Ah, denial: the hallmark of addiction. “He’s in denial,” a therapist will say to me, usually with a raised eyebrow and heavy sigh.
The field of substance abuse was built on a professional foundation of breaking through denial. “Therapeutic communities” like Synanon in California (basically a treatment cult) would break through the denial of their residents by berating, insulting, and humiliating each other into compliance. Threats, intimidation, and deprivation of basic needs was at times instrumental. Was there physical violence, such as mass beatings, fatal injuries, abductions, rattle snakes left in odd places, assault, and conspiracy to murder? I’ll let you take a guess.
The good news is that there have been developments in the field of substance abuse treatment since the most controversial days of Synanon in the ’60s and ’70s. We now know that most people seeking treatment for alcohol feel uncertain about signing up for torture. We also know that not every addict is the same. We have PET scans, evidence-based practices, tailored medications, fourth-wave behavior science, and professionally trained treatment teams.
Why, then, is it a problem to hang on to this idea of denial being the primary indicator of addiction?
Denial is not part of diagnosis. Under the DSM-V, “denial” is nowhere to be found among the criteria that indicate problem drinking.
Wait, I hear you saying, as you flip through your own DSM-V (and good for you for buying a copy – it is super expensive), doesn’t drinking in spite of negative consequences constitute denial?
From an outsider perspective, the terrible judgment of a problem drinker, the seeming ignorance and minimization of negative consequences, understandably looks a hell of a lot like denial. Why would a sane person do this to themselves? Denial, right? Wrong.
Someone can continue to do the same bad thing, over and over again, fully understanding how bad it is, feeling really bad about it, without being in denial. The reason your clients minimize the impact of alcohol on their lives or skirt around the issue is because they (understandably) are fearful that you, like everyone else, will judge and shame them.
But wait, I hear you saying again – and I really appreciate that you are still conversing with me while I type this! – I am such a nice and nonjudgmental therapist. How can they know what I’m going to think?
You’re right – your client doesn’t know what you’re going to think. But the relevant part of addiction, the real part that we’re talking about here, is shame. Whether you are working with someone who drank too much this one time and then did something bad or someone who drinks with gusto every day, each and every person with an alcohol use disorder is filled with shame.
Will they admit their shame to you and immediately elaborate on the complexity of their thoughts and feelings? Probably not. Why? Well, my therapist friend, you know the answer – because it’s shame. And shame just sucks like that.
When we tell ourselves that the client is in denial, it’s because we are failing to understand why he has chosen to present his life to us in a certain way, or how he actually experiences the negative consequences of drinking. By placing the label of “denial” squarely on our clients during clinical assessments, we are closing off the empathetic part of ourselves that they are actually paying to see.
It’s understandable and even defensible for friends and family members of our clients to call it denial. They’re not being paid by the hour to understand. It’s ok for people in AA to refer to denial. That’s part of their literature. But it’s not ok for us as professionals to take the easy way out and inadvertently impair our ability to truly attend to someone who has taken the time to see us and to talk about this difficult issue. Break the shame cycle. Let go of denial.