Ambivalence and the Perfect Answer


1.  uncertainty or fluctuation, especially when caused by inability to make a choice or by a simultaneous desire to say or do two opposite or conflicting things.

2.  Psychology : the coexistence within an individual of positive and negative feelings toward the same person, object, or action, simultaneously drawing him or her  in opposite directions.

Earlier this year, an Italian journalist who was writing about the concept of ambivalence for a Milanese newspaper came upon this earlier post where I covered ambivalence definition number two above.  In our interview, we discussed the ideas I put forward in that post, but her article examined ambivalence definition number one, as well.  I have some thoughts about that first aspect of ambivalence –the problems inherent in choosing — and some further reflections on the second.***

Over the years, many of my clients have discussed an inability to make up their minds when confronted with an important choice:   which career path to follow, where to vacation, how to spend some extra money, whether to accept a job offer, etc.; one client couldn’t decide which of two men she wanted to date on an exclusive basis and went endlessly back and forth between them without ever committing to either one.   In my experience, there are various reasons why people have such a hard time choosing, but at base, they usually reflect idealized expectations and an underlying perfectionism.

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Ethical Considerations Involved in Accepting Health Insurance

The fees we charge for psychotherapy, as discussed in the last two posts, also link to some ethical considerations that arise when psychotherapists accept health insurance for payment.  I’d like to discuss my experience in this area and invite my colleagues to share theirs.  I’d also like to hear how other readers who’ve been in treatment feel about these issues.

It’s been quite a while since I’ve accepted insurance, so this first issue may now be moot.  Earlier in my career, when insurance carriers offered more generous mental health benefits, it wasn’t unusual for a policy to pay 80% of the provider’s fee up to a fairly high limit.  Thus if my fee were $100 per session, it would pay $80 and the client would pay $20 out-of-pocket.  The maximum coverage used to be higher than what I actually charged.  On several occasions, I had clients ask if I would provide them with a bill that over-stated my charges so that the insurance company would reimburse me for the full amount of my actual fee; the client would pay nothing out-of-pocket.

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Defense Mechanisms II: Denial

Like projection and repression, denial is one of those psychological concepts that most people understand to some degree. It originated in the psychodynamic theories of Sigmund Freud, and his daughter Anna Freud wrote about it at length in The Ego and the Mechanisms of Defense.  Today,  virtually all psychotherapists recognize its existence, whether or not they regard it as clinically significant.  With the popularization of her Five Stages of Grief, Elisabeth Kubler-Ross raised the public profile of denial (the first of those stages) and the prevalence of 12-step programs has also promoted awareness of the concept:  a basic step in addressing addiction is to admit that you are, in fact, an addict, rather than to remain in denial about it.  The concept has become so much a part of our cultural knowledge that even  kids nowadays make joking reference to it:  The teenage son of a friend once told her (I no longer remember the occasion), “You are on that long river called Denial.”  Search that phrase on Google and you’ll get millions of results.

“You are in denial” is something most people have said or heard at one point or another in their lifetimes.  The expression generally refers to the denial of a fact.  “You’re in denial — can’t you see she has no interest you?”  Or:  “He is never going to leave his wife — you’re in denial.”  The concept is a simple one.  An unacceptable fact exists, one that conflicts with our wishes or beliefs, and so we deny that it is true.  We may also deny a feeling, especially if we’ve received cultural or parental messages that tell us such a feeling is unacceptable.   As a result of internalizing those messages, we may hide the existence of those feelings even from ourselves.  “I do not feel angry.” Or:  “No, I don’t hate my sister.”

As with most defenses, the existence of a conflict often motivates denial:   a fact conflicts with our wishes, or a feeling conflicts with our values and so we deny it.  Such denial can occur on the individual or group level, as with individual Holocaust deniers and whole countries that insist it never occurred. The wish to avoid pain also drives us to use denial.  Feelings of guilt for something that occurred may be unbearable to us so we deny responsibility for it.  I believe this variety of denial can also occur on group and national levels:  unbearable guilt surely plays some part in Holocaust denial and other instances of genocide.

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The Difference Between Shame and Guilt

According to Wikipedia, the “dividing line between the concepts of shame, guilt and embarrassment is not fully standardized.”  Many people use guilt and shame interchangeably, but from a psychological perspective, they actually refer to different experiences.   Quoting from Wikipedia:

“Psychoanalyst Helen B. Lewis argued that ‘The experience of shame is directly about the self, which is the focus of evaluation. In guilt, the self is not the central object of negative evaluation, but rather the thing done is the focus.’  Similarly, Fossum and Mason say in their book Facing Shame that ‘While guilt is a painful feeling of regret and responsibility for one’s actions, shame is a painful feeling about oneself as a person.'”

I would go further and say that the action that inspires guilt usually involves the infliction of pain, either intentionally or unintentionally, upon another person.  As an example, in the anecdote I related in my post on envy and jealousy, I once said something hurtful at a dinner party, and on some level, I intended it to be hurtful.  Afterward, I felt guilty about my actions because I could see that I had hurt my friend.  More painfully, I also felt ashamed that I was the sort of person who would behave that way.  Guilt arose as a result of inflicting pain on somebody else; I felt shame in relation to myself.

As a therapist, I find this distinction to be  important and useful.  Many deeply troubled people have very little capacity to feel guilt, for example.  In order to feel guilt about the harm you may have done to somebody else, you must recognize him or her as a distinct individual, to begin with.  Thus a person who struggles with separation and merger issues might not feel true guilt even if he or she were to use that word to describe a feeling.  Many people who display narcissistic behavior often suffer from profound feelings of shame but have little authentic concern for other people; they don’t tend to feel genuinely guilty.  This explains why an authentic sense of guilt rarely appears in narcissistic personality disorder and anti-social personality disorder:  guilt depends upon the ability to intuit how someone else might feel and as a result to experience remorse for the pain one has caused.

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Psychological Obstacles to Grief and the Grieving Process

We tend to talk about grief and the grieving process as if it were a separate category of emotional experience altogether,  different somehow from all the others.  Because it means confronting death, mortality and ultimate loss, the grieving process does have a uniquely large and pervasive impact on our psyches; from another point of view, however, grief is but one of the  emotions and when it becomes unbearable, we will ward it off in our characteristic ways.  In other words, when people go through the grieving process, you will often see them resort to their habitual defenses.  As discussed in my post on the tenacity of defenses, as we grow up, our modes of warding off pain become entrenched; even when we’ve evolved and developed new ways of coping on a day-to-day basis, when confronted with a feeling as difficult to bear as grief, we may fall into the familiar rut of our oldest defenses.

We had to put our dog Maddy to sleep yesterday.  While it’s not quite the same as losing a human member of our family, she has been a beloved part of our lives for the last ten years.  Her death has made me notice how we’re all responding to our grief, reflective of our particular defenses, and in not such unusual ways, I believe.  It has also stirred a lot of memories from 20 years ago when, within the space of a few months, my dear friend Tom Grant died of kidney cancer at the age of 45 and my mother-in-law Eva, then in her late 50s, succumbed to metastatic breast cancer.  These untimely deaths — Tom and his wife had two small children and my mother-in-law was fit, dynamic and vitally alive — have been among the major losses in my life and on occasions such as Maddy’s death, the feelings I had back then are still very much present to me.

Splitting and Projection

For the last year or so, Maddy has had a laryngeal problem common in older Labrador Retrievers; she was scheduled for corrective surgery on Monday.  In the four or five days leading up to the surgery, her condition had deteriorated badly and she basically stopped eating.  We thought it might have to do with her medications, but when we took her to the surgeon Monday morning, he immediately said, “This has nothing to do with her larynx problem.”  Her lungs were so full of fluid he couldn’t even read her X-ray.  He believed she had some fatal condition and presented euthanasia as an option, although he told us that congestive heart disease, a treatable condition, might also be to blame.

Maddy’s loss of appetite had filled me with dread.  Both my friend Tom and my mother-in-law lost their appetites as their conditions worsened; I felt sure Maddy had some form of cancer and I wanted to have her put to sleep that day — to prevent further needless suffering, I told myself.  The rest of the family felt otherwise and wanted to make sure of her condition first before taking such a step.  I felt very rational and level-headed but kept my opinions to myself.  This was my defense:  in order to evade the pain of loss, I split it off and projected it into the rest my family for them to carry; I became a bit detached and efficient, as I am wont to do at such a moment.  I’m good in crisis situations; my defenses help me put emotion aside and do what needs to be done, though in this case, it stopped me from feeling my own grief.

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