From Denial to Effective Pain Management

Posted on Friday, December the 28th at 7:30pm

By: Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

            Learning to identify and manage denial is a necessary first step for people living with chronic pain who want to learn how to develop and implement an effective pain management plan.  The Denial Management Counseling for Effective Pain Management Workbook is designed for people who have experienced significant problems related to living with chronic pain, but who honestly don’t believe—or don’t want to believe—that their decisions and behaviors are undermining what could be an effective pain management plan. 

A major obstacle to recognizing these self-sabotaging behaviors and achieving effective pain treatment is the denial system—a psychological defense mechanism that protects us from devastating pain and problems that is automatic and unconscious.  It is important to remember that this system of defense was developed to protect us from being overwhelmed by what I call Painful Reality. 

There are situations when denial can help us cope with painful reality; e.g., the death of a loved one, an unforeseen medical crisis, etc.  Unfortunately, denial can also prevent us from looking at or dealing with a situation that is causing life-damaging consequences.   

If we don’t realize how serious our problem really is, it can be extremely difficult for us to find a solution.  For example, many people have a mistaken belief that “I can’t be addicted because I’m in pain and a doctor gave me the medication.”  This can be a type of denial if in fact they have been abusing or are addicted to their medication and experiencing life-damaging consequences.  Denial can be even subtler than this.  It can also lead people to behave in ways that are inconsistent with appropriate treatment recommendations.

There are four levels of denial.  The first is a lack of information—in this case what ineffective pain management or medication abuse/addiction really is.  The above example demonstrates this first level—the mistaken belief that because a doctor prescribed the medication, there won’t be an addiction problem.  The solution here is education and up-to-date information about addiction.  It is crucial for people living with chronic pain to learn as much as possible about effective pain management, pain disorders, and substance use disorders—i.e., prescription drug abuse or prescription drug addiction.

The second level of denial is conscious defensiveness.  At this level we know that something is wrong, but we don’t want to look at the problem and face the pain of knowing.  The solution is to recognize that there is an inner conflict occurring where one part of us knows there’s a problem, but another part doesn’t want to admit it.  To resolve this conflict we must be willing to listen to the part that knows the truth and take action.  The old saying “the truth will set you free” is certainly relevant in this case. 

The third level is denial as an unconscious defense mechanism.  We get to this level when we have stayed in the inner conflict, mentioned above, and the defensive voice keeps winning.  Once this happens, denial becomes an automatic and unconscious defense mechanism.  The solution is much more difficult.  It usually takes an outside intervention, or what is called a motivational crisis, to break through this defense and allow us to know the truth, and then start addressing the problem.  For some of my patients this motivational crisis was generated when their treating physicians became concerned about their mismanaged chronic pain or use/abuse of pain medication.  For others it was family members intervening and urging them to seek help.

The fourth level is denial as a delusional system, which is the toughest level to address. This delusion is a mistaken belief that is firmly held to be true despite convincing evidence that it is not true.  If someone was experiencing denial at this level, they probably wouldn’t be open to reading this book.  People at this level of denial usually need long-term psychotherapy to resolve their delusional system.

            The Denial Management Counseling for Effective Pain Management Workbook can be very effective in overcoming the first three levels of denial.  The workbook is divided into nine exercises.  Each exercise explains some basic information about denial or denial management and then asks clients to answer a series of questions that helps them apply that information to their current situation.  Below is a brief summary of each exercise from the workbook.

Exercise #1: Understanding Denial As A Part Of the Human Condition: This exercise explains that denial is a normal and natural part of the human condition.  Denial is related to our need to search for the truth about what is happening to us in spite of our tendency to make mistakes.  Whether we like to admit it or not, we all sometimes have fragile egos that can be easily hurt when we make mistakes.  This creates the tendency for us to lie to ourselves when we do make mistakes in order to avoid the pain.  We are all capable of convincing ourselves that the lies that we tell ourselves are in fact true.  Once we start believing our own lies, we can become deceptive and start lying to others whether we mean to or not.  As a result, we all need to develop personal and social systems for finding the truth while protecting ourselves from self-deception and the lies of others.  Denial management is a personal system for finding the truth while protecting us from self-deception.

Exercise #2:  Understanding The Principles Of Denial Management:  This exercise explains the basic information that is needed to understand and recognize denial so we can make a choice between continuing to lie to ourselves or facing and dealing with the truth. Denial is the natural tendency to avoid the pain that is caused by thinking and talking about serious problems.  This pain is avoided by using a set of automatic and unconscious thoughts, feelings, and actions that keep us from thinking and talking about our problems.  Denial is a normal psychological defense that has both benefits and disadvantages.  The major benefit of using denial is that it allows us to avoid feeling the pain caused by serious or overwhelming problems.  The major disadvantage is that it prevents us from seeing what is really going on and effectively managing our problems.  Fortunately, there are two antidotes for denial: (1) accepting the truth about what is going wrong with our lives, and (2) developing effective problem solving strategies to address our problems. The four primary feelings that drive denial are anger, fear, guilt, and shame.  The good news is that denial can be recognized.  We can face the truth about what is happening in our lives, and as a result, we can turn our lives around.

Exercise #3: Recognizing Your Personal Denial Patterns:  This exercise describes twelve common denial patterns that people tend to use to deny that they have serious problems.  You will be asked to review a denial pattern checklist that explains these denial patterns and to select and personalize the three denial patterns that you tend to use most often or the ones that cause you the most problems.

Exercise #4: Managing Your Denial:  This exercise shows you how to begin to challenge your inner saboteur (denial) by identifying and managing the thoughts, feelings, urges, actions, and social reactions that drive your personal denial process.  This process allows your responsible/wise self to empower you in making positive changes in your life.  You will be guided through a strategic step-by-step process and asked to be as thorough and honest with yourself as possible.

Exercise #5:  Stopping Denial As You Think About Your Problems:  This first application exercise will test your ability to recognize and manage your own denial as you think and talk about the problems that caused you to seek help.  First you will be asked to describe the problems that generated your desire to seek help.  Then you will be asked to look at the relationship of your problems to self-defeating behaviors—including possible prescription medication problems—and the potential consequences, both good and bad, of continuing to use these self-defeating patterns.  You will then be asked to tie all of this information together in your mind, look at the big picture of what is happening at this moment in your life, and make a hard decision about what you want to do about your problems.  At each step in this process, you will be asked to notice if you were able to recognize and stop your denial when it was turned on, by reviewing a mini denial pattern checklist and answering a few simple questions.

Exercise #6: Stopping Denial As You Think About Your Pain History:  In this exercise you will be asked to review the important things that have happened to you in the course of your pain history and think about how self-defeating patterns were related to each of the key events. Again, at each step in this process, you will be asked to notice if you were able to recognize and stop your denial when it was turned on.

Exercise #7: Stopping Denial As You Think About Your Prescription Medication Use:  In this final application exercise you will review 30 questions from the Prescription Medication Problem Checklist that indicates whether or not you could be experiencing medication abuse or even addiction.  Then you will have a chance to determine which ones apply to you.  You will then be able to see the potential level of problem you may be experiencing by completing the Interpreting the Prescription Medication Problem Checklist exercise. At each step in this process, you will be asked to notice if you were able to recognize and stop your denial when it was turned on.

Exercise #8: Stopping Denial As You Decide What To Do Next:  In this exercise you will be asked to decide what you are going to do next.  You can decide to stay in denial and pretend your problems don’t exist or you can decide to recognize your problems and enter an appropriate process in order to learn how to effectively manage your chronic pain problems and get your life back on track.

Exercise #9:  Evaluating Your Denial Management Skills:  In this exercise you will evaluate how well you learned the skills needed to recognize and manage your denial.  If you have been honest with yourself and others while completing this workbook you no longer have to be like the ostrich with your head in the sand.  You can now enjoy safe and effective pain management.