Deck 10: Empathic Confrontation and the Creative New: Identifying and Challenging Client Conflict

Question 1

_______________ is essential if you are to challenge the client with a confrontation.

A)​An empathic relationship
B)​An assertive personality
C)​A strong affirmation
D)All of these

Answer 1

A

Question 2

Empathic confrontation is:

A)​a direct, harsh challenge guiding clients to face hard issues.
B)​a gentle skill that includes listening.
C)​seeking clarification by "going against" a client's ideas.
D)the primary skill used by interviewers.

Answer 2

B

Question 3

"Mobility" is to "immobility" as "cultural intentionality" is to ____.

A)​stuckness
B)​impasse
C)​blocked
D)all of the above

Answer 3

D

Question 4

Uncontrollable conflict and discrepancy bring stress to the client resulting in ____.

A)​active inhibition of neurons and damaging glucocorticoids and cortisol being released
B)​gradual strengthening of an individual through development of protective neural structures
C)​an ultimate challenge to the counselor
D)an ultimate challenge to the counselor

Question 5

Careful listening is one of the most powerful influencing skills. Which one of the following statements about influencing is NOT true?

A)​Paraphrasing is particularly useful when decisions need to be made.
B)​Reflection of feeling is useful to feed back mixed emotions.
C)​Direct and firm confrontation helps clients identify their errors.
D)A good summary brings together many thoughts, feelings, and behaviors.

Question 6

As a result of effective and empathic confrontation, a counselor or interviewer can anticipate that the client will ________.

A)​resolve his or her issues
B)​move to a more productive topic
C)​come up with new ideas, thoughts, and feelings
D)become angry

Question 7

Empathic confrontation is best described as _____________.

A)​direct eye contact and a clear voice
B)​identifying mixed messages
C)​a gentle, but firm, challenge
D)all of these

Question 8

A nonjudgmental attitude requires that you assume:

A)​an evaluative style of listening to detect client deception.
B)​a sense neutrality in relation to your client.
C)​active and assertive communication with your client.
D)all of these

Question 9

According to the authors, direct confrontation may be inappropriate for:

A)​European American clients.
B)​African American clients.
C)​European Canadian clients.
D)Native American clients.

Question 10

Empathic confrontation is:

A)​a direct, harsh challenge guiding clients to face hard issues.
B)​a complex set of skills requiring observation and listening.
C)​seeking clarification by "going against" a client's idea.
D)the primary skill used by interviewers to cause clients to see their errors.

Question 11

According to the authors, an important goal of interviewing is to move clients from

A)​ideas to feelings.
B)​problem focus to person focus.
C)​closed questions to open questions.
D)stuckness to intentionality.

Question 12

A nonjudgmental attitude requires that you:

A)​assert your opinions with a positive attitude.
B)​stop your listening skills and let client speak.
C)​suspend your own opinions and attitudes.
D)all of these

Question 13

The first step in confrontation is:

A)​establishing rapport.
B)​asking the client why he or she did it.
C)​identifying a contradiction or discrepancy.
D)confronting the client.

Question 14

Which one of the following is NOT a technique to supportively challenge or confront a client?

A)​Observe and note discrepancies and conflict.
B)​Feed back internal and external discrepancies to the client.
C)​Match tonal quality with the client during the feedback of discrepancies.
D)Evaluate the client response and whether there is change.

Question 15

What are the three major steps of confrontation?

A)​Step 1: Identifying conflict; Step 2: Pointing out conflicts and issues; Step 3: Evaluating effectiveness
B)​Step 1: Building rapport; Step 2: Identifying discrepancies; Step 3: Confronting client's thinking
C)​Step 1: Identifying conflict; Step 2: Countering client talk; Step 3: Closing with a directive
D)Step 1: Building rapport; Step 2: Pointing out conflicts and issues; Step 3: Evaluating client response

Question 16

"On the one hand..., and on the other hand..." This is typically used in _________.

A)​reframing
B)​empathic confrontation
C)​psychoeducation
D)interpretation

Question 17

Discrepancies internal to the client include:

A)​mixed messages observed in nonverbal client behavior.
B)​incongruities between two verbal statements.
C)​differences between what the client says and what the client does.
D)all of the above.

Question 18

A nonjudgmental attitude is expressed through which of the following?

A)​Body language
B)​Vocal qualities
C)​Statements that indicate neither approval nor disapproval
D)All of these

Question 19

Incongruities and discrepancies of the interviewee that should be identified include all EXCEPT which of the following?

A)​Between two statements
B)​Between statements and nonverbal behavior
C)​Between the influencing skill used by the interviewer and the interviewee response
D)Between what one says and what one does

Question 20

Which word is NOT interchangeable with all the others?

A)​Discrepancy
B)​Incongruity
C)​Conflict
D)Observation

Question 21

Client response: "I think I see what you're saying. There is a big incongruity there. I want to stop, but I was abused and hit by my parents. I think I'm doing better than they did-at least I don't strike Amie. But perhaps I can do something different next week. I'll try your new idea about disciplining her."This client is where on the CCS?

A)​Partial examination
B)​Full examination, no change
C)​Decision to live with incongruity
D)Development of new constructs, patterns, or behaviors

Question 22

"I've been avoiding my anger, and it is getting in my way. I'm going to start dealing with it." An interviewer may hear this statement in which level of the Client Change Scale (CCS)?

A)​Level 1: Denial
B)​Level 4: Generation of a new solution
C)​Level 5: Development of new constructs, patterns, or behaviors
D)Level 3: Acceptance and recognition, but no change

Question 23

Regarding discrepancies between you and your client, which of the following is NOT true?

A)​Never hide differences you may have with your client.
B)​If you sense differences, support the client by listening.
C)​Note your own or the client's discomfort with possible differences.
D)If you listen carefully, most discrepancies with your client will disappear.

Question 24

Client response: "I don't understand what you are saying. There's no need to put it together. There's no problem. That's the way I do it."This client is where on the CCS?

A)​Denial
B)​Partial examination
C)​Decision to live with incongruity
D)Development of new constructs, patterns, or behaviors

Question 25

Which of the following statements about the Client Change Scale (CCS) is NOT true?

A)​CCS measures the effectiveness of confronting clients about mixed messages.
B)​CCS assesses the client's position relative to how he/she copes with life changes.
C)​CCS measures the intensity of counselor statements during direct confrontation.
D)The way a client deals with a variety of life change issues can all be considered using the CCS.

Question 26

Client response: "Yes, I do love her. I care for her very much. She is extremely important to me. We do everything together. We really do so many things that work out OK."This client is where on the CCS?​

A)​Denial
B)​Partial examination
C)​Full examination, no change
D)Decision to live with incongruity

Question 27

A client who is dying comments, "It won't happen-not to me." This is an example of:

A)​denial.
B)​partial acceptance of reality.
C)​acceptance and recognition.
D)generation of a new solution.

Question 28

An interviewer may hear, "You helped me see my mixed feelings; I need to express my feelings more," in which level of the Client Change Scale (CCS)?

A)​Level 1: Denial
B)​Level 2: Partial examination
C)​Level 3: Acceptance and recognition, but no change
D)Level 5: Development of new constructs, patterns, or behaviors

Question 29

Confrontation during a single session and over a series of interviews may be measured on a 5-point scale called the Client Change Scale. Which of the following represents this scale?

A)​Denial, Identification, Recognition, Generating Solutions, and Development
B)​Denial, Partial Examination, Acceptance but No Change, Generation of New Solution, and Transcendence
C)​Identification, Examination, Acceptance, Forgiveness, and Evaluation
D)Identification, Partial Examination, Acceptance, Forgiveness, and Transcendence

Question 30

After four interviews, Dominic comments, "Wow, it's really working. Things are great at home. Sara and I are doing well. Working together works!" Dominic is in what level of the CCS scale?

A)​Denial
B)​Partial examination
C)​Acceptance and recognition, but no change
D)Development of new, larger, and more inclusive constructs, patterns, or behaviors-transcendence

Question 31

Achieving a major more lasting transformation in client thinking and behavior may require:

A)​several interviews.
B)​time to internalize new solutions.
C)​moving from denial or partial acceptance.
D)all of the above.

Question 32

Discrepancies between the client and the external world include:

A)​conflict between the client and another person.
B)​conflict between the client and a challenging situation.
C)​conflict between the client and a nurse at a hospital.
D)all of the above.

Question 33

The reality of the story is acknowledged during __________________ of the Client Change Scale (CCS).

A)​Level 1: Denial
B)​Level 2: Partial examination
C)​Level 3: Acceptance and recognition, but no change
D)Level 4: Generation of a new solution

Question 34

"On the one hand..., and on the other hand..." In which step of empathic confrontation would an interviewer most likely make this statement?

A)​Step 1: Identify conflict
B)​Step 2: Summarize
C)​Step 3: Evaluate
D)This is not included in supportive confrontation.

Question 35

Which of the following is TRUE?

A)​Confrontations exist in the form of both listening and influencing skills.
B)​Confrontation only exists as listening skills.
C)​Confrontation only exists as influencing skills.
D)None of the above

Question 36

Client response: "I heard what you are saying. I want to change, but right at the moment I just can't do what I want. I tried last week, it didn't work. The divorce is getting to me. I'll do the best I can to change, but it is so hard."​This client is where on the CCS?

A)​Partial examination
B)​Full examination, no change
C)​Decision to live with incongruity
D)Development of new larger and more inclusive constructs, patterns, behaviors

Question 37

Instructions:Imagine that you are talking with a client about emotional child abuse. You have just confronted the client with the following statement: "On one hand, you say you love your child, but on the other hand you continue to put her out in the hall of your apartment where you force her to stand in the dark. How do you put that together?"Classify the following client's response using the CCS scale.Client response: "I understand what you are saying. It just doesn't make sense what I'm doing. I seem to be saying one thing, but doing another."This client is where on the CCS?

A)​Denial
B)​Partial examination
C)​Full examination, no change
D)Development of new constructs, patterns, or behaviors

Question 38

The client may distort his or her story and blame others unfairly in which level of the Client Change Scale (CCS)?

A)​Level 1: Denial
B)​Level 2: Partial examination
C)​Level 3: Acceptance and recognition, but no change
D)Level 5: Development of new constructs, patterns, or behaviors

Question 39

An interviewer may hear, "Yes, I am hurt and perhaps I should be angry," in which level of the Client Change Scale (CCS)?

A)​Level 1: Denial
B)​Level 2: Partial examination
C)​Level 3: Acceptance and recognition, but no change
D)Level 5: Development of new constructs, patterns, or behaviors

Question 40

"You really want to meet him, but you're a little bit anxious." In which step of supportive confrontation would an interviewer most likely make this statement?

A)​Step 1: Identify conflict
B)​Step 2: Point out issues of incongruity
C)​Step 3: Evaluate change
D)This is not included in supportive confrontation.

Question 41

The CCS can be used be used to:

A)​determine the creative effect of your confrontation.
B)​assess the success of your interventions.
C)​determine client progress over a series of sessions.
D)all of the above.

Question 42

Family therapyTherapist: "The problem with this family is not just Sue's eating problem; what we need to work on as well is the way this family interacts."​

A)Mother: "Somehow that makes sense. I never thought of it that way before."​​​​
B)Father: "Yes, I now see that our perfectionism and constant demand for success​​left her with a feeling of being empty."​​​​
C)Sue: (5'6", 87 pounds) "I don't see why all the fuss. I'm overweight a little,​​that's all."​​​​
D)Mother: "Yes, doctor, that way we can work together better and you can help​​show us how to get Sue to eat."​​​​
E)Mother: "I see how we've avoided our own conflicts and used Sue to help us​​hide them. We're going to be more direct in the future."

Question 43

Which of the following contextual factors may lead to clients' low self-worth and self-esteem?

A)​Self-talk and internal dialogue
B)​Cognitive distortions and negative schemas
C)​Oppression and racism
D)All of the above

Question 44

Carl Rogers​To Mrs. Oak: "It's an experience that's awfully hard to put down accurately into words, and yet I get a sense of difference in this relationship, from the feeling that 'This is mine,' 'I am doing it,' and so on, to a somewhat different feeling that 'I could let you in'."​​

A)"Yes, it's as though that's how it should be. There's a feeling that this is good. I​​feel that it's right for me. I feel more open. I feel more me."​​​​
B)"Well, sort of. I do want to be close, but it doesn't seem safe."​​​​
C)"I do so much for others. Why do you accuse me like that?"​​​​
D)"Yes, I am doing it, and I feel I could let others in."​​​​
E)"It feels like a beginning; it's inevitable."

Question 45

If you observe closely in the here and now of the session, you can rate how effective your interventions have been.

Question 46

Developmental Change Scale—Rater Training Examples
Instructions: Imagine you are a counselor or therapist working with an array of client problems. You make a statement or have approached a case in a certain way. Then the client responds.
For example, imagine a client who is being abused by her husband. You, as interviewer, may say:
"Jane, this is the third interview in a row that you've come in beaten and bruised. Each time you say you need to try harder to meet your husband's expectations. When are you going to realize that it is he who is at fault, not you?"
The client responds to you in five different ways:

1. "But, I can't do anything about it. I have no place to go. I've simply got to try harder. Won't you please help me do better?"

2. "Yes, you're right, I am beginning to think he is involved in this, too. But I know how hard he works and if we just hang in there, maybe it will work out."

3. "I guess you're right. I am trying to meet what he wants. I can't stand being beaten. I know you think he's at fault and it isn't my responsibility to take care of him. I think I understand what you are saying."

4. "I'm beginning to get your drift. I used to think I could solve things if I tried harder, but I've been doing that now for months. Clearly, hitting me isn't right—it has to stop."

5. "Aha, I'm finally seeing what you mean. The more I try, the more he demands. I think the situation isn't safe for me anymore. How can I plan to get out, just as soon as possible?"

The above five responses correspond to specific ways a client might respond in the interview. Below are descriptions of each of the five responses. Note how the first response represents a form of denial, the second a partial response, etc.

Level 1. Denial, The negative alpha solution. The client seems unable to accommodate new data from the counselor or therapist. The client will fail to deal with the conflict or contradiction, make an abrupt topic shift, or show a clearly incorrect "off-the-wall" response.

Level 2. Partial examination, The more mature alpha solution. The client deals with only a portion of the issue or counselor's statement. The client may over-generalize, delete, or distort what has been said, but not as seriously as in Level 1. You may find irrational ideas and some blindness to problems.

Level 3. Acceptance and recognition, Beta solution. The client recognizes the situation as it is and the client's comment, feeling, or thought seems close to that presented by the therapist, but nothing new is added by the client. This level characterizes homeostasis or no change. Score as Beta if the client tends to describe a situation, event, or self-picture fairly clearly, but tends to leave it there.

Level 4. Generation of a new solution, Early gamma solution. In response to the counselor, the client moves to the creation of something new. The client has added something that was not there before. At times, the underlying conflict may remain—acceptance of insoluble problems begins here.

Level 5. Transcendence, Full gamma solution. The client has arrived at a new synthesis, a new way of thinking, behaving, or feeling. These are relatively rare moments in counseling and therapy and may represent the development of useful or important insights, the ability to engage in a truly new way of behaving, and the generation of a new ability to engage emotionally.

You will now be given a variety of counselor-client situations. The possible client responses are in random order. Please classify each client response at one of the five levels.


-Depressed client​
Counselor (to hospitalized patient): "Could you tell me what brought you to the hospital?"​​
________A)"I wasn't able to get up in the morning, yet I couldn't sleep at night and I have​​all these awful thoughts. I know I scared mom."​​​​

________B)(Tears-no response)​​​​

________C)"I guess mom just wanted to get rid of me."​​​​

________D)"Well, when I came here I was pretty depressed and mom was worried. But now​​I'm doing a better. Last night I slept through the whole night for the first time."​​​​

________E)"Extreme depression-I was immobilized. Small wonder mom brought me in.​​I know now that I can't stay home all the time and do nothing. I'm going to start getting out and being more active."

Question 47

Gestalt therapist​Therapist: "You say you're angry at your lover, but I see you smiling. Phony!"​​

A)"What do you mean? I'm really mad. You can't say that."​​​​
B)"Am I really smiling? I thought I was angry, but..."​​​​
C)"OK, OK. Let me try again." Angrily: "Jean, you really tick me off. You​​simply can't do that."​​​​
D)"When I'm angry, sometimes I smile. So what?"​​​​
E)"Dammit, I did it again! I'm beginning to think I'm afraid to allow myself to​​really feel."

Question 48

Confrontation is relevant to all clients, but it must be worded to meet individual and cultural needs if real creativity is to occur.

Question 49

____________ developed the Racial/Cultural Identity Development (R/CID) model.

A)​Ivey and Ivey
B)​Sue and Sue
C)​William Cross
D)Zalaquett and Montenegro

Question 50

Judgments should never be implicated in the counseling session.

Question 51

The most common empathic confrontation uses:

A)​paraphrasing.
B)​reflection of feelings.
C)​summarizations.
D)all of the above.

Question 52

You can assess the direct impact of confrontation, as well as any other microskill, in the here and now with the Client Change Scale (CCS).

Question 53

Death and dying​The following client statements could be expected following the discovery that the client has terminal cancer.​​

A)"It's so hard for me all the time. But it's hard for the family, too. Sometimes I​​just cry. But lately, I find that if I focus on the positives available to me still, I gain some peace."​​​​
B)"There really isn't any problem. I'm sure it's an error on the X-ray. It can't be​​correct."​​​​
C)"Why me? What happened?" With anger: "It isn't fair."​​​​
D)"I've been spending my time working with a cancer support group. I want to​​help others face this-somehow fighting and working with others to the end makes it seem easier."​​​​
E)"I accept it. I've had a good life, with my share of problems for sure. Sure I​​don't like it, but there's nothing I can do."

Question 54

Developmental Change Scale-Rater Training ExamplesInstructions: Imagine you are a counselor or therapist working with an array of client problems. You make a statement or have approached a case in a certain way. Then the client responds.For example, imagine a client who is being abused by her husband. You, as interviewer, may say:"Jane, this is the third interview in a row that you've come in beaten and bruised. Each time you say you need to try harder to meet your husband's expectations. When are you going to realize that it is he who is at fault, not you?"The client responds to you in five different ways:1. "But, I can't do anything about it. I have no place to go. I've simply got to try harder. Won't you please help me do better?"2. "Yes, you're right, I am beginning to think he is involved in this, too. But I know how hard he works and if we just hang in there, maybe it will work out."3. "I guess you're right. I am trying to meet what he wants. I can't stand being beaten. I know you think he's at fault and it isn't my responsibility to take care of him. I think I understand what you are saying."4. "I'm beginning to get your drift. I used to think I could solve things if I tried harder, but I've been doing that now for months. Clearly, hitting me isn't right-it has to stop."5. "Aha, I'm finally seeing what you mean. The more I try, the more he demands. I think the situation isn't safe for me anymore. How can I plan to get out, just as soon as possible?"The above five responses correspond to specific ways a client might respond in the interview. Below are descriptions of each of the five responses. Note how the first response represents a form of denial, the second a partial response, etc.Level 1. Denial, The negative alpha solution. The client seems unable to accommodate new data from the counselor or therapist. The client will fail to deal with the conflict or contradiction, make an abrupt topic shift, or show a clearly incorrect "off-the-wall" response.Level 2. Partial examination, The more mature alpha solution. The client deals with only a portion of the issue or counselor's statement. The client may over-generalize, delete, or distort what has been said, but not as seriously as in Level 1. You may find irrational ideas and some blindness to problems.Level 3. Acceptance and recognition, Beta solution. The client recognizes the situation as it is and the client's comment, feeling, or thought seems close to that presented by the therapist, but nothing new is added by the client. This level characterizes homeostasis or no change. Score as Beta if the client tends to describe a situation, event, or self-picture fairly clearly, but tends to leave it there.Level 4. Generation of a new solution, Early gamma solution. In response to the counselor, the client moves to the creation of something new. The client has added something that was not there before. At times, the underlying conflict may remain-acceptance of insoluble problems begins here.Level 5. Transcendence, Full gamma solution. The client has arrived at a new synthesis, a new way of thinking, behaving, or feeling. These are relatively rare moments in counseling and therapy and may represent the development of useful or important insights, the ability to engage in a truly new way of behaving, and the generation of a new ability to engage emotionally.You will now be given a variety of counselor-client situations. The possible client responses are in random order. Please classify each client response at one of the five levels.Career choiceCounselor (to a student who was referred by his engineering professor for failing grades): "John, we've gone through the tests and reviewed your work history. Given all the information we've come up with, how do you put it together?"Client:a. "Well, I see the results. They seem to be saying that I don't look like anengineer and that I appear more like a journalist or English major. And, it's true that I haven't done too well in math and that English courses have given me my best grades."b. "The tests don't seem to make much sense. I'm going to work harder. I can'tsee why they referred me here anyway."c. "It makes sense. I did enjoy the English courses. I guess it's time to give myselfa chance to do what I want. My dad wanted me to be an engineer like him. I've always tried to please him too much."d. "I don't know. Engineers make the best salaries. It's really important that I dowhat dad wants."e. "That settles it. I've given dad's idea a good try, but I haven't done well and Ireally like English better. I am going to do what I want and what makes sense for me. I'm going to change my major."

Question 55

If your client starts with you at denial or partial acceptance (Level 1 or 2) and then moves with your help to acceptance and generating new solutions (Level 3 or 4), you have clear evidence of:

A)​the effectiveness of your therapy process.
B)​the capacity of your client to achieve progress without your help.
C)​the strong need for leadership and direction your client has.
D)the powerful impact of the environment on our clients.

Question 56

Which of the following is NOT part of the Racial/Identity Development Model?

A)​Disillusionment Stage
B)​Resistance and Immersion Stage
C)​Introspection Stage
D)Integrative Awareness Stage

Question 57

Which of the following statements regarding empathic confrontation and mediation is NOT true?

A)​There is a need for actual contact and communication between combatants.
B)​Power needs to be equal between the two individuals or groups.
C)​There is a need to search for common goals and areas of agreement.
D)A win-win resolution is most achievable when two individuals or groups meet to address issues.

Question 58

Counseling helped Nelida:

A)​appreciate her culture and feel "proud" of her grandparents.
B)​appreciate herself and feel "proud" of her achievements.
C)​appreciate her mainstream culture and feel "proud" of her classmates.
D)appreciate and "proudly" adopt the counselor's worldviews.

Question 59

The counselor's or interviewer's task is to move clients beyond their issues and problems to realize their potential as human beings.

Question 60

Child counseling​Counselor: "Johnnie, why did you hit Susie on the playground?"​​

A)"I know she's the best student and I'm jealous. It makes me mad that I can't do​​as well. I'll try not to do it again-next time I'll count to ten like you taught me to do when I get angry."​​​​
B)"I didn't do good in math today and she laughed. I felt bad."​​​​
C)"I hit her because she teased me."​​​​
D)Looks down. "She made me do it."​​​​
E)Defiantly: "I didn't hit her."

Question 61

Describe the integrated steps of empathic confrontation and provide examples of each.

Question 62

Clients complete each developmental task in fairly quick succession, and their progress can be quickly assessed on the Client Change Scale (CCS).

Question 63

Define empathic confrontation and its place in the session and the counseling process.

Question 64

Present the Client Change Scale and explain how it is used in counseling and therapy. Illustrate each of the levels and uses.

Question 65

According to the authors, empathic confrontation is a distinct skill that relies heavily on influencing skills and strategies for client change.

Question 66

Nelida and Allen's two sessions highlight the importance of helping clients address conflicts related to racial/cultural identity.

Question 67

Explain and illustrate with clear examples the different stages of the Racial/Cultural Identity Developmental (R/CID) model.

Question 68

According to Ivey, Ivey, and Zalaquett, empathic confrontation is a not a distinct skill; it is a set of skills that may be used in different ways. The most common confrontation uses paraphrase, reflection of feeling, and summarization of discrepancies observed in the client, or between the client and her or his situation. However, questions and influencing skills and strategies can also lead to client change.

Question 69

You can evaluate the effectiveness of an interview by:

A)​the mood of the client as he or she leaves the session.
B)​changes observed using the Client Change Scale.
C)​the feeling of satisfaction you experience at the close of the session.
D)how well you followed your interview treatment plan.

Question 70

If you practice assessing client responses with the CCS model, eventually you will be able to make decisions automatically "on the spot" as you see how the client is responding to you.

Question 71

Discuss some of the key multicultural issues in the use of confrontation.​

Question 72

The ________________ is a systematic way to monitor the progress of clients toward their goals.

A)​Client Progress Scale
B)​Client Concrete Scale
C)​Client Change Scale
D)Client Developmental Identity Scale

Question 73

Confrontations are frequently observed in session conversations.

Question 74

A client comes to you saying the following: "I have no problems in stopping smoking, I've stopped ten times in the last year."​
a.Identify the incongruity in the statement.
b.Write a confrontation you might say to the client including the important check-out.
c.Follow this by writing client statements that would represent denial, partial examination, full examination, decision to live with the incongruity, and the development of new patterns, constructs, or behaviors.​