The term “denial” is a general term representing several universally recognized psychological defense mechanisms, namely repression/avoidance, regression, projection/introjection, reaction formation, displacement, attribution, rationalization sublimation/displacement and misattribution or excessive optimism. In their proper proportion in the adult psyche these are not indicators of mental illness per se, in fact some illusion is necessary for healthy adjustment; it is only when they displace problem-solving and risk assessment strategies can they be thought of as pathological. If the stress is sufficiently prolonged and the person perceives no solutions or alternatives, the resort to defense mechanisms can take on harmful dimensions.
Since you are not likely to get an accurate self-report from someone who is in denial about the stress they are experiencing, here are some objective indicators of their true situation:
The Defense Mechanisms
Repression/Avoidance/Displacement- This involves shoving unpleasant and discordant thoughts out of consciousness; this is done either purposely, as in “I’m not going to think about that” or on a less conscious level as in dissociating (‘spacing out’), avoiding awareness of a problem through compulsive/obsessive thinking or behaviour, and displacing through misattribution, as in assigning causes of the problem to other than their genuine sources (it’s an act of God) or adopting an overall passive fatalism (shit happens and there’s nothing to be done, so there’s no use thinking about it). Thought substitution is another a form of displacement, e.g. the person who has just lost his/her home to fire or flood might focus obsessively on a lost pet rather than facing the larger compelling issues. This is not to say that the well-being of pets is not important, but rather to illustrate a tendency of the mind of avoiding being overwhelmed by selectively focusing on something that occupies the mind in a way which pushes awareness of urgent problems out of consciousness.
Regression - This is about falling back onto patterns of thought and behaviour from an earlier stage of life, such as living in a fantasy world (escapism into TV, romance novels, etc.), returning to drug and alcohol abuse that one had since moved beyond, viewing one’s situation from the point of view of a helpless child, resurrecting simplistic religious, superstitious or other modes of ‘magical thinking’ (e.g. formulaic sayings and prayers, fantasies of being rescued i.e. “God/My Guides/guardian angel will help me” “someone [a father/mother/brave Knight/selfless nurse-nun/wise guru–type person] will save me”).
Projection/Introjection - This is assigning the consequences of an issue that has to do with oneself onto another or visa versa, i.e. feeling angry towards a person or group but turning it around by thinking “they must be angry with me” or “I must have done something/I am guilty/I am a failure so I deserve this.” The functional basis of projection is to justify one’s feelings in terms of someone else’s actions and the attribution of what those actions indicate about the other’s or one’s own feelings. Projection also has an aspect called in cognitive psychology “over- generalization” - the idea here is that one avoids the responsibility of looking at an issue in one’s distressed mind by overall projecting the situation to others, i.e. “I may cheat, everyone does” or “it is happening everywhere, so there is nothing to be done.”
Reaction Formation - this is a controversial category; it basically refers to a “flip-flop” in attitude formation wherein one forms a belief that is the opposite of a genuine recognition of how one ‘really’ feels about a situation. It often takes the form of an “Ain’t they awful” position that points away from one’s distress as in “Look at all these complainers, what’s wrong with them?” “I’m alright Jack” “They’re stupid/misinformed/wimpy/ and I’m not.” Often the underlying dynamic here is a strong identification with “authorities” as a means of warding off one’s sense of powerlessness, and in so doing taking on the presumed values and justifications of authoritarian oppressors (this aspect is discussed further at the end of this list under the heading “Identification with the Oppressor”).
Rationalization - This involves shifting interpretation and implications of a distressing situation in an attempt to remove its threatening nature, e.g. “It isn’t really so bad” “It is for the best in the long run” “It is a necessary sacrifice” “The people who’ve done this are the experts, they’re smarter than me.”
Sublimation/Displacement - This style is related to repression, but can be very active in form, where thought avoidance takes obsessive - compulsive behaviours to extremes, such as becoming a “shopaholic”, endlessly working on puzzles, pouring over pornography, revisiting old family conflicts or past love affairs, displacing one’s distress onto that of others through various “rescuing” campaigns and other codependent interactions unrelated to the subject of the stressor, and immersing oneself in endless rounds of “to do” activities of little consequence so that one is eternally too “busy” to acknowledge the stressor.
Excessive Optimism - this really incorporates several of the above, e.g. misattribution, displacement and avoidance, but deserves it’s own category, particularly in a culture that touts the efficacy of positive thinking and even magical thinking. Being optimistic certainly allows one to “see the glass half full” and that is in most circumstances a good thing in sustaining motivation and mood. The problem arises when optimism is summoned up inappropriately or excessively in the face of a dangerous situation, leading to faulty risk assessment and a failure to respond appropriately to avoid or minimize harm. Several studies have highlighted the motivation behind excessive optimism as being an attempt to gain a sense of control in the face of threatening events. I hasten to add that the flip side, excessive pessimism, may be equally harmful, in preventing action through a sense of hopelessness and immobilization by depression. A realistic appraisal of negative events, more akin to pessimism than optimism, is the most effective position for making realistic assessments of one’s situation.
Identification with the Oppressor Mentioned in a previous list item, this particular form of denial deserves a paragraph of its own due to its importance—it is another dimension of denial that is specifically found in powerless persons who find themselves oppressed by overwhelming circumstances beyond their control. This reaction consists of the internalization of the belief system and opinions of those in authority who would deny their legitimate basic needs and thereby add to their powerlessness through the resulting destruction of their self- esteem and personal efficacy in the world. This has been eloquently expressed by the renowned Brazilian intellectual and educator Paulo Freire:
“Self-depreciation is …[a]… characteristic of the oppressed, which derives from their internalization of the opinion the oppressors hold of them. So often do they hear that they are good for nothing, know nothing and are incapable of learning anything—that they are sick, lazy, and unproductive—that in the end they become convinced of their own unfitness” (Freire, Paulo [1998/1970]. Pedagogy of the Oppressed, translated by Myra Bergman Ramos. New York: Continuum, p. 49).
This insight has since been scientifically validated in the experimental and field study works of many social scientists, particularly social psychologists, social work researchers, political economists and sociologists, and is now a standard concept in these disciplines. The implications are that in working with disempowered people caught in an oppressive situation, the first impediment to be overcome in effective intervention is to give the affected people a sense of empowerment that allows them to explore and ultimately set aside their internalized identification with their oppressors so they can more clearly consider their situation from a point of view of their true self-interest. As with other mechanisms of denial, it is important to remember that arousing a sense of hope in disempowered people where there is no true alternative for them to carry out, is to set them up for even further battering of self-esteem and more desperate identification with their oppressors.
Any variety of the above avoidant types of thinking serve the following coping functions:
To summarize, denial and avoidance are only beneficial in short, or moderate stress situations. If a stressor goes on for any period of time, not only are these denial strategies ultimately ineffective, but also become dangerous barriers to well-being and survival. Though distressing thoughts and feelings may be repressed or rationalized, they routinely show up both in physiological parameters such as blood pressure, heart rate, disrupted sleep, headaches, depression or racing thoughts, and in a variety of psychological test measurements of cognitive distortions and stress levels. Numerous classic studies have shown that elderly and seriously ill people are highly prone to use various forms of denial in the face of their dilemmas—with the increasing gravity of illness and advance of age, a pattern of denial becomes more prevalent, e.g. in a study of 14 non-comatose gravely ill heart attack victims, 13 denied they were seriously ill or even concerned about the possibility of death. Similarly, in a study of 840 terminal cancer patients, 90% denied feelings of fear.
If a helping professional is sought for persons whose defense mechanisms are no longer working for them, either by the individual or someone involved with them, what can be done to get afflicted persons “out of the box” of their psychological traps?
Essential to any approach would be the conveyance of attitudes of non-judgment, empathy, sincerity and compassion. How one gets there is by the creation of a sense of “safety” in any exchange so confidence can be established. This can range from Rogerian methods of unconditional positive regard to the involvement of social and legal resources that have tangible means of protecting the individual. The latter involves a realistic explanation of the benefits and limitations of a given resource, the person’s permission to share their plight with the resource, and follow-up co-creation of new actions with the person being helped (it is not enough to simply refer someone somewhere, nor will every person accept a given avenue of assistance).
Some techniques to accomplish the above would be the creation of a place which is neutral and safe, the use of Active Listening skills, framing questions in an open-ended way and taking whatever answer one gets, reframing what one has heard to check that it has been received as intended by the speaker, and timing so the narrator is not interrupted, but is asked pertinent questions for further information and clarification at the optimal time.
Checking one’s own biases is also crucial, as we must be self-aware so as to minimize the effect of our own beliefs and judgments in limiting our effectiveness. If the helping person is committed to continuing self-awareness, there can develop a personal quality of transparency in interchanges that has a validating and trust-building effect on the quality of the exchange.
One further caveat: the resources to which the client is referred must be genuine and effective, i.e. really in a position to provide the means to intervene in the objective situation and effect meaningful change in the circumstances. The worst outcome would be where a disempowered person’s trust is gained, their expectations built up, then upon risking hope and exposure only to find that in the end there is no real help in their quest to better their situation, the results can be devastating. This is a crucial issue when the sociopolitical climate has degenerated to the point that under-equipped helping agencies are overwhelmed with clients’ problems and can in reality only effect minor adjustments in their advocacy, if at all. A clue to such a situation is when one agency is called, listens to the problem and promptly gives out the names and phone numbers of other agencies who only respond in the same way, leading to an eternal run-around with no genuine solutions.
To sum up, no meaningful intervention or help for these people can be accomplished until the defenses of denial have been sensitively defused. This does not mean that one aggressively rips away what the person has been utilizing in an attempt to cope. The best that can be done is to truly listen to the suffering person, show genuine empathy, be non-judgmental, create an atmosphere of safety, and have genuine alternatives at hand when the shift to more realistic recognition begins to emerge and the person is open to more realistic problem-solving and coping.
First, a study on denial with a focus on intervention: a scholarly paper from the Bowling Green State University’s College of Education and Human Development, Division of Intervention Services entitled Interventions in the Medical Rehabilitation Setting with Patients Who Deny Disabling Conditions, deals with the impediments (and occasional benefits) of denial commonly found among the disabled, click here.
Second, a megastudy of the effects of stress on the aged at Stanford University’s School of Medicine, Department of Psychiatry and Behavioral Sciences, called Stress, the HPA [Hypothalamus-Pituitary-Adrenal axis] and Health in Aging can be found here. If there was any doubt as to the extent of the impact of chronic stress on aged persons (and by extension disabled people who typically have a greater lifetime accumulation of stress) this comprehensive research project, though in its early stages, makes it clear that chronic stress can have truly devastating effects on the elderly, including onset or aggravation of tumor growth, particularly breast cancer, heart disease, Alzheimer’s disease and other forms of cognitive decline, measurable shrinkage of a component of the brain associated with emotion and memory (the hippocampus). Cortisol’s function is to raise blood sugar and suppress inflamation, part of the body’s “emergency response” to threatening stressors. Where stress is chronic, the body’s continuing emergency production of cortisol can precipitate or aggravate diabetes, mask inflammatory conditions, and suppress the immune system. (source reference)
Third, there is an extensive article on the damaging effects of stress on the sleep cycle of the aged, particularly the presence of the stress steroid hormone cortisol in the blood and urine (and having the greatest negative effect on males) in the journal Chronobiology International (the link to follow is just the abstract, it’ll cost you US$15.00 to obtain the full electronic version, but it is an important work and worth the money for those truly interested in the subject). The abstract can be found here. You’ll have to scroll up a bit to find the link for purchasing this article.
A brief but clear and informative article on the damage produced by chronic elevated levels of the stress hormone cortisol on the cardiovascular system leading to atherosclerosis (clogging of the arteries with plaque) can be found here.
From the above study, it is clear that in situations of stress, fats aren’t the culprit, as this negative outcome was found even among those on low-fat diets. It is chronic stress that is the true killer in clogged arteries. This study makes it clear that the hormone DHEA corrects somewhat for the effect of cortisol, but DHEA loses the battle in the natural system balance. Additional DHEA as a supplement is thus a means of moderating the problem; it is widely available in health products stores in the USA, but is illegal to buy/sell as a retail product in Canada. Canadians who know the issues and have the discretionary funds may well import DHEA overtly or clandestinely from USA sources (and being sensible types by virtue of their natural character, not misuse this powerful hormone, at least it is hoped). This option is not to be undertaken by the afflicted person alone, however, as hormonal imbalances are a complex matter and self-treatment may well bring about other than the desired results. That increasingly scarce entity in these days of “walk-in clinics”, the caring and knowledgeable physician who knows the patient, is required to implement an appropriate strategy of intervention on a chemical level. Note that often a physician will detect e.g. raised levels of blood pressure, but without information on changes in the patient’s life (stress events) may come to incorrect conclusions about the cause of the symptom and make inappropriate recommendation Therefore it is important to have a physician with whom you can really talk, one willing to listen and you must be willing to go beyond simple answers to questions and disclose to the doctor what your entire personal situation truly is without resort to your habits of denial.
It is well-known in general that stress weakens the immune system. One excellent article that is brief and to the point yet gives research-documented medical details about what is happening in the body, is written by Lewis Mehl-Madrona, M.D., Ph.D, called simply Stress and Immunity can be found here.
One additional bit of irony is worth mentioning: I have observed that a number of people who once had a smoking habit and had long-since matured to the point of giving it up, have returned to smoking in the face of a chronic and unavoidable stressor, living in a building which is going through a complete external reconstruction due to being a “leaky” building which has allowed moisture to collect in the walls. All the while the inhabitants have been put in a position that they have to continue to live in the building while the very disruptive (comparable to being in a war zone) construction activities are taking place around them (for details of that horrendous situation, click here). The irony is, there is strong evidence that smoking increases the body’s production of DHEA, as well as a neurohormone called dopamine (the “pleasure” hormone). It seems that on some level people under unremitting stress somehow intuit that tobacco smoking can help them cope with the effects of the stress, even though previously they were sufficiently aware of the dangers to quit the addictive habit. Lastly, being in a situation of chronic stress is likely to interfere with the ability to sleep, due to worry, the stressor itself precluding naps, etc. This adds insult to injury, as insufficient sleep in itself also raises cortisol levels. Maybe a drink or two might help you to relax and get some rest (alcohol also increases the levels of dopamine)? Nope, not only does alcohol distort the sleep cycle so that the essential dreaming stages are suppressed, but also it too raises cortisol levels. You can read about it here. For a full discussion of the wide-ranging negative effects of alcohol on all of your hormone-producing glands, click here.
Now for those readers who really want to follow this up, there is a book available in paperback that covers the issue of health effects of stress in great detail and with special emphasis on the hormone cortisol. It is called The Cortisol Connection–Why Stress Makes You Fat and Ruins Your Health–(and what you can do about it) by Shawn M. Talbott, Ph.D. Dr. Talbott’s home page can be found here. In this web site can be found many tips, including a cortisol self-test (just a questionnaire), a newsletter, a Frequently Asked Questions section and excerpts from the book. This book shows that a wide range of health problems and diseases are brought on or worsened by stress, but it doesn’t end there—many helpful strategies are described in detail for reducing the impact of stress and improving your health. It is recommended for anyone who is undergoing severe stress or knows and cares about someone who is. I say "recommended" with the following proviso: Dr. Talbott is associated with a "nutraceutical" company called Pharmanex that sells a preparation purported to reduce cortisol levels, so he is indirectly selling a particular approach; still the overall information in his book is valuable.
There is another possibility you need to be aware of—a lack of cortisol. If you, or the person you are helping, are undergoing a current acute or chronic stressor and it is taking you down very quickly, with fatigue, unrefreshing sleep or insomnia, a craving for starchy or sugary foods, depression, foggy thinking and a feeling of despair, you may have called upon your adrenals so many times in the past that you are “burnt-out”, your adrenals can no longer rise to the emergency situation with a dose of cortisol. This likely means you have already gone through the elevated cortisol levels and health effects described in the previous paragraph and have nothing left to respond to the current stress situation. As is the case with excess cortisol, you are not likely to find a doctor who can diagnose your situation or be willing to order the testing that will reveal the nature of your problem (in both cases, excess cortisol or adrenal exhaustion, the definitive test is not routinely available from testing labs, it is a test that requires the patient to preserve samples of saliva over a period of a day or more, and is only available at considerable expense and not recognized by the othordox medical establishment). Again, while this is a good book out on the subject, the author sells supplements so that you need to be aware of the bias. The author, James Wilson, Ph.D., has written a book called Adrenal Fatigue: The 21st Century Stress Syndrome; his web site, like that of Talbott’s, contains numerous informative pages and questionnaires. It can be accessed here.
Again, I stress that self-treatment may be at best ineffective, and could worsen your situation. The services of a health professional are important in determining your individual status (e.g. where you are along the continuum of adrenal exhaustion, complications arising from changes in your blood sugar level, immune system dysfunction, etc.). The problem is, such professionals are either in short supply or make additional money from using tests that are not paid for by our public health care system, leaving such services out of the reach of persons of limited financial means.
A final note—there are those tough-minded persons who might well be reading this and thinking something like “I wonder if this guy is exaggerating, or maybe a hypochondriac; I know of many people who have undergone far more drastic stresses lasting months, even years, including some who were getting on in years—the Vietnamese boat people come to mind. Those people didn’t arrive on our shores and all fall apart.” Well, to this I say, these people had a sense of in-group identity and a distrust for their new surroundings, so would not have sent the ailing among them for medical assistance, rather dealt with the suffering quietly within their own group. Further, and probably more importantly, not everyone is equally prepared to endure lengthy periods of stress. Not only reduced circumstances common to people in e.g. public housing, but also and more generally, there are people who having grown up in a time of economic depression, World War II and then rapid post-war change, may well have had exposure to neglect and trauma at crucial times of psychological development such that permanent alterations have taken place in the body/mind’s ability to resist the corrosion of stress. A 2001 “Meta-study” of the lasting vulnerability to stress of people whose maternal attachment was lacking during crucial formative years, is highly recommended if you wish to understand the physicality of so-called hypochondriacal or somaticized reactions to stress. It is entitled Attachment and Psychosomatic Medicine: Developmental Contributions to Stress and Disease.(<—click the link to view).