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Glenn Yank, MD is a Psychiatrist located in Tennessee.


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Question:
I was diagnosed several years ago with DID and it came at a time when I had just relapsed after eleven years of being drug free (I still have not drank for 21 years, but I had a bad fall and broke my foot and needed medication and this began the relapse on pain meds.) I was so angry because I had 10 years of therapy where my life kept getting better and better and even though towards the end I really did think there was something I wasn’t dealing with, something that felt like a whole other layer deeper, and I used the term psychological ritualistic to my therapist before I had ever even heard the term ritual abuse. Still I thought after all those years, all that hard work, I should be getting better and then that gets sprung on me. I have had such a hard time since then in and out of denial. Sometimes I think I have it when I hear conversations in my head and stuff but other times I think I don’t find clothes in my closet that I don’t remember buying (although I do seem to have a lot of clothes in there I never wear). Anyway, I guess plain and simple my question is how does one get out of denial? Thank you my name is Diane

Answer:

Thank you for your question and for your willingness to share some of the painful parts of your story with us. I think that your question is specifically about how does a person who has DID, but denies this to themselves and others, stop denying this problem in order to be able to deal with it more effectively. Before addressing this, I would like to say that I do not know whether you do or do not have DID and that I cannot tell with certainty from your email. Even if you were subjected to ritual abuse of some kind, and have some kinds of conversations in your head, that would not be enough to make the diagnosis of DID. So please do not interpret my comments as meaning that I agree with that diagnosis. What we do know is that something hurt you terribly, that you drank and used drugs at times to try to numb the pain of that hurt, that your efforts in therapy and recovery have helped you to improve your life, and that sometimes you have felt that there are “things” about your life you were not dealing with.

With that background, let’s talk about denial. Because I have rather a lot that I want to say about dealing with denial, I am going to split this response into two parts. Part one will talk about denial as a psychological mechanism of defense, and dealing with denial as a mechanism of defense. Part two will address present denial as a part of the process of mourning or grieving, and use this model to describe a process of getting through denial by allowing mourning to occur.

The word “denial” usually means the refusal to admit or acknowledge the truth or reality of something. People can deny that an illness or other “condition” exists, that events have or will happen, that they are in certain kinds of situations or relationships, that they have or had particular feelings or thoughts, that they are others have acted in particular ways, and all sorts of other things. In this meaning, it is not specified whether the person’s refusal to admit or acknowledge something is a conscious decision or the result of mental processes operating outside of awareness. Also, the function of denial is not specified.

As used in psychology, “denial” means one of several psychological defense mechanisms that function to decrease the amount of anxiety and distress a person feels, and which work outside of conscious awareness. Everyone uses psychological defense mechanisms as part of how they try to tolerate what they feel. A key point about all of these mechanisms is that they work unconsciously – a person is not aware that they are using a particular defense mechanism (except for suppression, which is the technical term for “stuffing” your feelings, and which does operate consciously, but is still classified as a defense mechanism). The intent of all defense mechanisms is to help a person tolerate their feelings in the present, even if this causes other complications in their life later on. What the defenses are “defending” against is worsening of emotional pain. By themselves, defense mechanisms are neither good nor bad, they are just part of how everyone’s mind operates. However, some defense mechanisms are considered more adaptive than others if they cause less distortion of a person’s reality testing, allow a person to better get their needs met (at least to some degree) by the people and activities available to them, and/or are less likely to get a person into trouble. I have attached a rather long, but partial listing of some defense mechanisms (there is really no complete, “official” list) to the end of this response, in case you or other readers are interested in defense mechanisms.

Of course, defense mechanisms not the only ways that people manage their emotions. Using alcohol or drugs to decrease one’s sense of distress is not classified as a defense mechanism, per se, because it is done consciously and is not a normal feature of child development. Alcohol and drugs, including prescription drugs, can decrease a person’s subjective sense of distress by modifying the activity of the brain systems that process distress, emotion, and arousal. When drugs are used other than as prescribed (and sometimes even when used as prescribed, unfortunately!) there may also occur a pattern of minimizing distress in the moment at the expense of longer-term consequences, as can occur with certain defense mechanisms.

People also manage their emotions and their response to stresses by the use of coping skills. Coping skills are not considered defense mechanisms because they are employed consciously. Sometimes, the distinction between whether a particular behavior (such as avoiding a situation in which you would become very upset) is classified as a coping skill or a defense mechanism is whether it occurs consciously or unconsciously. But there are certainly shades of gray, where people learn to use coping skills more automatically, and where people are using a mix of different coping skills and different defense mechanisms at the same time. Also, certain behaviors that may be considered coping skills by some people may be considered maladaptive by others because, as described above for certain defense mechanisms and drugs, they decrease distress in the moment at the expense of longer-term consequences. Examples of such behavior include self-injury and other self-soothing “habits,” which can be under more or less conscious control. A more detailed discussion of all the ways people try to manage their emotions, consciously and unconsciously, is obviously beyond the time and space I have here, but I wanted to provide a context for talking about denial, and to point out that defense mechanisms are not the only way people deal with feelings that are too intense to tolerate.

Now, let’s discuss further denial as a defense mechanism. When denial is used this way, a person not only keeps the awareness of some real-world phenomenon (such as a very intense feeling, an unacceptable wish, a terribly painful memory, etc.) out of consciousness, they are not even conscious that they are doing it. The phenomenon (feeling, wish, memory, fear, thought) just doesn’t show up in the person’s mind. Denial can be a costly defense mechanism because it sabotages reality-testing and problem-solving functions. People don’t try to solve the problems that they do not see. Denial is often accompanied by minimizing, in which people “accept” what happened, but only in a “watered down” form. People can minimize the severity or frequency of events they can’t completely deny: using self-talk such as “yes it happened, but it wasn’t that bad” or “it doesn’t happen often.” Denial and minimizing can be helpful in certain circumstances: research has shown that a certain amount of denial and minimizing help people to deal with risks of pain and relapse after physical illness and injury.

Another defense related to denial is rationalizing. Although rationalizing has a conscious element, it is still considered a defense mechanism because the person is not aware of the underlying anxiety that they are warding off by coming up with seemingly rational explanations for behaviors (their own or others) or events that are problematic. Also, rationalizing may be considered a defense when the driving force for the behavior being rationalized is outside of conscious awareness. Thus, some part of the pattern is operating outside of consciousness, which is part of the definition of a defense mechanism.

Denial, minimizing, and rationalization also frequently accompany behaviors that reduce stress in the present at the expense of longer-term consequences. For example, I have heard people many times state something like: “I only (self-injured, self-medicated, gambled, engaged in unsafe sex, binged, shopped, etc.) a little . . . that was better for me than what I was really thinking of doing!” We all make compromises between tolerating stress in the present and preserving our future options, and then have to make these compromises acceptable to ourselves. Some of this process occurs consciously and some of it occurs outside of awareness.

To get out of denial requires first accepting that one is using it, and that it serves a purpose to help you manage your feelings. You will not address denial in a healthy way by blaming yourself for using it. It is an automatic process and your mind is automatically doing the best it can to protect you from getting overwhelmed. If you accept these ideas, and want to gain more conscious control of your feelings and actions, then you can ask what purposes does denial serve. In particular, ask yourself, what might you have to feel if you let yourself be aware of, believe, and/or accept whatever it is you are in denial about. What other ways can you use to help tolerate those feelings that would be there?

It will also help a person to lessen their use of denial if they address the anxiety and distress sources in their life that they do know about, since anxiety and stress are cumulative. There are a wide range of techniques for doing this, many of which are described in various sections of this website.

Now, (finally) let me comment on what I think is your at the heart of your question, which is how does a person reconcile themselves to having a dissociative disorder, if they actually have one. Let me pose this from the perspective of a person who has a dissociative disorder but not true DID, and from the perspective of the primary personality in a person with DID. I will not address the perspective of the alter personalities in someone with DID, because they may be aware of each other (or at least some of the other alters) and the existence of a “system” before the primary personality accepts this. Following the discussion above, a key question that then needs to be asked is “what would I have to feel if I accept the diagnosis of Dissociative Disorder or DID?” This would be a very difficult question for anyone for several reasons. First, it is difficult to accept the diagnosis of any serious illness, and denial is a common response to being told a person has an illness for many physical and psychiatric illnesses. In addition, Dissociative Disorders are one of the more controversial psychiatric diagnoses, so accepting this diagnosis is accepting the possibility that some people will question the accuracy and/or legitimacy of the diagnosis. Also, the diagnosis of a Dissociative Disorder usually comes with a prescription for years of painful psychotherapy and the need to address a history of traumas that were so severe they overwhelmed the person previously. Further, a diagnosis of a Dissociative Disorder can feel like an attack on a person’s sense of autonomy and control, because it means that there are periods of time when “you” are not in control in one way or another. The combination of these factors, and possibly others, carry a significant burden of intense and painful feelings that will have to be addressed if one accepts the diagnosis, which makes it understandable that there will be a natural tendency to deny it.

Overcoming denial also requires accepting that denial comes with a high cost. Most often, that high cost is that some painful pattern of behavior and experience keeps being repeated because denial contributes to being unable to change that pattern. Denial gets in the way of making the changes necessary to allow healing to occur. Believing this will help you find the motivation to overcome your denial.

In part two, I will talk about the relationship of denial to grief and mourning, and how this relates in particular to people with dissociative disorders.

A Partial Listing Of Defense Mechanisms

  • Acting Out: A person deals with emotional conflict or internal or external stressors by actions rather than reflections or feelings. The action allows the person to keep the emotions out of awareness. This is different than “acting up,” in which the person is more conscious of their motivation.

  • Aim inhibition: Unconsciously placing a limitation upon a desire; accepting partial or modified fulfillment of a desire rather than risk rejection and no fulfillment, or that the desire will conflict with another value.

  • Altruism: This is a relatively mature defense mechanism and consists of an individual dealing with emotional conflict or internal or external stressors by unconsciously dedicating themselves to meeting the needs of others. Unlike the self-sacrifice sometimes characteristic of reaction formation, the individual receives gratification either vicariously or from the response of others.

  • Avoidance: A defense mechanism consisting of refusal to encounter situations, objects, or activities because they represent unconscious impulses and/or punishment for those impulses.

  • Compensation: Encountering failure or frustration in some sphere of activity, one overemphasizes another. People can also compensate in a conscious way, but the “defense mechanism” use is not conscious.

  • Conversion: Conflicts are presented by physical symptoms involving portions of the body innervated by sensory or motor nerves. These symptoms involve alterations in muscle activity, speech, pain sensation, numbness, etc.

  • Deflection: A defense mechanism consisting of redirecting attention to someone else.

  • Denial: Failing to recognize a thought, act, or situation, or the consequences they have.

  • Devaluation: The individual deals with emotional conflict or internal or external stressors by attributing exaggerated negative qualities to self or others. Devaluation may follow idealization after the idealized person cannot live up to the ideal image.

  • Displacement: A change in the goal or “object” by which a drive or longing is to be satisfied; shifting the emotional component from one object or idea to another.

  • Dissociation: Splitting-off or separating a group of thoughts, memories, feelings, and activities from the main portion of consciousness; compartmentalization.

  • Fantasy: The individual deals with emotional conflict or internal or external stressors by excessive daydreaming as a substitute for human relationships, more effective action, or problem solving.

  • Fixation: The partial cessation of the process of development of part of the personality at a stage short of full maturation due to severe frustration and/or trauma. Essentially, the person gets “stuck” due to inability to master a particular developmental task. When a person regresses (see below) the return to a developmentally earlier fixation point.

  • Humor: The individual deals with emotional conflict or external stressors by emphasizing the amusing or ironic aspects of the conflict or stressors.

  • Idealization: Overestimation of the desirable qualities and underestimation of the limitations of a desired person. Idealizing helps deal with the frustration inherent in relationship.

  • Identification: The unconscious modeling of one’s self upon another person. One may also identify with values and attitudes of a group. Identification can be a taking of something about another person into one’s self as a defense against loss of the other.

  • Incorporation: This term is used similarly to introjection and means the “taking in” of the representation of another person into one’s own developing self. This is one of the earliest mechanisms utilized by very young children to deal with the anxiety of their parent/caretaker not being present and then feeling helpless. The “image” or representation of the parent/caretaker becomes almost literally a part of the child’s mind.

  • Intellectualization: The individual deals with emotional conflict or internal or external stressors by the excessive use of abstract thinking or the making of generalizations to control or minimize disturbing feelings.

  • Introjection: See incorporation, above. Introjection is used to describe the part of this process that result in the presence of psychological structures based on the representations of others.

  • Isolation: The splitting-off of the emotional components from a thought, so that the emotional content remains unconscious.

  • Numbing: A general restriction of emotional responsiveness, sense of detachment, diminished interest in activities or being with others. This is often seen in people who have been traumatized.

  • Passive Aggression: The individual deals with emotional conflict or internal or external stressors by indirectly and unassertively expressing anger toward others, or expresses anger by withholding something that is desired. There may be a facade of overt compliance masking covert resistance, resentment, or hostility. Passive aggression often occurs in response to demands for performance. A type of passive-aggressive behavior is help rejecting complaining, in which a person deals with emotional conflict or stressors by complaining or making repetitious requests for help that disguise covert feelings of hostility or reproach toward others, which are then expressed by rejecting the suggestions, advice, or help that others offer.

  • Projection: Attributing one’s thoughts, impulses, desires, fantasies, or emotions to another person or group, or some other agency outside of oneself, such as the government.

  • Projective Identification: As in projection, the individual deals with emotional conflict or internal or external stressors by attributing to another his or her own unacceptable feelings, impulses, thoughts, and/or emotions. Unlike simple projection, the individual does not fully disown what is projected. Instead, the individual remains aware of his or her own affects or impulses but sees them in the other person and tries to control them in the other person. Not infrequently, the individual induces the very feelings in others that they believe to be there, thus they almost project their feelings into the other person and the other person starts to feel them. This process can make it difficult to clarify who really feels what.

  • Rationalization: Offering a socially acceptable and apparently more or less logical explanation for an act or decision actually produced by unconscious impulses. The person rationalizing is not consciously inventing a story to fool someone else, but instead is dealing with their own anxiety about the action or decision.

  • Reaction Formation: Going to the opposite extreme; overcompensation for unacceptable impulses, thoughts, wishes, or feelings. This is occurring outside of awareness and is a replacement of an impulse or thought with its opposite.

  • Regression: A mechanism of decreasing distress by unconsciously “going back in time” developmentally to a fixation point where the current conflict was not conscious. The person continues to experience themselves to be at their correct age (this is not dissociation to a younger alter), but has the feelings and behavior patterns that they had at a younger age.

  • Repression: The involuntary exclusion of a painful or conflictual thought, impulse, memory, or emotion from awareness. The repressed mental content becomes unconscious.

  • Restitution: The mechanism of relieving the mind of a load of guilt by making up or reparation. This is used here to mean this process occurring unconsciously. This is one of many defenses that has a conscious analogue.

  • Somatization: Conflicts are represented by physical symptoms involving parts of the body innervated by the autonomic nervous system, commonly the g.i. tract, cardiovascular and respiratory systems.

  • Splitting: The defense keeping apart of inner representations that are experienced as “good” and “bad” in order to preserve the “good” and prevent it from being contaminated or destroyed. The process described as “staff splitting” or splitting between different persons is based on the phenomenon that different people will evoke different sides of the internal split.

  • Sublimation: Decreasing the force of an instinctual drive (sex, aggression, need for someone to be present) by using the energy in other activities, which may symbolically represent the original force. For example, a person may play violent video or computer games as a way to sublimate intense anger at others.

  • Substitution: The process of securing alternative or substitutive gratification of a desire when frustrated by the inability to fulfill it with the intended “object.” For example, a child accepts nurturing from a caretaker when the parent is not available.

  • Suppression: Usually listed as an ego defense mechanism but actually the conscious analog of repression; the conscious intentional exclusion of emotionally charged thoughts and memories from consciousness. This is the technical term for what people call “stuffing” their feelings.

  • Undoing: An action that serves the psychological function of negating an unacceptable action, impulse, or idea. Undoing is seen to a great degree in certain obsessional rituals, where the repeated behavior may serve the function of psychologically counteracting or warding off some feared thought or impulse.

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Do you have a question relating to a mental health issue? Do you have a question relating to abuse or multiplicity? Do you have a question about medication? Once a month a new question will be answered and posted on this column. A special thanks to Dr. Yank for donating his time to answer the questions.

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