This natural defense mechanism can be problematic for people with diabetes to get their self-management under control. Psychotherapist Eliot LeBow, LCSW, explains what denial is and how providers can recognize it and get patients the help they need for it.

By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net

The middle-aged man sits down on the table in the examining room of his primary care provider’s (PCP) office. He is clinically obese, yet he doesn’t feel like his situation is a big deal. He just needs to lose weight. His blood sugars suggest otherwise. In fact, this man has type 2 diabetes and has had the disease for a little over a year.

The patient does not realize what the high blood sugars coursing through his veins, extremities, and internal organs are doing to him. Maybe, the man reasons, I’ll be really old before my diabetes bothers me and it won’t matter at that point. This man may be suffering from denial, a typically healthy self-defense mechanism that everyone has, according to psychotherapist Eliot LeBow , LCSW. However, LeBow explains that to much denial hurts because the person doesn’t recognize the danger’s that come with diabetes and fails to act in his best interests to take care of his disease.

The man’s physician, somewhat frustrated at this point, has tried to help his patient get under control through medication, suggested joining a gym, and counseled him on his diet. Unfortunately, the man doesn’t see what good any of this will do. The provider has tried to get the patient to accept his diabetes and the need for self-management. And LeBow cautions this approach while seemingly the natural thing for the provider to do, might actually be the wrong approach to go about getting the patient to be self compliant.

A person with type 1 himself, LeBow, has a private psychotherapy practice in New York City and specializes in seeing patients with diabetes. Having had the disease for over 30 years, he knows many of the ups and down associated with the disease.

This aforementioned scenario, while alarming to those with diabetes who understand the long-term effects of diabetes, could be happening to any person with the disease.

DiabetesCare.net spoke with LeBow about defining denial in persons with diabetes, the differences between it and depression, how clinicians can recognize it, and methods to overcome it.

DiabetesCare.net: Can you provide an overview of what denial of diabetes would be?

LeBow: Denial is primary defense mechanism where an individual refuses to acknowledge the very existence or severity of ones internal and external realities, which are kept out of our consciousness. Denial is one of the first defense mechanisms we learn as children. Denial is a way that humans cope with life as a survival function. It is when there is too much denial that it becomes detrimental.

It can be characterized in diabetes by not accepting that lifestyle changes need to occur. In diabetes, there are many elements of management and some examples of denial might include not checking blood sugars, not eating the right things or exercising. It always comes back to how someone is looking at their lifestyle, and not taking care of themselves in relationship to lifestyle.

DiabetesCare.net: What is the difference between denial of diabetes and depression?

LeBow: When depressed with diabetes as a factor--the individual may be overly aware he or she has the disease and focuses on the negative impact of the illness. Denial is a lack of recognition of the impact diabetes will play on their lives.

In a severe form of denial, people may say they don’t have diabetes and that the doctors are lying. They will make up an excuse like, ‘it doesn’t run in my family therefore I can’t have it,’ so that they don’t have to face the actual illness.

It is hard for people who don’t understand psychology or illnesses to understand how people can go around saying they don’t have diabetes. There are some realities depending on who you are, that just cannot be faced.

DiabetesCare.net: What are some of the signs medical providers look for in determining a patient is in denial about their diabetes?

LeBow: One of the biggest ones right off the bat is they don’t change their diet. Or, they never have their glucose meters or supplies to take care of themselves with them.  As a provider, when I have someone who has diabetes come in for the first time, I ask them to test their blood sugar. Meters are a lifeline in diabetes, and it’s how you know where you are with your glucose. Most of the time, if you are not in denial, you carry it around with you so you stay safe.

At times, people don’t have their meters, and so there is some level of denial there.

When a patient says they can manage their diabetes without changing their lifestyle that could be a sign.

If they spend their whole appointment with the doctor, saying they are not or cannot do any of the things that are requested of them, that could another sign of denial.

A big sign of denial is if a person states how he or she knows a friend or family member with diabetes who is doing much worse than they are. Most denial statements come with a ‘I’m not that bad or I am fine, because I am doing better then other diabetics I know.’

DiabetesCare.net: Could there be other underlying mental issues with a person that is creating the denial or is it simply that denial is a defense mechanism and it just affects people differently?

LeBow: There can be underlying mental health issues that can reinforce ones denial but there doesn’t have to be. An example of a psychiatric disorder that uses denial is Narcissistic Personality Disorder where the person disregards all information that suggests that they are not perfect. Denial is a defense mechanism that people with or without mental illness use. Allot of times denial is happening because a person is afraid and sometimes terrified to look at something happening in their life or around them.

DiabetesCare.net: For those medical providers who may be inclined to want to provide testing before recommending a referral to a mental health professional are there any tests they can administer to patients or is this more of a professional hunch in listening to people?

LeBow: In terms of tests there is a scale measure. There is a general overall self-denial scale test which is the Balanced Inventory of Desirable Responding (BIDR) scale. It goes through several random questions, and based on how you answer, it calculates how much overall denial you have in life.

While providers can administer this BIDR test, I would recommend providers go on their hunches. If they see a patient is not following what the provider is asking, it would be good to get them to a psychotherapist because there is something there that is stopping them from going forward. If the person is not doing what they need to do to take care of themselves, something is blocking that.

One of the problems in understanding where that is coming from is that doctors tend to see diabetics when they are sick. The person with diabetes goes into the provider’s office when the sugars are high and they haven’t learned anything about their diabetes yet.

They get taught information when they are cognitively unable to retain it. The person can be in denial or the person’s blood sugars can be out of control so they are not able to retain the information.

The doctor might say in a follow-up appointment that, ‘I told you this last week.” The patient might respond by deny being told that, and therefore, the patient might not have absorbed it if their blood sugars were high.

It can get a little tricky. In general a psychotherapist may not look at whether a person’s blood sugar is a cause of their symptoms and take the time to work with them in getting their diabetes under control. At the moment, there are just a few psychotherapists like myself who specialize in diabetes worldwide. It is growing, but I always recommend that endocrinologists refer their patients to a certified diabetes educator in conjunction with a psychotherapist. The difficulty comes in when fluctuating or abnormal blood sugars levels change the emotional state of the diabetic while they are being evaluated for mental illness. The symptoms of abnormal blood sugars are very similar to some psychiatric issues.

DiabetesCare.net: Do you recommend these patients being referred to a psychiatrist first before a psychotherapist?

LeBow: If the doctor thinks the patient is in denial or that they needs help dealing with their diabetes, then they should be referred to a psychotherapist. If there is a major psychiatric disorder, then referral to a psychotherapist or a psychiatrist maybe warranted based on the doctors judgment but if the patient is suicidal then they will need hospitalization.

When the doctor does the referral to a psychotherapist, the doctor needs to inform the patient he or she needs to be clear with the therapist in the beginning that they have diabetes. The endochronologist or a nurse should call the psychotherapist a head of time & inform the psychotherapist that abnormal blood sugars levels impact emotional states and produce psychiatric symptoms that can mirror depression or panic disorders and what symptoms to expect.

To make it easier a form with the symptoms and impact of diabetes on the diagnosing process might be good to create to send with the patient. Otherwise, it might go undiscovered when seeing a psychotherapist leading to possible misdiagnosis.

DiabetesCare.net: While denial can be dangerous for someone with diabetes in taking care of themselves, it might be hard to make the case to refer someone to a mental health professional for treatment. How do you frame the discussion to either people with the disease and medical providers that it is something that should be addressed by a mental health professional?

LeBow: The doctor should not address the denial directly because the doctor won’t get anywhere with it. He needs to tell the patient they need to be evaluated by a psychotherapist, due to trauma that being diagnosed with diabetes may cause. As far as explaining it to the patient, the doctor just needs to say, ‘as part of my practice I have patients go to see a psychotherapist for evaluation.’  The doctor can utilize his position of authority here.

Diabetescare.net: When sitting down with a patient who is in denial, how would you go about trying to get them to accept their diagnosis and work towards better disease self-management?

LeBow: The best thing to do is not address the actual denial; they don’t want to face that they have diabetes. One of the best approaches is to ask them, ‘what areas of your life are you unhappiest?’ You have to find out what the patient wants to work on. There is usually something in there that is related to their health and well-being. It can be something the patient works on and as he or she works on it, slowly the denial will unravel. As you work on these other parts of their lives, the diabetes will come into play.

So, if the person has an issue with his weight, two-thirds of diabetes management is exercise and eating well. So these things fall into weight management. You may send them to a weight-loss program and suggest some sort of exercise to get them moving.

The person with diabetes may begin an exercise program and while they are doing exercise, they have a hypoglycemic episode where the person has to take something with sugar in it. Now they want to address the weight issue, but now they have come across a problem. The person might go to their therapist and tell them about the hypoglycemic incident.

Now if someone came to me with this problem, I would inform the patient he or she needs to adjust for this. And that is the beginning of self-care. This way, if this person continues to exercise, he or she knows they will have to carry hard candy with them for the reaction. They don’t have to acknowledge they have diabetes out loud, but the person has begun the self-management process.

You may have someone with type 1 diabetes, and they are not checking their blood sugar regularly, but you discover they have a relationship issue. You may start to bring them into couples counseling. You are attempting to solve another problem, and once you are able to solve that problem the other issues will be addressed.

DiabetesCare.net: It sounds like you don’t address the denial head on, but look for projects they can work on, and then they might start to realize denial has been a part of their life?

LeBow: No, a person may never realize they were in denial. It is the therapist’s job to work them out of it. And telling someone he or she has denial will only make the person say, ‘I don’t have denial.’ It is one of those issues where people don’t want to be told that.

Over time, while the therapist works on other issues and guides, the diabetic, they will go through issues brought about by the diabetes that helps the person wake up to the fact that they need to take care of their diabetes. It the therapist is successful, person eventually realizes how much the disease is impacting their lives and they might say I have to take better care of myself.

It is a gradual process. There are some clinicians who tell their patients, ‘you have to accept this.’ The clinicians have this need to want to take care of their patients. You have to allow patients to learn from their own experiences, and if they are in denial they are not ready to accept they have an illness.

One of the hardest parts is that there is a dangerous medical aspect; if they go too low or high they could end up in the hospital. If they are in denial and you sit there fighting with them, they could go further into denial, and their defenses go higher, and they still end up in the hospital. However, if you work with them slowly and carefully, these people are more likely to open up to say I have a problem.

If you try to force the realization of the disease on them it is going to have the opposite effect on them. It takes time to change, and you want to give them guidance along the way.

LeBow specializes in treating people with diabetes, and If you are interested in finding out more about LeBow's practice, you can visit his website here or contact him at: eliot.lebow@gmail.com.

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