Understanding Denial and Avoidance

About this page

This page moves between clinical research and my own experience. Where I use first person, I am describing what denial has felt like for me, not offering a test for whether somebody else has DID.¹

Learning about DID can bring relief, fear, embarrassment, disbelief, or all four in quick succession. During an assessment, a therapist follows what happens over time: changes in identity, memory, and daily life, along with other possible explanations.¹

When doubt changes from one day to the next

Someone may describe the pattern clearly in one appointment and wonder why they ever brought it up at the next. A therapist can take both accounts seriously while gathering history and examples.¹

Doubt comes up often in accounts of DID. It may arrive as a sudden certainty that the whole thing was imagined.²³ In that moment, the doubt feels more convincing than everything that came before it.

When one state handles most of daily life

One state may handle work, appointments, and most conversations with family. Another may be more closely tied to traumatic memories and defensive responses. The theory of structural dissociation describes these broad orientations as an "apparently normal part" (ANP) and an "emotional part" (EP).⁴⁵

“Apparently normal” describes the state handling daily life. It does not mean “the real person.”⁵

The state handling daily life is often the one family, friends, or a therapist know best.⁵ Familiarity can become a hierarchy: this is the “main” person, while other states are treated as interruptions.⁶

Kluft noticed the same mistake in clinical work. He describes clinicians giving the host face validity as “the real person”⁶ because that state feels familiar and easier to work with. ISSTD guidance tells therapists not to treat any identity as more “real” or more important than another.⁷

In a 2024 qualitative study of first-person material, Söderberg and colleagues found that trust grew when professionals respected all parts.⁸ When only the familiar state is welcomed, the person can be left with a much harsher message: we want the part of you we already know. Other states may feel unwanted or treated as obstacles in the very room where all of them should be able to receive care.

When looking inward feels dangerous

Within this model, the ANP may avoid trauma reminders while an EP remains tied to traumatic memory and defensive responses.⁵

Clinicians call this “phobic avoidance.”⁹ It can happen quickly. A person goes blank in therapy, suddenly needs to change the subject, or becomes certain that none of it could be real.⁹

The structural-dissociation model gives a therapist and client something concrete to discuss: what happened just before the mind went blank, what changed, and what helped the person return.¹

Talk about what happens in the room

If reading about DID makes you want to close the tab, bring that moment into therapy. The same goes for going blank after a question, feeling pushed, or realizing you agreed just to move the session along.¹⁰

Therapists have a word for this: metacommunication. It means talking about the conversation or the relationship itself. Maybe the topic is too much. Maybe the pace is wrong. Maybe something the therapist said landed badly.¹⁰

A therapist may think the session went fine while the client leaves feeling pushed or unheard. In a longitudinal study of 132 people with DID or DDNOS, the clients' ratings of trust, goals, and collaboration predicted later symptoms and functioning more consistently than the therapists' ratings.¹¹ Across 11 psychotherapy studies, repairing strains like these had a moderate association with better outcomes.¹²

This can sound as ordinary as: “I don't want to talk about this today,” “I need you to slow down,” or “that explanation made me feel less safe.” The therapist may have missed the reaction until you said it.¹⁰

When a client says, “I need you to slow down,” the plan needs to change. As an example, hypnosis should not be used to get around that reluctance or bring up memories before the person is ready. ISSTD guidance starts with safety and stabilization, then moves into trauma work at a pace the person can manage.¹³¹⁴¹⁵ The treatment overview covers hypnosis and other methods in more detail.

Denial doesn't always feel like denial

I used to imagine denial as knowing something was true and deliberately refusing to admit it. My experience has been almost the opposite. When I am deeply in denial, I genuinely cannot understand why I ever believed I had DID.²

Things that previously felt obvious become distant and unconvincing. I may remember what happened, but lose whatever made it feel meaningful. Carolyn Spring describes something similar as only being able to see one “column” of knowledge at a time, while everything that contradicts it becomes difficult to reach.²

This is what makes denial so difficult to argue with. My current perspective feels like the sensible one simply because it is the perspective I have access to now. Then it changes again.²

Strouza and colleagues asked participants with DID to rate personally relevant, trauma-related words while different identity states were active. The ratings varied by state, and the pattern was still present at follow-up.¹⁶

When OCD gets tangled in it

For me, that uncertainty became tangled up with OCD. OCD can turn uncertainty into a demand for certainty, then keep me ruminating or re-checking long after I have stopped learning anything new.¹⁷ At the same time, denial around DID can leave me wanting to avoid the diagnosis altogether. I end up wanting an answer immediately and wanting nothing to do with the question.

For me, the phobia of internal experience feels like an alarm going off: “do not go there.” From the outside, that may look like refusal or “being difficult.” Inside, it feels urgent and automatic.⁹

Self-blame, guilt, and shame are common reactions after trauma.¹⁸ For me, they often sound like this: I am “too difficult.” I am causing problems for no reason. I should be able to stop.

A different way to ask the trauma question

Psychiatrist Mark Ettensohn makes a distinction I find helpful: trauma is better understood as the psychological injury left by an experience rather than the experience itself.¹⁹ Two people can live through a similar situation and carry different effects from it.¹⁹

This is one way denial can get a foothold. Someone may compare their history with a more obvious kind of harm, decide it does not qualify, and then dismiss the impact it has had on them.¹⁹ The question “was it bad enough?” comes up a lot. Ettensohn's distinction changes what the question is asking: the event alone cannot tell you what injury it left. The urge to find a threshold can still be strong, especially when I am looking for a reason why things are the way they are.

Denial can still have a protective purpose. It creates distance from material that feels too painful or overwhelming to hold all at once, making it possible to continue with ordinary life.²³¹³

Handling denial

ACT has a name for stepping back from a thought without trying to prove or disprove it: cognitive defusion.²⁰ Therapist Aid describes the move as shifting attention away from the content of thoughts to the process of thinking²¹. “I made it all up” becomes “I'm having the thought that I made it all up.”

DBT's radical acceptance deals with the moment in front of you. It asks a person to acknowledge reality without having to like or approve it.²² Therapist Aid writes: This doesn’t mean that you like or condone something - only that you accept it as a reality.²³ Here, reality may be no more settled than: “I am uncertain, and I am having experiences I do not yet understand.”

I have found that trying to reason my way into certainty rarely helps. I can reread diagnostic criteria, examine old messages, and ask for reassurance, but the relief does not last. My mind simply finds another objection. DIS-SOS recommends stepping away when this becomes circular, reducing stress, and returning to what can actually be observed in the present.³

Instead of deciding immediately what an experience proves, I can write down what happened:³

• I found something I do not remember writing.
• My understanding of myself changed sharply again.
• Something felt real yesterday and completely implausible today.
• I remember what happened, but it no longer feels like it happened to me.

Sometimes I notice denial becoming stronger when difficult material feels too close. Both DIS-SOS and Carolyn Spring describe approaching it carefully rather than tearing the defense down by force.²³ Understanding why it is needed may be part of the work itself.

I would still like certainty. I would like one stable understanding of myself that remains available no matter what state I am in. But perhaps the more realistic goal is learning to tolerate some uncertainty without repeatedly erasing what I have experienced.³

Sometimes all I can say is: “This feels impossible to believe today.” And leave the door open.²

Footnotes23

Footnotes

1. International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12(2), 115-187. pp. 123-125. Dissociation-focused clinical interviewing and corroborating history. ↩ ↩² ↩³ ↩⁴

2. Spring, C. (n.d.). My experience of living with dissociative identity disorder: Denial. Denial and the 'columns' metaphor. Lived-experience account of denial and periods when conflicting knowledge becomes difficult to access. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷

3. DIS-SOS. (2020, April 17). Denial and doubt in dissociative disorders. Stress, denial, and breaking circular doubt. Educational discussion of denial, self-doubt, stress reduction, and stepping away from unproductive cycles of checking. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

4. Nijenhuis, E. R. S., van der Hart, O., & Steele, K. (2010). Trauma-related structural dissociation of the personality. Activitas Nervosa Superior, 52, 1-23. Structural dissociation, ANP, EP, and phobic avoidance. Clinical-theoretical description of apparently normal parts, emotional parts, trauma-related action systems, and avoidance. ↩

5. Temple, M. J. (2018). Understanding, identifying and managing severe dissociative disorders in general psychiatric settings. BJPsych Advances, 25(1), 10-20. Structural dissociation theory. Clinical overview presenting structural dissociation as one explanatory model and describing ANP/EP terminology in severe dissociative disorders. ↩ ↩² ↩³ ↩⁴

6. Kluft, R. P. (2006). Dealing with alters: A pragmatic clinical perspective. Psychiatric Clinics of North America, 29(1), 281-304. p. 290, Box 1: Acknowledging the dissociative surface. Clinical discussion of why therapists may mistake the familiar host for the real person and why that ranking lacks a scientific or clinical basis. ↩ ↩²

7. International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12(2), 115-187. pp. 132-133. Clinical guidance against treating one identity as more real or important than another or excluding identities from treatment. ↩

8. Söderberg, A., Gabrielsson, S., Looi, G. E., Wiklund Gustin, L., Bäckström, J., & Lindgren, B. M. (2024). Being human under inhuman conditions: Meanings of living with severe dissociative states involving the experience of being in parts. Issues in Mental Health Nursing, 45(6), 597-606. p. 602, Daring to trust. Qualitative analysis of first-person online material describing trust when professionals understand and respect all parts, and harm when care does not provide safety or trust. ↩

9. Steele, K., van der Hart, O., & Nijenhuis, E. R. S. (2005). Phase-oriented treatment of structural dissociation in complex traumatization: Overcoming trauma-related phobias. Journal of Trauma & Dissociation, 6(3), 11-53. Abstract. Clinical account of trauma-related phobias, including traumatic memories and dissociative parts, within phase-oriented treatment. ↩ ↩² ↩³

10. Eubanks, C. F., Burckell, L. A., & Goldfried, M. R. (2018). Clinical consensus strategies to repair ruptures in the therapeutic alliance. Journal of Psychotherapy Integration, 28(1), 60-76. Results and discussion. Expert therapists rated addressing a rupture, exploring the person's experience, and exploring avoidance among the effective responses to strains in therapy. ↩ ↩² ↩³

11. Cronin, E., Brand, B. L., & Mattanah, J. F. (2014). The impact of the therapeutic alliance on treatment outcome in patients with dissociative disorders. European Journal of Psychotraumatology, 5, 22676. Abstract, results, and discussion. Longitudinal findings from 132 patients with DID or DDNOS; patient-rated alliance predicted later symptoms and functioning more consistently than therapist-rated alliance. ↩

12. Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55(4), 508-519. Abstract and first meta-analysis. Across 11 studies and 1,314 patients, rupture resolution had a moderate association with better psychotherapy outcomes. ↩

13. International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12(2), 115-187. pp. 135-136. Consensus model for sequenced treatment. ↩ ↩²

14. International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12(2), 115-187. pp. 136-141. Safety assessment, stabilization, symptom management, and pacing. ↩

15. International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12(2), 115-187. pp. 157-158. Leading questions, memory distortion, unwarranted confidence in recalled material, clinician training, and informed consent. ↩

16. Strouza, A. I., Lawrence, A. J., Vissia, E. M., Kakouris, A., Akan, A., Nijenhuis, E. R. S., Draijer, N., Chalavi, S., & Reinders, A. A. T. S. (2023). Identity state-dependent self-relevance and emotional intensity ratings of words in dissociative identity disorder: A controlled longitudinal study. Brain and Behavior, 13(10), e3208. Abstract and longitudinal results. Controlled study finding identity-state-dependent self-relevant and emotional processing in the DID group, with effects assessed again at follow-up. ↩

17. National Institute of Mental Health. (n.d.). Obsessive-compulsive disorder: When unwanted thoughts or repetitive behaviors take over. Signs and symptoms. Overview of obsessions, compulsions, recurring thoughts, and repetitive checking behavior in OCD. ↩

18. U.S. Department of Veterans Affairs, National Center for PTSD. (n.d.). Common reactions after trauma. Self-blame, guilt and shame. Public trauma guidance describing self-blame, guilt, and shame as common reactions after trauma. ↩

19. Ettensohn, M. (2026, July 24). The truth about narcissism and trauma [Video]. Heal NPD. 1:37-2:24, trauma as psychological injury. Clinical commentary about personality disorders. Included as a separate perspective on why the impact of an experience cannot be read from an event alone. ↩ ↩² ↩³

20. Biglan, A., Hayes, S. C., & Pistorello, J. (2008). Acceptance and commitment: Implications for prevention science. Prevention Science, 9(3), 139-152. Cognitive defusion. ACT overview describing cognitive defusion as changing a person's relationship to thoughts so they are experienced as thoughts rather than literal facts. ↩

21. Therapist Aid. (n.d.). Thought defusion: Cognitive distancing techniques [Worksheet]. Worksheet overview. Plain-language ACT worksheet describing defusion as shifting attention from what a thought says to the process of thinking. ↩

22. Wolbert, R. (2020, February 5). On radical acceptance (part 1). Behavioral Tech Institute. Acknowledgment, agreement, and approval. DBT educational explanation distinguishing radical acceptance from agreement or approval. ↩

23. Therapist Aid. (n.d.). Radical acceptance examples [Worksheet]. Worksheet overview. Plain-language DBT worksheet distinguishing acceptance of reality from liking or condoning it. ↩