Ambivalence and the Perfect Answer

Ambivalence:

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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