Understanding Denial and Avoidance

About this page

This page combines clinical models, research, and personal experience. Personal sections are clearly identified and illustrate one way denial may feel; they are not evidence for or against any diagnosis.¹

Doubt is not a verdict

Learning about DID can bring relief, fear, embarrassment, disbelief, or all four in quick succession. None of those reactions confirms the diagnosis, and none rules it out. A careful assessment of identity disruption, memory, history, daily impact, and other possible explanations is still needed.¹

Someone may feel certain one day and dismiss the whole subject the next. This swing can be worth discussing in therapy, but it should not be taken as proof that a particular event happened or that a particular diagnosis is correct.¹

Doubt comes up often in accounts of DID, including the sudden conviction that the whole thing was imagined.²³ Whatever an assessment eventually finds, one doubtful thought doesn't get to decide the answer by itself. ACT calls one way of stepping back cognitive defusion: noticing a thought as a thought rather than treating it as literal truth.⁴ Therapist Aid describes the move as shifting attention away from the content of thoughts to the process of thinking⁵. “I made it all up” becomes “I'm having the thought that I made it all up.” DBT takes another route through radical acceptance, which asks a person to acknowledge reality without confusing acceptance with approval.⁶ Therapist Aid puts the distinction plainly: This doesn’t mean that you like or condone something - only that you accept it as a reality.⁷ In this case, reality may be no more settled than: “I am uncertain, and I am having experiences I do not yet understand.” That is enough to work with while the diagnosis remains open.

One model clinicians use to explain this

One framework clinicians use to make sense of that complexity is the theory of structural dissociation. It describes a trauma-related division between systems organized around ordinary daily life and systems organized around threat and survival.⁸

The theory uses the terms "apparently normal part" (ANP) and "emotional part" (EP). These are clinical shorthand, not official DSM or ICD criteria, and they are not a ranking of which state is the “real” person.⁹

An ANP may handle much of daily life, which often makes that state the one family, friends, or a therapist know best.⁹ Familiarity can quietly turn into a hierarchy: this is the “main” person, while other states are treated as interruptions.¹⁰

Kluft noticed the same mistake in clinical work. He describes clinicians giving the host face validity as “the real person”¹⁰ 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.¹¹

That distinction has a human cost. A 2024 qualitative study of first-person material found that trust grew when professionals respected all parts.¹² 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.

ANP, EP, and the pull to look away

Within this model, an ANP is oriented toward getting through daily life. An EP is organized around traumatic memory and defensive responses. The ANP actively avoids trauma-related cues, while the EP remains tied to them.⁹

This is why clinicians sometimes describe trauma as being surrounded by “phobic avoidance.” A person may recoil from traumatic memories, intense bodily feelings, or internal experiences associated with another state.¹³ The avoidance can be swift: a mind going blank in therapy, a sudden need to change the subject, or a fierce conviction that none of it could be real.¹³

Use the model, not a diagnosis

Some people find the model useful because it gives them language for experiences that were hard to describe. A clinician still needs concrete examples and enough time to see the pattern. They also need to consider other reasons memory or a person's sense of self may change. The model cannot confirm a memory or make every uncomfortable feeling evidence of an EP.¹

If the topic of DID makes you want to shut the tab, that reaction is worth noticing: structural dissociation is a framework for understanding experience, not a verdict, and the right next step is to bring your questions to a clinician rather than trying to sort it out on your own. You do not have to decide the whole question in one appointment.¹⁴

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.¹⁵ At the same time, denial around DID can leave me wanting to avoid the diagnosis altogether. It is a strange push and pull: one part of me wants an answer right now, while another wants 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.¹³

Self-blame, guilt, and shame are common reactions after trauma.¹⁶ It is all too easy to turn that reaction back on myself: I am “too difficult,” I am causing problems for no reason, I should be able to stop.

When it comes to treatment, clinical guidelines generally advise against forcing contact with memories or identity states. Clinical guidance favors safety, stabilization, and work that stays within what the person can manage before deeper trauma processing.¹⁴¹⁷

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

There is some clinical research that may help explain this experience. In a controlled longitudinal study, participants with DID rated personally relevant, trauma-related words differently across the identity states studied; the study also found that the group differences in self-relevance and emotional processing were consistent at follow-up.¹⁸

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, but as Ettensohn says, it's not about the event itself. This makes the premise of the question flawed and as such, not a useful one to ask, despite the strong temptations to find justifications for 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.²³¹⁴

Handling denial

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

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. 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. ↩

5. 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. ↩

6. 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. ↩

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

8. 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. ↩

9. 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

10. 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

11. 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. ↩

12. 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. ↩

13. 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

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. 135-136. Consensus model for sequenced treatment. ↩ ↩² ↩³

15. 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. ↩

16. 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. ↩

17. 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. ↩

18. 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. ↩

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