Tuesday, May 19, 2009

Addiction Assumptions: Denial

Is denial always part of the deal?

Maybe denial really IS just a river in Egypt. Lorraine T. Midanik, dean of the School of Social Welfare at the University of California in Berkeley, is convinced that the contemporary concept of denial as applied to alcoholism represents a weak link in the disease model of addiction.

Neither the founding fathers of Alcoholics Anonymous, nor the foremost early proponent of the disease model—E.M. Jellinek—specifically identified denial as a core concept of alcoholism, according to Midanik. In “The Philosophy of Denial in Alcohol Studies: Implications for Research,” which appears as a chapter in The Praeger International Collection on Addictions, Midanik highlights the conclusion that often results from making a strict association between alcoholism and denial: “There is no room in this perspective for truth telling from the drinker himself.”

The more often and the more energetically a drinker protests against the hypothesis that he is drinking alcoholically, the more telling the proof that the drinker is “in denial” and therefore incapable of rational decision-making about drinking. Clearly, this is exactly the case in many instances. Denial exists. However, Midanik argues that “the definition of denial in alcohol studies has been expanded well beyond its original meaning” to include a host of vaguely Freudian defense mechanisms, including hostility and other forms of negative behavior. Midanik, who is openly skeptical regarding many aspects of the disease model, complains that denial has been broadened into a catchall category “for any behavior that prevents the adoption of the disease model system.”

As the “disease model system” is often presented to patients in various rehab centers around the country, I would tend to agree. But Midanik also questions whether there really exists anything beyond what she labels “tactical denial,” meaning “deceptive maneuvers used by alcoholics to conceal the extent of their drinking.” In such cases, the drinker is obviously aware of what he or she is doing, so the more appropriate term might be “lying.” Nonetheless, I firmly believe that denial, in the sense of lack of self-awareness, or dissociation, is often an acute part of the presenting symptoms of alcoholism, if not quite the “central core of alcoholism treatment,” as Midanik sees it.

Midanik describes something like a cabal of interests helping to foster and inflate the denial concept—AA, Al-Anon, and various codependency groups in particular—even though “study after study and review after review report that alcoholics give valid self-reports....” Here Midanik is onto something interesting. As she intriguingly relates, the near-universal presumption guiding “interventions” or “structured encounters” with supposed alcoholics is that “there is a continuum with denial on one end and truth telling on the other. Overreporting rarely if ever exists.”

Yet overreporting is a well-known issue in clinical research. Midanik refers to the “hello-goodbye effect,” in which patients tend to overemphasize their symptoms when entering treatment, and to minimize them at the end of treatment. If new patients overreport their alcohol consumption, “there are important implications for treatment personnel who base treatment decisions on these self-reports.” Moreover, overreporting may also bias clinical studies “by inflating success rates (presuming there was an opposite bias after treatment). Yet despite the implications of these findings, little interest has been shown by researchers in the alcohol field to explore this area.”

Photo Credit: shatteringdenial.com


Peter O'Loughlin said...

Your views that the both Jellnek and the founders of AA did not cover the the presence of denial are inaccurate.

Step 1 of the programme of recovery explicitly covers that area with the comment 'none of us like to admit that we are mentally or bodily different from others'

That view is repeated in various ways throughout the 12 steps. In addition a perusal of the 'Big Book has numerous references to the futility of denial and one chapter specifically devoted to what is describe as 'The river of denial'.

Adi Jaffe said...

I think that it's untrue to say that denial is part of the definition of addiction, at least as far as the medical field goes.

If you look at the DSM, there's no requirement for denial in order for a person to be identified as meeting a substance abuse or dependence definition.

Dirk Hanson said...

Specifically, Midanik writes in her article: "Interestingly, denial was never originally mentioned in the Big Book of AA nor was it listed as a specific symptom or even part of a symptom in Jellinenk's early work."

Subsequent editions of the Big Book have had plenty to say about denial, as Peter makes clear.

Adi is also correct in noting that no formal definition of alcoholism in the fields of medicine and psychology includes the requirement of denial.

For my part, I think denial is a regular part of the symptomology of alcoholism--for some, maybe even most, alcoholics.

Dennis R. Bates said...

While I believe there are certainly symptomatic instances of denial in addiction, I struggle w/the fact that so many of my peers label their clients in denial w/out even considering ambivalence as an option.

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