Someone once said an unexamined life is not worth living; however, it is sometimes easier to buy into the concept of ignorance as bliss. Denial works to block out that which does not serve our reality as we see it. This denial, all positive intentions aside, does not always serve us well. The ability to examine our actions and see them for what they are can sometimes be the only true way to bliss.
In my research on the subject of denial, I have encountered many interesting works. For example, the following excerpt from the Columbia Encyclopedia, Sixth Edition (2001) helped me to realize that denial was recognized as a defense mechanism by early psychologists, in psychology, an ego defense mechanism operates unconsciously to resolve emotional conflict and to allay anxiety by refusing to perceive the more unpleasant aspects of external reality. In the psychoanalytic theory of Sigmund Freud, denial is described as a primitive defense mechanism. Anna Freud studied the widespread occurrence of denial among small children and explained that the mature ego does not continue to make extensive use of denial, because it conflicts with the capacity to recognize and critically test reality. Most people employ denial at some time in their lives when coping with stressful situations, such as the death of a loved one. Elisabeth Kubler-Ross’s influential theory describes denial as the first stage of a dying person’s progress in coming to terms with a terminal illness. In such instances, denial may be considered adaptive. It is considered maladaptive, however, when it becomes delusional. In recent years, the term is used more generally to describe the suppression of reality rather than a particular defense mechanism in the Freudian sense.
The modern use of denial has a much broader application than was previously conceived. Denial has been described in various ways by many different people. I personally think Webster’s Dictionary’s definition of denial more adequately reflects its current use: an assertion that an allegation is a false disbelief in the existence or reality of a thing; self-denial and the reduction of anxiety by the unconscious exclusion from the mind of intolerable thoughts, feelings or facts. I also think if denial is expressed in a slightly different way, it can be more easily understood by chemically dependent individuals. For this application, denial is a psychological process typically used to protect or shield the individual from things or situations that threaten or would be painful if encountered by blocking or by masking awareness of these things. Consequently, it is a psychological defense mechanism that distorts reality and shields the individual from the pain and anxiety related to acceptance or acknowledgment of an item or situation. Denial can function as a buffer against experiences we may not be able to accept (at a given time) in our consciousness. It then enables an individual to psychologically adjust to the situation and to mobilize other less radical defenses. From this perspective, one can conclude that denial is a defense mechanism and, as such, is a very valuable tool to help one cope with situations that would otherwise be beyond his/her ability to deal with. In many cases, denial allows a person to cope with situations or to delay the actual encounter until he/she is ready and until it is time for the individual to face what it is that they had previously avoided.
How Big is the Problem of Denial?
The National Household Survey on drug use and abuse conducted in 2001 revealed that many users who meet the criteria for needing substance abuse treatment do not personally recognize that they have a problem. The survey estimated that more than 4.6 million substance-using individuals are in denial regarding their use;
consequently, there are approximately 4.6 million individuals in need of professional help that is not likely to seek help because they deny the existence of a problem. As a matter of fact, this situation is believed to account for the high rate of unsuccessful treatment programs as it’s very difficult to help someone who does not think they have a problem (ergo denial).
Mr. John Walters, Director of National Drug Control Policy, states: we have a large and growing denial gap when it comes to drug abuse and dependency in this country. He went on to state; we have a responsibility as family members, employers, physicians, educators, religious leaders, neighbors, colleagues, friends, and counselors to reach out to help these people. Sometimes it requires a helping individual to apply a tough love concept that focuses on an intervention that will guide the individual toward the help that is needed as opposed to enabling the individual to continue with his or her destructive behavior. While I was in private practice, I had a personal experience with a family that was faced with a complex dilemma. Their teenage son was deeply into hard drugs. The father said his son left home several times and only returned after he had exhausted his money, gotten ill, and was destitute. The father said he and his wife always welcomed their son home, helped to restore him to health, and hoped he would never return to drugs. After the parents exhausted all hope, they finally realized they were helping (enabling) their son to continue to use by providing a safe place for him to recover after an episode. The parents finally refused to accept their son when he was involved with drugs. Eventually, the son left, and the parents had no contact with him for over two years. This story ends on a good note, as so many don’t. The son finally searched and found the help he needed. Through a very comprehensive treatment program, he was able to recover from drugs and learn to live a drug-free life, and become a valued member of his family and the community. One will never know how this story would have ended if the parents had continued to enable their son to continue his involvement with drugs. The simple message is that a repetitive cycle of abuse/enabling/denial/abuse can often extend an individual’s involvement with drugs. Sometimes, if not often, when this cycle is disrupted, it opens the door to effective treatment. I think one of the most important challenges for the 21st century is to find ways to reach out to help in situations such as this. We must discover better and more effective treatment options to help lead individuals to productive and drug-free lives. The earlier in the use-enable cycle, an intervention can be made the earlier they are reached, and the greater the likelihood of success.
I would be remiss if I did not indicate the magnitude of the drug problem in this country. A survey completed in 2002 found that almost 16 million Americans age 12 and older used an illicit drug the month before the survey. Add to that the number of individuals who abuse prescription drugs and the number of abusers increases dramatically. In 2001, illicit drug users represented approximately 7 percent of the total U.S. population. Mr. Charles G. Curie, who is the Administrator for Substance Abuse and Mental Health Services (SAMHSA), emphasized that behind these numbers are real children and adults impacted by drug use. We must refuse to give up on people who have handed over their aspirations and their futures to drug use. People need to know help is available, treatment is effective, and recovery is possible. Curie added that the prevalence of drug use and abuse is partly due to a drop in the number of people who see certain substances, such as marijuana, as harmful. This is again, denial.
Types of Denial
Denial is generally accepted as a psychological process that is automatically invoked when an individual faces a threatening and/or frightful situation. It is used to protect an individual by masking their awareness of a pending calamity or by diverting attention toward other things. Therefore, it is a psychological defense mechanism that distorts reality and helps an individual avoid the feeling of acute pain associated with the situation. It is common for most individuals to experience denial. For example, an individual will often reject unfavorable medical diagnoses, family issues, dysfunctional relationships, or negative behavioral indicators. The tendency is to report that everything is fine when, in reality, their life may be very chaotic.
There are also unique applications of denial in the chemically dependent sub-population. It appears they have taken a basic, natural process and perfected it for their personal benefit. In other words, they become professionals at denial and use it to the detriment of themselves, to the frustration of their counselors, and the harm to those around them. The result for many addicted individuals is that they need to hang on to denial as it enables them to continue their use and abuse of alcohol and/or other drugs. It is also interesting to note the progressive nature of denial (from small lies to larger lies and so on) and to recognize that the progression of denial parallels the progression of the disease of addiction (more on this later).
Individuals also develop methods, tendencies, and creative ways of retaining their denial or avoiding even having to admit (to others) that they use various forms of denial regularly. The following are common types of denial that are used by the chemically dependent individual, as well as other persons. It should be noted that most forms of denial are not necessarily unhealthy, nor do they (in themselves) reflect an out-of-control personality. However, for most chemically dependent individuals, it is a fairly accurate indicator of the severity of his/her problem.
Denial may be automatic in most situations; however, it may not be a matter of deliberate lying or willful deception. Unfortunately, most chemically dependent individuals are out of touch with reality to the point where they do not know what is true or false concerning their drinking or drug use and its consequences. The denial system, in conjunction with excessive use, distorts their perceptions of reality and impairs their judgment to the point that they become self-deluded and virtually incapable of accurate self-awareness. Needless to say, it’s truly sad when an individual represses the truth even from themselves and destroys their life rather than undergoing treatment and following a prescribed recovery plan.
As noted earlier, denial is generally progressive. Specifically, as the illness of chemical dependency progresses, the denial system becomes increasingly more pronounced and entrenched. In the early stages of alcoholism, for example, it is frequently minimal, and with proper treatment, most people can view their problems objectively and fairly realistically. Unfortunately, by the time an individual’s illness is sufficiently advanced that the problem is serious in the perception of others, an elaborate system of defenses shields him or her from being aware of what is happening. I am reminded of a gentleman in one of my outpatient groups. He had received six driving under the influence charges over his lifetime. He had been abusive to his wife while under the influence of alcohol numerous times throughout his 22-year marriage. Even still, he was court-ordered to attend the group! He stated in the group, mandating me to treatment was the best thing the law ever did for me. I never saw a problem.
Most addicted persons have assembled around them those who will enable, in some ways support, their destructive behavior. These enablers will help the individual escape the consequences of their actions. In some cases, an enabler will be so proficient they pretend that destructive behavior is not occurring. In this environment, with an efficient and dependable protective shield around the addictive individual, he/she is much less likely to accept his/her substance-related problem and to seek and accept treatment. Typical behaviors of the enabling persons include:
Through the team of enablers, the addict can continue to drink without ever having to accept the consequences of his/her behavior. He/she does not have to feel the pain that is caused by drinking. The enabler always rushes in to cushion the addict from the consequences of his/her use; consequently, the addict never experiences the pain of his/her involvement with drugs. It is obvious from most people around the alcoholic that his/her drinking or other drug use has placed him/her in a dependent and helpless situation, however, the addict can continue to believe he/she is independent because he/she has been rescued from the entanglements by his well-meaning enabling team (family, friends, employer, co-worker and possibly counselors).
It should be noted that the relationship between an enabler and an alcoholic is often a two-way street. Often a spouse with low self-esteem can feel useful and also feel that their life is meaningful through his/her helping their spouse. In situations like this, the enabler is sometimes in denial regarding their situation and, on some level, frequently needs the alcoholic to continue to drink so that she will have a purpose in life.
In this environment and with their support system in place, the alcoholic may continue in the progression of the disease of alcoholism until he/she hits bottom. When this occurs, even the most dedicated drinker must admit they have a problem. Typically they begin a relapsing phase where they abstain for varying periods, and then they resume drinking or using. Most enabling teams are quickly regrouped and also resume this prior activity. This relapsing process can continue until the alcoholic or addict finally accepts his/her illness and is willing to accept help. In many cases, the choice is to either accept help or die.
Attributes of Denial
It has been noted by many researchers that denial is progressive. It begins with small, insignificant falsehoods and progresses to where an individual is immersed into a lifestyle of misrepresentation and lies. It has been suggested that some individuals progress to the level that they are unable to discern between truth and falsehoods. Many have also hypothesized that denial progresses in direct proportion to the progression of the disease of alcoholism/addiction. Moreover, to better understand the attributes of denial, we will look at the disease concept of addiction and then look at the corresponding aspect of denial about the stages of the progression of alcoholism/addiction.
The Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) by the American Psychiatric Association help define and understand the progression of this disease. It should be noted the category of experimental or recreational use is not in the DSM-IV as it is not considered a psychiatric disorder. This classification is used to describe a single episode that may not have any adverse consequences or self-limiting multiple episodes (recreational/social) where the user can control his/her use to where they have no long-term adverse consequences. The second stage is problem use or abuse which is described in DSM IV. It infers the use of any drug, medically speaking, to the point where it seriously interferes with the health, economic status, or social functioning of the user or others affected by the user’s behavior. A diagnosis of substance abuse can be made when the user demonstrates the following characteristics:
A. A maladaptive pattern of substance use leading to clinically
significant impairment or distress, as manifested by one (or more) of the following, occurring within 12 months:
1. Recurrent substance use failing to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household).
2. Recurrent substance use in situations where it is physically
hazardous (e.g., driving an automobile or operating a machine
when impaired by substance use)
3. Recurrent substance-related legal problems (e.g., arrests for
substance-related disorderly conduct or public intoxication).
4. Continued substance use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the
effects of the substance (e.g., arguments with spouse about
consequences of intoxication, and physical fights).
B. The symptoms have never met the criteria for Substance Dependence for this class.
The final stage in the progression of the disease of addiction is dependency/addiction. Dependency is generally defined as when a user experiences physical or psychological distress upon discontinuing the use of the drug. Addiction implies compulsive use that leads to impaired control, preoccupation with obtaining and using the drug, and continued use despite adverse consequences. DSM-IV criteria for a diagnosis, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
1. Tolerance, as defined by either of the following:
a. a need for markedly increased amounts of the substance to achieve intoxication or desired effect.
b. markedly diminished effect with continued use of the same amount of the substance.
2. Withdrawal, as manifested by either of the following:
a. the characteristic withdrawal syndrome for the substance
b. the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.
3. The substance is often taken in larger amounts or over a longer period than was intended.
4. There is a persistent desire or unsuccessful effort to cut down,
control, or stop substance use.
5. A great deal of time is spent in activities necessary to obtain, use, or recover from the effects of use.
6. Important social, occupational, or recreational activities are given up or reduced because of substance use.
7. The substance use is continued despite knowledge of having a
persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).
Table 2 presents the characteristics of the three stages of use from experimental/social use through the abuse phase and into the addiction/dependency phase. As can be seen from the table, the Frequency of administration, as well as the amount of the drug, used increases with each phase. Also, the pleasurable, euphoric feeling produced by earlier uses is continuously sought, but after the effects of the drug subside then pain, aggression, depression, and discontent generally occur. Most dependent individuals are unlikely to experience euphoria or other pleasant effects from the drug; continued administration is needed to achieve a state of homeostasis feeling normal or not having pain. In summary, this information indicates that as individuals progress through the stages, he/she becomes less committed to traditional social functions. Their main focus is on procuring and using alcohol and other drugs.
Table 2 data was adapted from the Florida Certification Exam Study Guide, 2001.
Table 2 CHARACTERISTICS OF AOD USERS
Experimental & Social Abuse Dependency/Addiction
Phase Phase Phase
Reason >Peer Pressure >Manipulate >Avoid Pain/
For >Satisfy Curiosity emotions Discomfort
Using >Relieve Boredom >Cope with >Escape reality
>Defy authority stress >Avoid withdrawal
>Risk/thrill-seeking >Mask feelings >Satisfy compulsive
>Reduce inhibitions of inadequacy and desire to use
>Social acceptance and low self
Frequency >Occasional (monthly) >Regular (2-3 xs >Daily
Of Use >Social functions per week)
Sources >Peers >Purchase >any means
>Family >Friends necessary
>Friends >Criminal activity >Criminal activity
Desired >Euphoria/ >Euphoria >Euphoria
Effect return to normal >Intoxication >Avoid Guilt/
state >Pleasure/relief shame/remorse
>Intoxication from negative >Achieve a state of
>Reduced inhibitions >Avoid guilt homeostasis
Table 3 relates the attributes of denial to the corresponding substance use stages. As noted previously, there is a worsening of the denial traits associated with each use stage. In essence, the progression goes from an attempt to misrepresent a total emersion into a state where untrue statements are made with the intent to deceive. I also think it may go beyond an attempt to deceive to where some individuals have lost all concepts of reality and have lost the ability to discern between true and untrue in their world.
Table 3 ATTRIBUTES OF DENIAL
Use Phase Denial Attributes
Experimental/ Simple Lies:
Social Use > About Amount
-I barely drank anything
-One or two drinks are healthy
-I haven’t drunk in a long time
-Everyone else drinks more than me
-I don’t drink as much.
-I only drink beer
-All my friends drink
Abuse Phase Complex Lies:
-I never drink to intoxication
-I’m always in control
-I can handle my alcohol
-I don’t take risks when I drink
-I only drink on weekends
-I stopped today, and I will never drink again
-Everyone I know drinks more frequently than me
-I’m okay; it’s all your fault
-Everyone picks on me
-I’m a lightweight compared to my friends
Addictive Phase More Complex Lies
-Real alcoholics drink all day long
-I have never had a blackout
-I don’t drink more now than I did last year
-I don’t need to drink daily
-Real alcoholics drink liquor every day
-All of my friends and family are alcoholics
-I need to drink /use it to sleep
-I drink to cope with my stress level
-My health problem is not related to drinking
-I need alcohol to feel normal
Breaking Through Denial
Which came first the chicken or the egg? This has been debated since the beginning of time, and we are no closer to an answer today than when we first posed the question. Is it possible that both chicken and the egg are universal in that if you have either, you can get the other (assuming the egg has been fertilized)? The argument can be carried over into the addiction versus denial arena. Again, which came first, the addiction or the denial? I will say, based on my own counseling experiences, that I have known some dishonest people who were not substance abusers; however, I have never met an addict whose integrity hadn’t been flexed over the years. Getting closer to the question of how to break the cycle of addiction, it can be stated that addiction and denial are so closely related that both must be worked simultaneously to help the addict get into an effective treatment program and learn how to live a happy and successful life free of drugs. Program outcome studies reveal that it does very little good to force an alcoholic/addict into treatment before his/her acceptance of a substance abuse problem. I will present an overview of the cycle of addiction and then relate to the areas where it may be possible to attack denial.
The cycle of addiction begins with an individual’s set of values surrounding his/her convictions, opinions, persuasions, and/or sentiments. In essence, it is one’s belief system and represents the perception one holds toward relationships, values (what’s good/what’s bad, what’s right/what’s wrong, etc.), religion, jobs, etc. Most professionals in the mental health field agree that most individuals have a very well-defined belief system at an early age, and this will be further defined by their experiences throughout their lifetime. This belief system will guide the decisions made around most subjects throughout their life. It should be noted this system also includes a set of values or judgments regarding the use and abuse of alcohol and will become the set parameters by which one will judge if they have a problem with drinking or not. For example, if an individual believes that an alcoholic is a falling-down drunk and he or she never falls while drinking, then that person concludes (internally) that he/she does not have a problem with alcohol. Consequently, there is a very close relationship between a faulty belief system and denial. Most counselors would agree that one of the root causes of denial is that the individual has a flawed concept of alcoholism.
An abnormal or misconceived notion or belief system results in an individual making poor decisions. They seldom conceive the truth or the reality of an action or activity. It is very easy to bridge from the concept of impaired thinking to the world of denial for an alcoholic/addict. The main form of denial (rationalizing, minimizing, and blaming) is all mental exercises to mask the reality of alcoholism or addiction.
The final element of the cycle of addiction is an out-of-control lifestyle, the consequence of which is pain. The good news is that when the pain becomes severe enough, the individual may seek help.
The consequences of an out-of-control lifestyle are increased health problems, more accidents, as well as emotional problems such as feelings of shame, guilt, and depression. Again, this relates very well to the attributes of denial during this dependency phase.
The aforementioned concepts help to enhance the understanding of relationships between alcoholism/addiction and denial. It goes back to the chicken versus the egg; they are universal in that with one, an individual almost always has the other. How does one break through denial? I don’t think there is one solution to this problem, as we have found out (the hard way) that one treatment modality does not work for everyone. The following is a generalized plan that has proven effective with many substance-abusing clients:
Problem Recognition: The identified patient must be brought to recognize and accept his or her problem. This can be accomplished via an intervention where the family and friends confront the individual with the facts of how his/her behavior is impacting the people around them. This is sometimes more effective concurrent with or immediately after a family crisis. The intervention generally addresses the physical, material, and spiritual ramifications of the individual’s use. The intervention also results in a disbanding of the enabling team and outlines a plan of care that is aimed at helping the individual accept responsibility for his/her actions, ultimately, the goal is total abstinence.
Another aspect of an effective intervention is to educate the identified patient on the disease of alcoholism/addiction and to increase his/her awareness of the increased health, safety, and family risks associated with continued use. A technique that I found effective is to relate the reasons individual drinks to the layers of an onion. The reasons vary somewhat from person to person, but in general, they relate to the physical, psychological, and social needs of the individual. In an open discussion type environment, such as an intervention, the reasons or layers can be discussed in detail. After all plausible reasons have been discussed and discarded, the intervention team leaders can present a final and sometimes shocking reason, and that is one of selfishness. The major theme is that the individual chooses a behavior without concern or caring about what impact his/her behavior may have on others. This can get fairly detailed and deal with safety (driving under the influence with his family in the vehicle), family unity (always absent from family activities), financial support (family income used to purchase alcohol and/or other drugs instead of helping meet the needs of the family). This list is endless, and I have known individuals to become very emotional when faced with this information, and some make statements like I never intended to be selfish. It can also result in a breakthrough for the addict to the point they accept their problem and become willing to accept help.
In conjunction with the intervention, the identified patient should be examined by an addictionologist to determine if medication would ease the withdrawal symptoms. In many cases, medications can also help to reduce the desire or craving for a particular substance. The doctor may also prescribe an anti-anxiety medication and/or other medication that will help calm emotions and help the patient rest and recover more quickly. This is a critical step as much progress has been made in the field of pharmacology, and new medications are becoming available regularly.
Concurrent with intervention and medical support are individual counseling and support groups. They are aimed at helping the individual develop additional coping skills and stress management techniques and also to help educate the individuals regarding addictions. The support groups help the individual to relate to other individuals who have had similar problems and have found a way to recover.
Exercises to Break Denial:
If we say that reality is what each of us perceives it to be, then how can we expect to change an addict’s perception because that is his/her reality? Again, it relates to their perception of an alcoholic or addict. If he/she believes that an addict is someone who lives under a bridge and they don t then they are not an addict, how do you as a professional help them to help themselves?
One exercise used with a client with multiple charges of underage drinking and DUI, although on the abrupt side follows: the client was asked about her most recent DUI, and she said it was no big deal she wasn’t hurt, and the other guy was released from the hospital with just a broken leg. She stated she drank because all of her friends were older than her, and that was the only way to hang out with them. She expressed that she was going to continue her drinking despite the past and current consequences. In a measure of desperation, the counselor asked her to close her eyes and describe the man she was in an accident with. She said I don’t know that much about him. The counselor said to create it, give him a name, a family, and so on. The counselor asked what he looked like, what his name was, how many kids he had and what their names were, what their ages were, what his wife was like, and what their family did together on the weekends. They got to know this created personality. Then the counselor asked the client to change the accident and have him killed. The counselor asked the client to describe the family’s reaction, the funeral, etc. The client was disturbed by the exercise. The point of counseling is not to upset your client with scenarios that didn’t even happen, but the exercise did help the client grow in a very necessary direction. She agreed this could have been the result and felt differently leaving the office.
Another exercise is to have a client write a story about what their life would be like if their drinking or drug abuse was out of control. Then go back and look at how the story parallels what they have heard their family, friends, and co-workers complain about in reality. In what ways does it sound familiar to what they have already or very nearly gone through?
It can be helpful for a client to list any of the consequences they have endured at the hands of others due to their drinking. The consequences, in the beginning, are the fault of the others, but nonetheless they can see the negative impact using has had on their life.
The use of tests such as the SASSI can often help individuals see in black and white, so to speak that the medical field would classify them as problematic users and caution them regarding continued use.
Group treatment can also be effective at helping individuals see through their denial. In hearing stories from others who can have issues with abuse and dependency, they can see similarities in themselves without it being forced upon them. Being told something or coming to their own conclusion can make a world of difference.
The net result inherent in this process is that denial is broken down concurrent with breaking the addiction cycle. I seriously doubt if breaking through denial would be effective without addressing the problem of chemical dependency. In summary, the issues must be addressed concurrently.
Denying addiction is simply another articulation of the denial everyone experiences all the time; people struggling with addiction rationalize, minimize, repress, self-deceive, and selectively forget to avoid confronting the unbearable reality of their substance use disorder. This process may be conscious, unconscious, or often both, particularly as substance use itself diminishes their aptitude for accurate self-perception. The deep stigma attached to addiction and its possible consequences can make denial particularly appealing since admitting addiction, either to themselves or others, comes with a host of painful implications, whether true or not. If I am an addict, I am a bad person. If I am an addict, I do not have control over my life. If I am an addict, I will cause my loved ones pain. If I am an addict, I have to go to treatment, cut off my friends, and give up the substance that is helping me cope.
But while people struggling with addiction may have a unique impetus for denial, some experts believe the notion that addicts’ denial is fundamentally different than other types of denial does a disservice to both addicts and their families. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) publication, Enhancing Motivation for Change in Substance Abuse Treatment:
“Engaging in denial, rationalization, evasion, defensiveness, manipulation, and resistance are characteristics that are often attributed to substance users. Furthermore, because these responses can be barriers to successful treatment, clinicians and interventions often focus on these issues. Research, however, has not supported the conclusion that substance-dependent persons, as a group, have abnormally robust defense mechanisms”