What is denial as a cognitive mechanism?

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Denial is a cognitive mechanism in which aspects of reality are kept out of conscious awareness. It can serve as a defense against painful emotions or result from neurological impairment. It has an important emotional function in managing trauma and in coping with severe physical illness, particularly cancer.
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Introduction

The term “denial” originally described a psychological defense in which aspects of reality were kept out of a subject’s consciousness. In the strict sense, the person who denies something acts as if it does not exist. For example, a person with cancer looks in the mirror at a large facial tumor, blandly claims to see nothing there, does not seek medical care, and does not attend to the wound.

Types of Denial

Over time, the term has been broadened and refined, and related terms have been introduced. “Disavowal” is essentially a synonym, translated from Sigmund Freud’s use of the German word Verleugnung. Denial and disavowal include internal emotions; for example, unacceptable anger toward a parent who died. There is also denial of the emotional meaning of external events, such as the failure by Jews in the Warsaw Ghetto to recognize the relevance to them posed by Nazi genocide in other areas, even as they recognized the facts of what was happening. One can deny personal relevance, urgency, danger, emotion, or information. In each example, the subject has an unconscious emotional motivation for not allowing something into awareness.

To some degree, all defenses help a person avoid awareness of some part of the self or external reality. To this extent, denial is the cornerstone of the ego’s defensive functions. In denial, however, the excluded idea or feeling is not available to the subject in any form. In contrast, related ego defenses allow greater conscious and preconscious awareness of the avoided elements.

“Repression” is a related term for a psychological defense in which an emotionally charged fact is temporarily ignored and held out of consciousness but can emerge easily. For example, a student who knows he has bad grades on a report card may “forget” to bring home his school backpack containing the grades. However, he will be aware of a nagging feeling of something amiss and instantly remember that he has left it at school when questioned.

Similarly, “negation” refers to a defense in which a fact is allowed into consciousness but only in the negative. An example would be someone who states, “I’m not jealous. I really admire all that she has.” By allowing the possibility of jealousy but negating one’s connection to it, denial of the emotion is maintained. In contrast, in true denial the idea of jealousy could not be allowed in consciousness at all.

Denial functions to prevent the individual from becoming overwhelmed by the threatening aspects of a situation. If the emotional impact of something is too great, it is initially kept out of awareness. Patients diagnosed with a terminal illness often respond with denial when they first receive this news. After the destruction of the World Trade Center towers in 2001, some Americans denied the facts of the huge buildings’ collapse into dust, maintaining hope of survivors being found far beyond what could be medically expected, to soften the impact of that magnitude of loss.

Denial can be adaptive or maladaptive. Adaptive denial allows a person to function in a situation of unavoidable pain or danger. Maladaptive denial worsens functioning because action is needed on the denied elements. For example, in Roberto Benigni’s film La Vita é Bella (1997; Life Is Beautiful, 1998), a father and son are in a German concentration camp in World War II. The father translates German commands incorrectly for his son, making up a game in which they must do certain things truly demanded by the Germans to get a big prize. By denying the danger and the meaning of the subjugation they face, he protects his son from overwhelming fear, humiliation, and anger. His denial is also adaptive because his son is still able to function as he must to survive. Ultimately, however, the father’s denial becomes maladaptive for him. He becomes too wrapped up in the story to accommodate a changing situation and makes mistakes that result in his death.

Common examples of adaptive denial include disavowal of one’s eventual death or the degree of risk in daily behaviors such as driving a car. Common examples of maladaptive denial include a substance abuser’s refusal to see a problem or a teenager’s denial of the risk in experimental behavior. In empirical studies, for example, smokers rate the health risk of smoking, especially for themselves, lower than do nonsmokers.

Neurology of Denial

Denial can also result from neurological impairment. Anosognosia is a phenomenon common to patients with right hemispheric stroke in which they fail to recognize (neglect) or seem indifferent to anything located to their left. This can be visual—objects held up, words, or their own body parts—as well as tactile or auditory. For example, they will not shave the left side of the face, will forget to wear a left shoe, or will read only “girl” if shown the word “schoolgirl.” Alienation is an extreme version of this, in which patients fail to recognize their own body parts. Shown their left arm, they may say, “Yes, it is attached to my left shoulder, but it is not mine,” or “That is your arm, doctor.” They maintain this view even when confronted. For example, when asked, “Is this not your wedding ring on this hand?” they may answer, “Yes, doctor. Why are you wearing my ring?” Anosodiaphoria is a related syndrome in which the patient recognizes he or she is paralyzed but denies the emotional significance of the inability to move.

Denial and neglect of this type are most often associated with lesions of the right inferior parietal lobule, a brain area thought important in the circuitry of the general arousal response that allows people to attend to stimuli from the opposite side. The cingulate gyrus and right thalamus have also been associated with this deficit. That these lesions are part of more global self-awareness and arousal circuits, however, is demonstrated by the disease of Wernicke-Korsakoff syndrome. In Wernicke-Korsakoff syndrome, caused by alcoholism, there is no discrete brain lesion. The individual loses the ability to form new memories and will confabulate, that is, make up stories about his or her life and also make up answers to questions, while appearing to deny any awareness that the stories are not true. Anton’s syndrome is another denial syndrome, associated with bilateral occipital blindness, in which the individual believes and acts as if he or she is not blind.

The use and consequences of denial in cancer patients have been extensively studied. The majority of the studies suggest that people with heavier use of denial as a personality trait have an increased risk of breast, melanoma, and other cancers. Such people show increased levels of physical stress, such as blood pressure changes, when confronted with disturbing stimuli, but they are more likely not to report feeling upset. Chronic stress such as this, particularly linked to anger, is likely connected to changes in immune function and other physical events that compromise tumor suppression. Such people also tend to delay going to the doctor for diagnosis and treatment, further worsening prognosis.

In contrast, patients who deny their emotional reactions while in the state of recent diagnosis of cancer tend to have complied with treatment and report less emotional distress when evaluated months later. Their denial helps them not be overwhelmed by the traumatic news that they have cancer. Thus it appears that, in cancer patients, denial as a reaction to an acute threat promotes physical and mental health, while denial as a general coping strategy does not.

History of Denial

Psychoanalyst Sigmund Freud first described the concept of disavowal, or Verleugnung, in 1923, in developing his notions of infantile sexuality. He said that children see a little girl’s lack of a penis but “disavow” this fact and believe they see one anyway. He believed children later accept that the girl lacks a penis but are traumatized by this awareness, which Freud linked to female penis envy and male castration anxiety. Freud described a similar disavowal in writing about the fetishist in 1927. He believed fetishists choose a fetishistic object to replace a penis and thereby deny female castration in external reality but also experience anxiety if the object is not available, showing internal awareness of castration.

Freud believed that all human capacity to say “no” was fueled by the death instinct. He linked denial to three other types of “saying no”: projection, negation, and repression. Because disavowal most rejects external reality, however, he thought that it “split the ego” and was the first step toward psychosis. It was also the most extreme form of negation.

Anna Freud also wrote about denial as a basic defense that was normal in children but not in adults. René Spitz described a developmental course to the infant’s ability to say no. He took the infant who closes his eyes or falls asleep in an intensely stimulating or upsetting environment as the prototype for later forms of denial. Head-shaking and hiding behind a parent are later forms of denial. Spitz thought that denial expressed in this way was the first abstract thought of the infant because it involves imagining an alternative option to the current reality. He also noted its positive role in promoting independence, both in infants and in adolescents. Contemporary theorists such as Theodore Dorpat and Charles Brenner have refined notions of the psychological mechanism of denial and its subtypes, and they have struggled to distinguish how it differs from and underlies other psychological defenses. Others have studied the effects of denial in different populations, such as cancer patients. In everyday clinical practice, psychoanalysts and psychologists work with individual patients to determine when denial must be broken through to promote the individual’s self-acceptance and mental and physical health, and when denial should not be confronted to avoid overwhelming a person with painful feelings. In this ongoing work, the understanding of denial remains at the core of the understanding of human coping and defense.

Bibliography

Becker, Ernest. The Denial of Death. London: Souvenir, 2011. Print.

Edelstein, E. L., D. L. Nathanson, and A. M. Stone, eds. Denial: A Clarification of Concepts and Research. New York: Plenum, 1989. Print.

Freud, Anna. The Ego and the Mechanisms of Defense. New York: International UP, 1974. Print.

Gillick, Muriel R. The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies. Cambridge: Harvard UP, 2007. Print.

Heffernan, Margaret. Willful Blindness: Why We Ignore the Obvious at our Peril. New York: Walker, 2011. Print.

Kreitler, S. “Denial in Cancer Patients.” Cancer Investigation 17.7 (1999): 514–34. Print.

Trivers, Robert. The Folly of Fools: The Logic of Deceit and Self-Deception in Human Life. New York: Basic, 2011. Print.

Zerubavel, Eviatar. The Elephant in the Room: Silence and Denial in Everyday Life. New York: Oxford UP, 2007. Print.

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