Depression and denial in psychotherapy of persons with disabilities

Disability may challenge some basic assumptions about the world, and some psychological aspects of self may be profoundly violated, particularly when onset is sudden and functional changes seem catastrophic. The losses incurred in disability, broadly defined, whether minimal or major, physical, psychologic, symbolic, or all of the above, may lead to some predictable human emotional responses, although individual patients' responses do vary. Factors including prior life history, concurrent life stressors, social and financial resources, intrapsychic functions, psychodynamic issues, and personal/subcultural issues may influence the experience of disability. Depression, as a natural concomitant to loss, may present in clinical form or in bereavement and grief patterns, and warrants full consideration (both diagnostically and therapeutically). In treating the patient with a disabling loss, the dynamic nature of denial must also be considered. The often visible inability or disability may stand in sharp contrast to that which is denied. The risk/benefit ratio of denial is a consideration when the psychotherapist weighs the need to maintain denial defensively versus the advisability of confronting the denial in an attempt to soften its brittleness. Countertransference reactions are also of prime importance and may differ from more typical reactions by virtue of the enormity of the patient's losses and their tendency to evoke the psychotherapist's own sense of vulnerability, mortality, and humanity.