Managing the Inner Saboteur for Effective Chronic Pain Management

Posted on Friday, September the 10th at 12:27pm

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

Have you ever had an exciting dream or goal you wanted to accomplish but somehow got in your own way? Sometimes you don’t even realize how you set yourself up to fail which is often very frustrating. But if someone doesn’t believe they have a problem; it will be impossible to find a solution. If you refuse to acknowledge that there are self-defeating patterns that keep getting in your way, it will be extremely difficult to overcome them.

There are different ways of talking about that part of ourselves that can protect and sabotage us—sometimes at the same time. Some people call this our psychological defense system, while others call it denial or the inner saboteur. Have you ever heard the expression the committee in your head? Other people refer to it by the Zen concept called monkey mind.

Whatever phrase you use for this protective dynamic, it’s a combination of thoughts, opinions and beliefs that have developed over our lifetime. Sometimes there is a positive payoff and you feel protected while at the same time getting your needs met. Unfortunately, it can also be a blind spot that hurts more than it helps.

I have worked with many people living with chronic pain who developed coexisting disorders, such as addiction, depression, anxiety, or sleep disorders but they were unaware of it happening. They often didn’t manage these conditions very well and experienced life damaging consequences as a result. Others began having problems with their pain medication and developed a substance use disorder—prescription drug abuse or even addiction—and didn’t see it.
Just as the human body has an immune system to protect it from dangerous physical organisms, the human mind has a mental immune system to protect it from overwhelming pain and problems. I call this painful reality. That mental immune system is called a psychological defense. The purpose of this psychological defense is to protect our mind and personality.

Denial is a Normal and Natural Human Defense Mechanism

Denial is one part of this defensive system. It is activated whenever we are asked to think or talk about a painful or overwhelming problem. There is nothing sick, pathological, or wrong about this. Denial is a normal and natural human response to severe pain and problems, or painful reality.

During times of high stress the brain can get emotionally overloaded. The brain will activate automatic defenses called denial patterns. Each pattern is turned on by a specific trigger that threatens something that we value. As a severe problem causes intense stress, the brain turns on intense fear and/or anger. This activates a psychological program that starts mobilizing automatic defensive thoughts and urges to use resistant behaviors.

The denial system is major obstacle to recognizing these patterns of behavior and achieving effective pain treatment. This psychological defense mechanism protects us from devastating pain and problems and is automatic and unconscious. It is important to remember that this system of defense was developed to protect us from being overwhelmed by painful reality.

There are Four Levels of Denial

It is also important to realize that 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 then 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 arrive at this level when we have stayed too long in the inner conflict 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 level of defense and allow us to know the truth. Only then can we begin to address our 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 article. People at this level of denial usually need long-term psychotherapy to resolve their delusional system.

There are Two Primary Antidotes for Denial—Acceptance and Problem Solving

Acceptance is a peaceful acknowledgement of the truth. If you can calmly face the problem, acknowledge the truth about what is going on, and accept that it is happening to you, you can develop a way for handling any situation. The person who has accepted the truth of a serious problem has the ability to honestly affirm to themselves: "I have a serious problem! I am responsible for dealing with it! I'm willing to learn how!"

Problem Solving is a system for finding solutions to your problems. Effective problem solving systems involve identification and clarification of your problems, identifying and projecting the logical consequences of alternatives, deciding which alternative to use, taking action, and evaluating the outcome. By recognizing and accepting the problem and developing an effective problem solving plan, your need to use denial will go down because your ability to manage your problems will go up.

I teamed up with Terry Gorski and Dr. Jennifer Messier to write the Denial Management Counseling (DMC) for Effective Pain Management Workbook to offer a helpful resource for people with substance use disorders who need to learn how to identify and manage denial. This is also a necessary first step for anyone living with chronic pain who wants to develop and implement an effective pain management plan for long-term recovery. 

The DMC/Pain 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 their attempts at recovery. It can be one of the most important tools to help someone identify and learn to manage their inner saboteur.