Part One: Why Difficult Reality Becomes So Hard to Face
Denial is one of the psychological defence mechanisms that can become particularly visible during psychotherapy.
At first, this may appear contradictory. A patient comes to psychotherapy because they already recognise that something is wrong. They may be experiencing difficulties in relationships, at work, within the family or in their general emotional life. They have actively sought the assistance of a psychotherapist because they want these difficulties to be understood and addressed.
Why, then, would the same patient deny some of the very realities that need to be explored?
The answer lies in the function of psychological defence.
Defence mechanisms are not simply obstacles created by an uncooperative patient. They form part of the way human beings protect themselves psychologically. Just as the body responds to physical danger, the mind develops ways of protecting the internal world from experiences that feel threatening, overwhelming or potentially damaging.
The threat does not have to involve physical violence.
For one person, harm may mean being physically attacked. For another, a humiliating remark, persistent criticism or rejection can have an enormous psychological impact. Someone who is highly sensitive, quiet or uncomfortable with confrontation may experience certain words as deeply injurious, particularly when those words communicate that they are inadequate, weak, incapable, unattractive, unwanted or useless.
Repeated social experiences can reinforce this injury. The person may have been bullied, excluded, pushed around, misunderstood or made to feel that they were not loved or valued.
Many patients entering psychotherapy have not necessarily experienced extreme physical violence. Their difficulties may instead have developed through years of emotional strain within relationships with parents, grandparents, brothers and sisters, partners, teachers, classmates or colleagues.
What happened externally becomes stored internally.
Later experiences can reactivate these earlier emotional memories. A person may be living in completely different circumstances and interacting with entirely different people, yet something about a current situation resembles what happened in the past.
A tone of voice, criticism, rejection, exclusion or conflict may reactivate an earlier experience of harm.
The present situation then carries considerably more emotional weight than it appears to contain on its own.
When ordinary coping is no longer sufficient
People frequently manage painful emotions by directing their attention elsewhere.
They work.
They study.
They concentrate on practical responsibilities.
They exercise.
They socialise.
They occupy themselves with tasks that provide structure and prevent difficult thoughts from dominating consciousness.
For a time, this can work extremely well.
The person may feel stronger because they are functioning and because the painful experience has moved temporarily into the background.
The difficulty develops when the surrounding environment repeatedly reactivates what has never been emotionally resolved.
The person can no longer refocus indefinitely.
Something at work, within a relationship or in everyday social life repeatedly brings the old experience back. The psychological protection becomes less effective and the individual becomes increasingly anxious, preoccupied or emotionally disturbed.
What makes this particularly difficult is that the patient is responding simultaneously to the present and the past.
They are speaking to somebody who exists today, but the emotional response may also contain memories of another person, another relationship and another time.
This is one reason difficult reality can become so complicated psychologically.
The patient is not simply refusing to look at what is happening now. Present-day reality may be awakening an internal reality that has remained painful for many years.
The anxiety of entering psychotherapy
When somebody finally seeks psychotherapy, another uncertainty appears.
The patient does not yet know what psychotherapy is going to do to them.
They may consciously hope:
“Perhaps this person will help me.”
At the same time, another part of them may fear:
“What is going to happen if I start talking about this?”
“Will psychotherapy make me feel worse?”
“Will I be judged?”
“Will this person understand me?”
“Will I lose control of emotions that I have spent years containing?”
This anxiety can be substantial.
The patient may already have spent a considerable part of their life protecting themselves from particular emotional experiences. They are now entering a relationship in which they are expected to speak about exactly those experiences.
For this reason, the first contact between the psychotherapist and the patient can be extremely important.
Before email and online booking became commonplace, the initial telephone conversation frequently provided the first indication of what the psychotherapist might be like. The patient listened carefully to the voice at the other end: whether the person sounded attentive, interested and receptive, or whether the contact seemed purely administrative.
The same principle remains relevant today.
The initial email, telephone conversation, consultation and first session all contribute to the patient’s developing sense of whether the psychotherapist feels trustworthy, reliable and emotionally safe.
The first encounter does not determine everything permanently, but it can strongly influence how the therapeutic alliance begins to develop.
This anxiety is not limited to somebody entering psychotherapy for the first time. Patients who have previously spent years in psychotherapy, and even practitioners themselves, can experience considerable apprehension when beginning work with a new psychotherapist.
The relationship is new.
The psychotherapist is unfamiliar.
The patient does not yet know whether what is most vulnerable inside them will be understood or mishandled.
When the patient talks about everything except the central difficulty
Suppose the initial consultation goes well and the patient decides to continue.
They attend regularly and discuss many aspects of their life.
They describe work.
They talk about relationships.
They discuss family members, current anxieties and practical difficulties.
Yet the most difficult material remains untouched.
The conversation repeatedly moves towards something important and then changes direction.
Another subject suddenly becomes more interesting.
Another problem appears more urgent.
A long explanation takes the discussion somewhere else.
This can sometimes be understood as a defensive process.
The patient is not necessarily sitting in the session deliberately thinking:
“I am going to stop the psychotherapist from discovering this.”
The avoidance may be substantially unconscious.
The conversation moves away because approaching the difficult reality would also mean approaching the emotions attached to it.
Denial therefore protects the patient even within psychotherapy.
The patient has consciously entered treatment because they want help, while unconsciously continuing to protect themselves from an experience that still feels psychologically dangerous.
These two positions can exist at the same time.
Why forcing the issue rarely helps
The psychotherapist therefore needs patience.
A patient cannot simply be ordered to confront something because the psychotherapist believes it is important.
A forceful approach can reproduce exactly the kind of intrusion the patient has spent years protecting themselves against.
The patient needs enough time to establish that the therapeutic relationship is dependable, confidential and psychologically safe.
Only then may certain experiences become possible to approach.
This can take weeks.
It can take months.
With some patients, it can take considerably longer.
Psychotherapy requires attention to timing.
An interpretation offered too early may obstruct the process because the patient does not yet have sufficient trust or emotional capacity to use it.
An important observation left too late can also lose its usefulness.
Learning when to intervene is part of the clinical skill of psychotherapy and develops through experience, supervision, teaching and continued reflection on the therapeutic process.
The psychotherapist is therefore not simply waiting passively.
They are observing.
They are listening for what repeatedly disappears from the conversation.
They are noticing when emotional tone suddenly changes.
They are considering what can be approached now and what still requires time.
Describing the reality while denying its emotional impact
Other patients present very differently.
They do not avoid the difficult event.
They can describe it immediately.
They may give an accurate and detailed account of childhood mistreatment, the ending of a relationship, a traumatic event or the death of somebody important.
Everything is factual.
What appears absent is the emotional response.
The patient may describe an extraordinarily painful event almost as though they were reporting something that happened to somebody else.
They know what happened.
They do not necessarily deny the factual reality.
What remains inaccessible is the emotional reality.
This is an important distinction.
A patient can recognise:
“My partner left.”
“My father died.”
“My child moved away.”
“My marriage ended.”
and still be unable to assimilate what that event means internally.
In these circumstances, denial may concern less the existence of the event than its psychological significance.
Loss as one of the most difficult realities
Loss and bereavement provide particularly clear examples.
Loss does not only mean death.
A marriage can end.
A partner can leave.
A friendship can disappear.
A child who has lived at home for eighteen or twenty years can move away to university, employment or another city.
For the child, this may represent independence and the beginning of adult life.
For the parent, it may represent the ending of an entire way of living.
The routines that existed from the time the child was born suddenly change.
The parent no longer sees them every morning.
Meals are different.
The house feels different.
The daily responsibilities that structured many years of life are no longer the same.
For some parents this transition is manageable.
For others it can feel remarkably similar to bereavement.
Attempts to retain the previous relationship may then appear through excessive questioning, constant contact, monitoring of the adult child’s whereabouts or attempts to control decisions that now belong to the child.
What appears externally as controlling behaviour may partly represent difficulty assimilating separation.
The parent is attempting to preserve something that psychologically feels as though it has been taken away.
Bereavement after prolonged illness
Death introduces an even more definitive reality.
When somebody has been seriously ill for a long period, relatives sometimes have an opportunity to anticipate what is going to happen.
For some people, witnessing a prolonged illness gradually makes the eventual death more possible to accept.
They have seen the deterioration.
They understand the medical reality.
They may even recognise that death will bring an end to severe suffering.
Other people remain unable to assimilate the loss despite understanding all of these facts.
After the person dies, they may continue speaking about them in the present tense.
Their routines may continue as though the deceased person were still going to return.
The emotional representation of the loved person remains alive inside them even though external reality has changed completely.
This should not immediately be pathologised.
Early grief frequently includes disbelief and difficulty absorbing what has happened.
The clinical concern is how rigidly this position persists, how greatly it interferes with functioning and whether the patient gradually becomes able to recognise the changed reality without becoming psychologically overwhelmed.
Sudden death and the absence of preparation
Unexpected death can be particularly difficult.
A road accident, sudden cardiac event, brain haemorrhage, undiagnosed illness or another unforeseen event can remove somebody from ordinary life almost instantly.
There has been no period of preparation.
Yesterday the person existed within the ordinary structure of life.
Today they do not.
The surviving person may repeatedly ask:
“Why?”
“How could this have happened?”
“Why did nobody know?”
“What if something had been done differently?”
“Why them?”
Questions about causality, destiny, responsibility and chance can become extremely powerful.
The mind searches for an explanation because the actual reality feels impossible to contain.
Denial can provide temporary protection against the emotional finality of what has happened.
But where the loss remains impossible to integrate, the denial that originally protected the patient can gradually become part of the difficulty itself.
Part Two: How Denial Becomes Visible and Is Worked With in Psychotherapy
Loss that has not been fully assimilated often becomes visible in the therapeutic relationship.
A patient who cannot tolerate separation from somebody who has died or departed may also find separation from the psychotherapist unusually difficult.
They may try to extend the session beyond its agreed ending.
They may repeatedly introduce important subjects during the final minutes.
They may attempt to telephone or make contact outside the agreed therapeutic framework.
They may experience breaks, holidays or changes in routine with considerable anxiety.
The boundaries of psychotherapy can begin to feel intolerable because every separation carries more than its immediate meaning.
The psychotherapist is no longer experienced only as the person conducting psychotherapy.
Over time, they may acquire some of the emotional meaning associated with the person who has been lost.
The psychotherapist may be experienced as dependable, reassuring, knowledgeable, safe and emotionally important.
The therapeutic relationship can then become the place in which the earlier loss is repeated in another form.
The internal representation of the lost person
Psychoanalytic thinking is particularly useful here.
Human beings do not retain important relationships only as factual memories.
We carry internal representations of people who have mattered to us.
Their voices, emotional qualities, habits and the ways in which they made us feel become part of our internal world.
When somebody important dies or leaves, the external relationship ends, but the internal representation remains.
In psychotherapy, elements of that representation may become attached to the psychotherapist through transference.
The patient may experience the psychotherapist as representing some of the goodness, reliability, authority or emotional security previously associated with the lost person.
The patient’s difficulty separating from the deceased person may consequently reappear as difficulty tolerating separation from the psychotherapist.
This does not mean that the psychotherapist literally becomes the lost parent, partner or child.
The present relationship remains real and distinct.
However, the emotional meanings carried from earlier relationships can become active within it.
Working through loss in the here and now
This is where transference and countertransference can become particularly valuable.
Rather than merely telling the patient:
“You have not accepted the death,”
the psychotherapist can observe how separation is being experienced in the present therapeutic relationship.
What happens towards the end of the session?
What happens before a break?
What happens when the psychotherapist is temporarily unavailable?
What feelings appear when the possibility of ending psychotherapy is discussed?
The answers may reveal something about the original difficulty with separation.
This material needs to be explored from different angles and over an extended period of time.
It should not be rushed.
One observation is rarely sufficient.
The patient needs repeated opportunities to see how the pattern appears, to think about it, reject interpretations that do not fit, reconsider others and gradually develop a more tolerable understanding of what loss means emotionally.
The purpose is not to force the patient to acknowledge:
“This person is gone.”
They usually know that already.
The purpose is to help the patient become psychologically able to live with what that reality means.
Conscious withholding is not the same as unconscious denial
Another essential distinction concerns information the patient deliberately chooses not to disclose.
A patient may have been unfaithful to a partner.
They may have engaged in financial dishonesty.
They may have lied, betrayed somebody or participated in behaviour they experience as shameful.
They may enter psychotherapy knowing exactly what happened while consciously deciding:
“I am not going to tell the psychotherapist about that.”
This is different from unconscious denial.
The person possesses the information.
They recognise its reality.
They know they are withholding it.
The reason may be shame, guilt, fear of judgement or concern about how they will be perceived.
This is conscious concealment.
A psychotherapist may sometimes sense that something important is being withheld because the patient’s account contains gaps or inconsistencies, but this does not justify interrogation.
The patient should not be put under a psychological spotlight and pressured into confession.
The therapeutic relationship is not an investigative interview.
Nevertheless, persistent deliberate deception can severely restrict psychotherapy.
If the patient constructs a version of themselves that they know to be false, the psychotherapist is being asked to work with information that does not accurately represent the patient’s life.
The deception then also becomes a deception of the self.
The same interpersonal pattern may continue outside psychotherapy because the patient never allows the underlying difficulty to become available for thought.
This is why the distinction is technically important:
conscious withholding involves knowing and deliberately concealing; unconscious denial involves being psychologically unable to assimilate a difficult reality or its emotional implications.
Confusing the two can lead to serious clinical errors.
Keeping emotion on the back burner
There is another group of patients who do not conceal the information at all.
They speak openly about what happened.
They know the circumstances.
They can provide substantial detail.
Yet the associated emotion remains heavily contained.
Outside psychotherapy, these patients may have spent years managing themselves by staying busy.
They work.
They study.
They socialise.
They organise other people.
They fill every available hour.
The activity prevents painful emotion from coming too close.
When they enter psychotherapy, the story may be told very clearly, but the raw emotional experience remains largely inaccessible.
In these circumstances, the cathartic element can become important.
There may eventually be a session in which grief, anger, fear or pain that has been held back for years finally becomes emotionally available.
That can be profoundly therapeutic.
But catharsis should not be manufactured.
The psychotherapist should not believe that the patient must cry, become angry or display intense emotion in order for psychotherapy to be successful.
The emotional release becomes meaningful when it emerges within a relationship that is sufficiently safe and when the patient has developed enough psychological capacity to tolerate what is being felt.
Again, timing is crucial.
Too early, and the experience may overwhelm the patient.
Too late, and an important therapeutic opportunity may be missed.
The aim is not simply to remove denial
When denial is understood only as a symptom to be eliminated, the psychotherapist can easily become too confrontational.
The more useful question is:
What would happen to this patient if the denial disappeared today?
Would they be able to tolerate the grief?
Would they collapse into shame?
Would the anxiety become unmanageable?
Would they become unable to work?
Would traumatic memories become overwhelming?
The defence exists for a reason.
The task is therefore not initially to destroy it.
The patient needs to become psychologically stronger.
They need sufficient internal capacity to survive the emotional experience that the denial has been protecting them from.
One might describe this as developing stronger internal psychological muscles.
The difficult experience does not necessarily disappear.
Instead, the patient becomes increasingly capable of carrying it.
From intrusive preoccupation to something that can be lived with
A patient who is struggling with unresolved loss may initially feel continuously invaded by it.
Thoughts enter consciousness repeatedly.
Memories interrupt work.
Emotions interfere with relationships.
The person wakes thinking about what has happened and goes to sleep with the same thoughts still present.
The experience can feel subjectively persecutory: intrusive, aggressive and impossible to escape.
This does not mean persecutory anxiety in the psychotic sense. Rather, the patient experiences their own thoughts and emotions as though they are continually attacking the mind.
Psychotherapy can gradually reduce this intrusive quality.
The aim is not necessarily to make the memory disappear.
The loved person may remain important for the rest of the patient’s life.
The loss remains part of their history.
What changes is the degree to which it dominates consciousness.
Something that once occupied almost the entire psychological field may gradually occupy much less of it.
The patient becomes able to work.
They can concentrate.
They can form relationships.
They can remember without being overwhelmed every time.
They can think about the loss consciously and digest the emotions attached to it without feeling psychologically destroyed.
This is an important measure of change.
The reality remains real, but it no longer interferes with everyday existence in the same relentless way.
Denial as both protection and obstacle
This is the paradox at the centre of denial.
At first, the defence protects the patient from pain.
Without it, the emotional experience may feel impossible.
But when denial persists rigidly, the same protection begins to interfere with life.
The patient cannot mourn because the loss cannot be acknowledged emotionally.
They cannot leave a destructive relationship because its reality cannot be accepted.
They cannot understand their anger because acknowledging it threatens an attachment.
They cannot adjust to change because part of them remains organised around a reality that no longer exists.
The defence that once helped the patient survive has become an obstacle to further psychological development.
This is why the work has to be gradual.
The psychotherapist helps the patient move from needing the denial towards being able to experience the underlying reality without becoming overwhelmed.
Building the capacity to live with painful reality
The ultimate therapeutic aim is not to erase what happened.
Bereavement cannot be reversed.
A relationship that ended cannot be made never to have ended.
Childhood cannot be rewritten.
A painful event cannot be removed from history.
Psychotherapy therefore works towards something more realistic.
The patient develops greater capacity to live with the truth of what happened.
They become able to remember without constant psychological intrusion.
They can experience sadness without collapsing into it.
They can acknowledge anger without destroying a relationship.
They can recognise separation without having to deny attachment.
They can understand that somebody is gone while still retaining a meaningful internal connection with that person.
This process can take a long time.
Biology, personality, earlier development, relationships and the current environment all influence how easily a person can assimilate painful reality.
For some patients, the process is relatively straightforward.
For others, it is one of the most difficult psychological tasks they will undertake.
Why the psychotherapist should not give up
Complexity does not make the work pointless.
Some patients require more time, more attention and a more carefully paced therapeutic process.
Progress may initially be very small.
The patient may tolerate one thought for slightly longer.
They may acknowledge one emotion that was previously inaccessible.
They may cope with one separation without the same degree of anxiety.
Over time, these changes can accumulate.
A reality that once felt psychologically impossible can become something the patient is capable of thinking about, feeling and surviving.
That achievement can be enormously important.
The patient may eventually recognise that they have reached a point they once believed was impossible: the painful reality still exists, but it no longer controls every part of their emotional life.
This is not because the past has been erased.
It is because the patient has changed in relation to it.
Denial in psychotherapy is therefore not simply refusal
When a patient denies difficult reality in psychotherapy, the psychotherapist needs to ask more than:
“Why won’t this person admit what is obvious?”
The more useful questions are:
What does acknowledging this reality threaten?
What emotion would appear if the denial weakened?
What has the patient needed the defence to protect?
How much can the patient currently tolerate?
And how can the therapeutic relationship help them become strong enough to experience something that previously had to remain psychologically distant?
Denial is present across many different areas of psychological life, but in psychotherapy it is particularly visible around loss, bereavement, separation, dependency, shame and emotionally painful memories.
Its presence does not mean that psychotherapy has failed.
Very often, it identifies exactly where some of the most important work needs to take place.
The task of the psychotherapist is not to expose, shame or defeat the patient.
It is to understand the protective function of the denial, establish sufficient trust and stability, and then work patiently with the difficult reality as it becomes increasingly possible for the patient to experience it.
When this process succeeds, reality does not become less real.
The patient becomes more capable of living with it.
Discussion Points
- Why might a patient seek psychotherapy for help while still unconsciously denying some of the most difficult realities affecting them?
- How does denial protect the patient from emotional pain, anxiety, grief or psychological overwhelm?
- Why is it important to distinguish unconscious denial from conscious withholding or deliberate deception in psychotherapy?
- How can a patient acknowledge that an event happened while still denying or remaining disconnected from its emotional impact?
- Why are loss, bereavement and separation particularly likely to activate denial as a defence mechanism?
- How can the departure of a child, the end of a relationship or the death of a loved one challenge a person’s internal sense of stability and continuity?
- In what ways can unresolved loss become re-enacted through the patient’s relationship with the psychotherapist?
- Why can confronting denial too quickly interfere with the therapeutic process rather than promote insight?
- How can transference and countertransference help the psychotherapist understand what difficult reality the patient is struggling to assimilate?
- What does therapeutic progress look like when the painful reality remains unchanged, but the patient becomes increasingly able to live with it without being overwhelmed?
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