The Role of Denial in Chronic Pain Management

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

The Roadblock Called Denial

If you don’t know whether or not you have a problem, it can be difficult to find a solution. Many of my clients have the mistaken belief that “I can’t be addicted because I’m in pain and a doctor gave me the medication.” If you do have a problem, and if in fact have been abusing or are addicted to your pain medication, as well as experiencing life-damaging consequences, this can be one of the four levels of denial. The first step in managing denial is recognizing it and understanding what level you’re at.

The Four Levels of Denial

The first level of denial is a lack of information about addiction, pain and recovery. The above example shows this first level. The solution here is for you to be open to education and information about addiction, pain and recovery. It is important for you to learn as much as you possibly can about medication dependency, abuse or addiction and what constitutes effective pain management.

The second level of denial is conscious defensiveness. You know that something is wrong but you don’t want to look at the problem and face the pain of knowing. You tend to vigorously defend yourself and deny a problem even though you know you have one. The solution for this level of denial is to recognize that you are experiencing an inner conflict where one part of you knows there’s a problem, but another part doesn’t want to admit it. To resolve this conflict you must be willing to listen to the part that knows the truth and take authentic action. The old saying “the truth will set you free” is certainly relevant in this case.

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

The fourth level is denial is the delusional system—this is the toughest level to get through. Terence Gorski describes this level of denial as “a mistaken belief that is firmly held to be true despite convincing evidence that it is not true.” Sometimes this fourth level is exacerbated by brain damage that was caused by the use of psychoactive substances, such as prescription medication and/or alcohol and other drugs. If your denial were at this level you probably would not be reading this article. People at this level of denial usually need psychotherapy and probably medication management to resolve their delusional system.

The Denial Management Process

Denial Management Counseling (DMC) is a treatment modality designed to assist people with alcohol and drug related problems or other self-defeating behaviors that are also experiencing high levels of denial and treatment resistance.

The DMC process focuses upon developing appropriate treatment plans, targeted interviewing, and using a sequence of proven action steps to help people to make the initial commitment to treatment. The main goal of DMC is to help motivate people to accept the need for additional help, to seek it out and follow through with specific action plans. Identifying and managing denial and resistance is often the missing link in many programs that treat addiction or chronic pain.

Goals of DMC

- Interrupt patterns of denial
- Recognize potential addiction related, or other self-defeating life problems
- Identify the problems and negative consequences that result from these self-defeating patterns
- Motivate clients to accept a referral to the next level of treatment

In my new Denial Management Counseling for Effective Pain Management Workbook by Stephen F. Grinstead, Terence T. Gorski, and Jennifer C. Messier, I adapted the DMC process and specified it for pain management. It is an excellent resource for those people who may need more comprehensive denial management work. To learn more about it please go to my website articles page http://www.addiction-free.com/articles/articles/view/from-denial-to-effective-pain-management; or go to my publications page http://www.addiction-free.com/publications.html to see how to order.

I believe that understanding and managing denial is crucial for effective pain management. The following are the titles and brief description of the twelve pain denial patterns from the Denial Management Counseling for Effective Pain Management Workbook, used with full permission.

The Pain Denial Pattern Checklist

1. Avoidance: "I'll do anything to not talk about my pain management problem!"

2. Total Denial: "No not me! I don’t have a problem with my pain!”

3. Minimizing: “My pain management problems aren’t that big of a deal!"

4. Rationalizing: "If I can find good enough reasons for my problems with pain management, I won’t have to deal with them!"

5. Blaming: "If I can prove that my problems with pain management aren’t my fault, I won’t have to deal with them!"

6. Comparing: “Showing that others are worse off than me proves that I don’t have serious problem with my pain management!"

7. Compliance: "I’ll pretend to give you what you want so you’ll leave me alone!"

8. Manipulating: "I play the game to convince others to do all the work for my pain management.”

9. Having A Flight Into Health: "Feeling better means that I’m cured and I can coast!"

10. Fear of Change: "If I don’t focus on having a problem with my pain I won’t know who I am or how else to relate!"

11. Diagnosing Myself as Beyond Help: "Since nothing I do has ever worked for my pain management, I don’t have to try anymore—I don’t want to be let down yet again!"

12. I Have the Right to be This Way, AKA It’s My Body: "I have the right to do whatever I want to do or don’t want to do with my body and for my pain management and no one has the right to tell me any different!"