The special case of denial in addiction: mechanisms and psychological factors

Nowhere do we see more serious denial than in that which accompanies both behavioural and substance addictions. Those with addictive disorders typically choose denial variations of minimisation (minimising the severity of the addiction or its impact), rationalisation (generating excuse statements to lessen the perceived negative consequences associated with their addiction, and projection/blame (which involve the projecting or shifting of responsibility and blame onto external factors and/or other people rather than acknowledging personal accountability) (iResearchNet, n.d.). Where addiction denial is concerned, fear, self-deception, and cognitive biases loom large as the psychological dynamics which commonly maintain the denial.

Given the frequent depth of the self-deception involved in addictive denial, we note that addressing it within the recovery process requires a nuanced approach in a non-confrontational therapeutic environment that encourages self-reflection and being personally accountable (Heshmat, 2018). We list approaches which work well for this, but first, a note on assessment.

Resource tip: This article highlights why addiction training is essential for all mental health professionals, and this video interview explores the ins and outs of working with clients with behavioural addictions and/or substance use disorders.

Assessment: The Illness Denial Questionnaire (IDQ) and clinical evaluation

The IDQ

One instrument which has been empirically demonstrated to show validity in assessing for denial is the IDQ for Patients and Caregivers. After administering the IDQ to 400 subjects (219 patients and 181 caregivers) together with the Anxiety–Depression Questionnaire, analyses showed good concurrent validity. The authors concluded that of their three hypothesised factors, “denial of negative emotions” and “resistance to change” seem to contribute to a real expression of denial, and “conscious avoidance” seems to constitute a further step in the process of cognitive–affective elaboration of the illness (Rosi-Ferrario et al, 2017). You can purchase a template of the IDQ from here.

The clinical evaluation

The value of the IDQ is its ability to provide clinicians with quantifiable data specifically relating to denial to supplement their clinical evaluation. The latter is also important, with the integration of clinical judgment with measures such as the IDQ enhancing the overall accuracy of identifying and assessing denial. There are several challenges, though. Clients with addiction may be hesitant to openly acknowledge the extent of their addiction due to fear, shame, or concerns about judgment. Equally, people with mental health conditions typically do not want to face how unwell they may feel, and often are highly reluctant to share their experience with others, including therapists. Some clients may genuinely lack insight into the severity of their behaviours, while others may intentionally downplay or distort their experiences (iResearchNet, n.d.).

The interventions for lack of insight: Inviting the client into it

If the problematic lack of insight arises from denial rather than anosognosia, an organic inability to come into relationship with reality is usually not the case (although in 2007, Naqvi and associates found that some people with a history of chronic drug abuse have impairment of insight and self-awareness due to dysfunction of the insular cortex). In most cases, treatment for denial follows the logical route back to self-awareness through employing the elements of introspection and self-reflection, communication with trusted others to provide an external perspective, and professional help to receive psychoeducation and develop healthier coping strategies. A well-recognised path to self-awareness integrating these components is seen in insight therapies.

Insight-oriented psychotherapies

Also known as insight-oriented or psychodynamic therapies, insight therapies focus on gaining self-awareness of thoughts, emotions, and behaviours through exploration of past experiences and unconscious processes to gain access to current difficulties. A key notion with such therapies is that gaining insight into the underlying causes of emotional struggles is the most effective route to meaningful change. Thus, by examining recurring patterns, childhood experiences, and unconscious motivations, clients can gain a deeper understanding of why they think, feel, and behave as they do (Andriy, n.d.). We list some of the more well-known types of insight-oriented psychotherapies, and what the benefits of insight therapy are, especially for people struggling with denial.

Types of insight-oriented psychotherapies

You are likely to know many of the basics of insight therapies even if you have not heard all the developers’ names before. For example, few people, even lay people to the mental health professions, are unaware of Freud’s signature psychotherapy, psychoanalysis. His and other therapies developed since then can all be included in the type of therapy that aims to help clients gain a deeper understanding of themselves and their experiences. Some of the other more well-known ones that psychology writers tend to place under this umbrella include:

  • Carl Jung and Jungian analysis
  • Roberto Assagioli and Psychosynthesis
  • Melanie Klein and object relations
  • Gestalt Therapy
  • Existential Therapy (Psychology Today, 2024a).

The interesting case of cognitive behavioural therapies 

Surprisingly, some writers include cognitive behavioural therapy as an insight-oriented psychotherapy. While it is not a psychodynamic therapy in the traditional sense, it certainly counts as an evidence-based approach that targets denial mechanisms. It incorporates elements of insight therapy in that, by identifying underlying beliefs and assumptions, individuals can develop a greater understanding of how these cognitive processes contribute to their emotional difficulties. When unhelpful, denial-related thought patterns are restructured, clients’ ability to recognise their condition (i.e., a personality disorder or addiction) is enhanced, allowing for a healthier perspective. This can translate to sustainable modifications of maladaptive behaviours (iResearchNet, n.d.).

Motivational interviewing: Made for denial

As people begin to come into relationship with how denial is weighing them down, making complete healing impossible, they may have a glimmer of insight about the seriousness of their denied condition – and about the denial itself. But change is not generally a linear process, and the person will normally go back and forth between suspecting that they should change and then flocking back to the protective covering of denial. Motivational Interviewing (MI) was developed specifically to deal with this ambivalence. While not focusing on past issues as do other insight-oriented therapies, MI techniques foster a client-centered dialogue that helps individuals in denial confront the inconsistencies between their goals and addictive or otherwise maladaptive behaviours and enhances their sense of autonomy and self-efficacy (Miller & Rollnick, 2002; iResearchNet, n.d.).

The importance of Other to insight therapy: Family therapy, social support, and community-based interventions

One effect of denial is to undermine relationships of the person experiencing the denial. This is unfortunate, because those relationships with “Other” – as in all others: family and friends, social support people, and those in the community – can be important in helping a person move out of denial. Briefly, here are some aspects of how other people figure in the scheme of denial.

Family dynamics. On the positive side, therapists work collaboratively with family members to promote open communication, establish healthy boundaries, and create a supportive environment to understand the impact of denial on healing other health conditions, especially addictions. Therapists also can help families identify enabling behaviours. On the negative side of family dynamics, it is often the family members who inadvertently perpetuate denial through enacting those enabling behaviours! They may minimise the severity of the person’s health condition, not wanting to face it. They sometimes cover up the consequences of the person engaging in behaviours that go against medical advice. And, in the case of addictions, family members have been known to provide financial support which sustains addictions. Positive or negative, the family dynamics loom large as an influence in overcoming denial.

Social support. Peer groups can be named here as significant contributors to overcoming denial, as those experiencing denial interact with others who have faced similar challenges. The most well-known such group is probably Alcoholics Anonymous, but there are many similar “anonymous” groups which have been started in recent years, such as Gamblers Anonymous or Narcotics Anonymous. Talking with peers can help validate a person’s experience and offer a forum for sharing experience, fostering accountability, and thereby challenging denial in a supportive community setting.

Community-based interventions. Some health conditions engender more sense of shame and stigma than others. Addiction is perceived as highly stigmatising, as are mental health conditions. Community-based interventions broaden a client’s base of social support by helping connect them with local resources and networks. These could include community outreach programs, educational initiatives related to their health condition, or collaboration with community organisations to engender awareness-promoting environments. All of these efforts reduce stigma (which reduces the need for denial), and they can facilitate the integration of clients into supportive social networks. Broad-based community approaches reinforce the importance of collective responsibility in addressing health issues, particularly when denial is rife (iResearchNet, n.d.).

Techniques used by insight-oriented therapists

Some of the less well-known and more psychodynamically-oriented techniques that may be used in insight-oriented therapies include the following:

  • Free association
  • Dream interpretation
  • Exploration of the past
  • Interpretation of symptoms
  • Subpersonality work (in Psychosynthesis)
  • Use of metaphors
  • Confrontation
  • Psychoeducation (adapted from Cuncic, 2024)

Multifaceted works best

A plethora of books dives deeply into the therapeutic schools and insight-oriented techniques we have outlined above, and Mental Health Academy has many courses explaining the various therapies – and the techniques they employ. Perhaps the best thing to take away from our discussion of these as potentially powerful denial-busting approaches is that each client has a different situation, a different co-morbid condition, and a different set of denied emotions and potential triggers. Accordingly, a treatment that is tailored uniquely for each client is likely to be most helpful. Even better may be the realisation that a multi-faceted approach will achieve the best outcome.

Benefits of insight-oriented therapy

You may have heard a charge levelled at therapies like Freud’s psychoanalysis along the lines of, “So now I understand how my father’s constant criticism made me insecure. What do I do with that?” These are among the benefits of insight-oriented therapy:

  • Opportunities for self-reflection and introspection
  • Increased self-awareness
  • Emotional healing fostered
  • Personal growth and transformation
  • Ongoing support (Andriy, n.d.; Better Help, 2024b)

Conclusion

In this article, we have overviewed aspects of denial, identifying the Insight Denial Questionnaire (IDQ), along with clinical evaluation, as a useful means of assessing it. We noted how insight-oriented therapies are most effective to help the client confront unpleasant realities and listed a range of techniques that can assist with elimination of denial. We pointed out myriad benefits of addressing lack of insight from this source. We acknowledge that the road to an insightful, denial-free perspective is not a short or easy one, but it is possible to help a client move into an awareness of their own condition which facilitates healing.

Key takeaways

  • Denial is a defence mechanism which can help people by allowing them to take in a confronting reality more slowly but can hurt them when they stay stuck in denial and thus cannot move forward in healing.
  • Avoidance, justification, and blame are signs of denial occurring in response to stress, fear, emotional pain, and shame.
  • Denial can be triggered by many adverse experiences, such as abuse, grief, or medical diagnoses, and results in relational strain, worsening conditions, self-harm behaviours, and obstructed personal growth.
  • The IDQ and clinical evaluation together are valid ways of assessing for denial; insight-oriented psychotherapies such as those developed by Freud, Jung, and object relations therapists are effective ways of treating it, although CBT therapies and MI are also used.
  • Family support, social support groups (e.g., Alcoholics Anonymous), and community-oriented interventions are important interventions using the power of “Other” to help reduce denial.
  • Increased self-awareness, personal growth, and emotional healing are among the benefits of insight-oriented therapy.

References

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