Jim Williams
Cambridge College Program on
 Alcohol and Drug Counseling
November 19, 2007

Denial
Reconciling Clinical and 12-Step Perspectives

Within the clinical community, the terms denial and resistance have a lengthy history going back to the works of Sigmund Freud and Anna Freud.  Similarly named terms in the 12-step community have evolved somewhat independently of the clinical community, and there is no a priori reason to assume that these terms now have the same meaning in the two communities.  Comparing the two sets of concepts provides insights into the nature of addiction that suggest a rationale for when and how to use various techniques of drug education and recovery.

Psychotherapeutic Tradition

Definitions of resistance often connote oppositional attitudes towards treatment (cf. Flores 1996, Longshore 2006).  Miller and Rollnick have broadened the definition to mean resistance to change (Miller 2002).  This very broad definition is sufficiently general to encompass most barriers to recovery.

The term denial is traditionally defined as a defense mechanism that hides painful truths.  Denial in this sense combines the idea of a persistent counterfactual belief or attitude with a specific underlying mechanism, namely psychological defense.

As far as I know, there is no standard term for the broader notion of clinging to a counterfactual belief, independently of motivation or mechanism.  However, one can certainly find research on persistent counterfactual beliefs and associated behaviors.   Children's candy cigarettes are a preconditioning reward for smoking (Klein 2007).  Targeted advertising can increase alcohol sales to minors by as much as 50% (Collins 2007).  False learning is not limited to drug-related behaviors (cf. Valins 2005).

While a wide variety of reward mechanisms might be used to instill and maintain false beliefs, the case most relevant to addiction would seem to be the direct chemical stimulation of the brain's reward centers through the use of psychoactive substances.  To my surprise, I was unable to find any research that directly addresses this topic.

The 12-step tradition

Twelve-step groups are strongly focused on characterological barriers to recovery such as such as the lack of self honesty and the inability to accept help.  Such barriers qualify as resistance in the sense of Miller and Rollnick (Miller 2002).  The Big Book of Alcoholics Anonymous mentions traditional psychotherapeutic resistance in an appendix titled "The Medical View," and it identifies denial as both a symptom of alcoholism and a barrier to recovery (AA 2002).  

In actual practice, the recovering alcoholic's or addict's understanding of denial arises through visceral identification with others in recovery.  As stark memories of botched opportunities and outright harm emerge from the fog of early recovery, the perception of drinking a bit too much for a bit too long gives way to the reality of long‑term drunkenness and active addiction.  Discoveries of false impressions are celebrated with such slogans as "FEAR is False Evidence Appearing Real" and "That's the alcohol talking!"

An oft-told story is that "Despite [enumeration of past woes] and several years of recovery, I started drinking again because I still didn't really believe I was an alcoholic!"  This is a story of false belief that has persisted despite the alcoholic's successful identification of strong evidence to the contrary and despite an apparently successful attempt at recovery.  In such cases, the persisting belief seems not to be simply a defense mechanism for avoiding the pain of remembrance.

When defense mechanisms are included in people's stories of recovery, they are typically not defenses of alcoholism per se, but are instead alcohol-fortified defenses against seemingly unrelated difficulties, as for example: "I probably started drinking when I was a teenager because I was in denial about childhood sexual abuse."  In fact, the generic recovery story doesn't include psychological defense mechanisms at all but instead goes something like this:

A man took a drink.  The drink took a drink.  The drink took the man. ...

A Testable Hypothesis Regarding the Denial of Addiction

If an addict's denial of addiction isn't quite Anna Freud's notion of denial, what is it?  A plausible hypothesis is that this is literally a drug-induced denial — a belief in the absence of one's own addiction that has been created and heavily reinforced by means of a reward mechanism involving the action of addictive substances on the brain's own reward centers.

Direct Consequences of the Hypothesis.  Because drug-induced false learning comes directly from the brain's trusted reward centers, it is likely to be both more effective and more trusted in the eyes of the addict than most other kinds of learning.  Greater effectiveness implies that, for those who are actively addicted, mundane rewards do not compete well with drug-based rewards (cf. Goldstein 2007) but may still be useful for encouraging participation in effective treatment approaches (Franco 1995).   

Greater trust implies that effective recovery must invoke highly trusted sources of information and reward.  To date, three such sources are in wide use:  other addicts and alcoholics; a higher spiritual power; and chemicals able to reprogram the brain's own reward centers, as in the case of Chantix (Cahill 2007).  Direct comparisons of these sources are difficult, but it is safe to say that corroboration among multiple trustworthy sources improves credibility.  Hence, combinations of chemical intervention, recovery groups, and spiritual principles are more effective than any one of these taken alone.  12-step techniques for improving credibility include the ubiquitous suggestion "Identify rather than Compare" and the NA affirmation "Just for today, I will have faith in someone in NA who believes in me and wants to help me in my recovery" (NA 1988, Chapter 9).

The hypothesis of drug-induced denial explains why addicts and alcoholics seem to make so little progress before achieving complete abstinence.  Their strongest, most trusted teachings about addiction are still coming straight from their brain's own drug‑activated reward centers. 

The great trust and effectiveness of drug-induced beliefs also implies that with long-term use, false beliefs and related maladaptive behaviors permeate all aspects of life, so that full recovery will require many years of sustained effort (cf. Brown 1999).

Explication of Differing Drug-Addiction Profiles.  According to the hypothesis of drug-induced denial, substances that act most strongly and directly on the brain's reward centers should produce the strongest, most persistent denial beliefs.  Such drugs include ethanol, cocaine, heroin, and cannabis (Julian 2005).  Conversely, substances that are not strongly associated with direct chemical reward should be less often associated with drug-induced denial.  Three cases where this might be tested are nicotine, psychedelics, and anabolic steroids. 

Typically, the "high" from nicotine is both brief and mild, unlike its associated withdrawal symptoms.  Thus, we can predict more drug-induced denial in people who learn primarily from negative reinforcement than in people who learn primarily from positive reinforcement.  Having less drug-induced denial, this latter group should also have a better response to smoking cessation programs.  Interventions that reduce withdrawal symptoms may be especially important for negative responders.  In addition, it may help for negative responders to increase their responsiveness to positive stimuli and/or decrease their responsiveness to negative stimuli in preparation for quitting.

Although LSD is a partial dopamine agonist (Minuzzi 2005), it does not typically lead to long-term use (McGlothlin 1971), and so it is thought not to act strongly on the brain's reward centers.  The same is essentially true of anabolic steroids.  Although long‑term destructive use does occur, steroid use does not follow the stereotypical pattern of addiction.  If one is to believe Cohen's study, the typical steroid user is a well‑educated, white collar, 30-year-old Caucasian male who carefully controls use to maximize benefit (Cohen 2007).  Thus, LSD and steroids may be the least likely drugs of abuse to cause drug-induced denial of addiction.

Implications for the Transtheoretical Model of Change.  The need for abstinence prior to visible progress is tantamount to saying that drug-induced denial interferes with the contemplation, preparation and action phases of change, as defined in the transtheoretical model (Prochaska 1979). 

Applications of the transtheoretical model (TTM) often assume that stages of change occur in order, although that is not required by the model, and in the case of alcoholism, it is empirically not the case (Callaghan 2007).  Due to difficulties with the ordering of stages created by drug-induced denial, TTM may enjoy more success at encouraging healthy diets (cf. Di Noia 2005) than in treating alcoholism (cf. Migneault 2005; Gerard 2001).  Similarly, TTM may find more success in changing alcohol abuse programs than in directly changing alcoholics, which could explain Janis Prochaska's claims of success (cf. Prochaska 2004). 

The above observations suggest a refinement to the transformational model when applied to addiction.  Consistent with the observation that conventional rewards (e.g., AA coins. NA key tags) are effective only for the action stage of change (Prochaska 1994), other techniques, including abstinence, may be needed for undoing false learning as an essential aspect of contemplation and preparation.

Implications for Motivational Interviewing.  Terms such as "false," "counterfactual," "misinformation," and "not true" are missing from Miller and Resnick’s classic text (Miller 2002).  Counselors are advised to tread lightly in confronting false beliefs to avoid stimulating confrontational resistance.  In the case of drug-induced denial, there is a second reason, namely compromising their own credibility.  Thus, such restraint may be especially important in the precontemplation and contemplation stages before drug-induced false beliefs begin to crumble.  

Implications for Cognitive Behavioral Therapy.  The hypothesis of drug‑induced denial is a hypothesis about beliefs derived from drug-induced feelings, a phenomenon that runs opposite to the core CBT assumption that feelings and behaviors follow thoughts. 

An avowed goal of CBT is educating the client to approach his problems rationally by finding alternate behaviors that will achieve the same rewards (SAMHSA 1999, Chapter 4).  This goal seems to imply that addictive drugs are no better at stimulating the brain’s reward centers than appropriately chosen behaviors.  Actually, there are some addicts for whom this is true; they have inspired a good many interesting 12-step fellowships – EA, GA, OA, SA, etc.

As explained above, the hypothesis of drug-induced denial implies that recovery is inherently a long‑term process, whereas CBT is traditionally a short‑term effort.  This discrepancy encourages practitioners to overstate the effectiveness of short-term goals, thereby undermining the credibility of CBT.  An example would be trying to counter the belief “drinking and drugging is the only way to feel good” with the naively optimistic “I can feel good by jogging or taking a walk” (SAMHSA 1999, Chapter 4).  If it were this simple, only invalids would be addicts.

The above observations suggest that CBT may be most useful for the pursuit of limited short-term objectives in early recovery once abstinence is achieved, so that direct competition with drug-induced rewards and beliefs is unnecessary.  Relapse‑prevention techniques taught to abstinent addicts in early recovery provide a successful example.

Implications for Drug Education.  Tolerance of false beliefs in childhood may predict later drug-induced denial and thus increased likelihood of addiction.  Moreover, we would expect to find a lack of drug-induced denial in young children from families that have not been contaminated by addiction.  This is a time when teachable moments may occur in abundance, as such children have not yet received persistent drug-induced false beliefs about the nature (or nonexistence) of addiction.  Thus, learning about drug-induced denial may be substantially easier for children than for those who have become actively addicted.  In fact, the most effective children's anti-drug film to date may well be the 1940 Disney classic, Pinocchio.  Every child learns the story.  Every addict discovers Pleasure Island.  Nobody forgets Pinocchio's nose or his tolerance of false beliefs.

The highly credible nature of drug-induced denial suggests that, especially among the already addicted, educational sources which are discredited by drug-induced beliefs may be ineffective, as for example, police (cf. West 2004).

Conclusions, Implications for Treatment and Prevention

Numerous studies show that the brain's main reward centers play a central role in learning and behavior.  Highly addictive drugs invariably simulate the brain's reward centers, primarily through increases in dopamine levels.  The stories of those in recovery provide evidence that drug-induced reward leads to false learning and denial of addiction. 

This hypothesis of drug-induced false-learning and denial corroborates well‑established impressions of addiction, such as why some substances are more addictive than others, why some treatment methods are more effective than others, and why the combination of chemical intervention, recovery groups, and spiritual principles is more effective than any one of these taken alone.

Research into the ability of chemical rewards to induce false learning is needed to more fully corroborate the hypothesis of drug-induced denial and is likely to provide deeper insights into the nature of addiction as well.

Finally, the hypothesis of drug-induced learning and denial effectively sorts out some commonly used prevention and recovery techniques, showing at what stage each is likely to be useful:

·   Preventive education is most useful prior to active addiction when presented facts compete on an even footing with drug-induced false beliefs promulgated by users and distributors.  Preventive education is more effective if it relies on sources that are credible to potential addicts, as opposed to teachers or other authorities. 

·   The confrontation-avoiding style of motivational interviewing may be most useful for achieving an initial contemplation of change in the face of competition from drug‑induced beliefs.

·   An orderly progression through the various stages of change works better for drugs that rely primarily on negative reinforcement, e.g., tobacco.  For the rest, abstinence is an important adjunct to contemplation and preparation for action.

·    Relapse-prevention techniques from Cognitive Behavioral Therapy may help to stabilize addicts in early recovery. 

·   Major long-term changes are necessary to finally live and enjoy life without the use of drugs.  Twelve‑step fellowships are well-suited to this aspect of recovery.

References

AA 2002

AA World Services, Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism, February 2002.

Brown 1999

Brown, Stephanie, and Virginia Lewis, The Alcoholic Family in Recovery: A developmental Approach, 1999.

Cahill 2007

Cahill, K., L.F. Stead, and T. Lancaster, "Nicotine receptor partial agonists for smoking cessation," Cochrane Database Syst Rev, 2007 Jan 24;(1).

Callaghan 2007

Callaghan, R. C., L. Taykor, and J. A. Cunningham, "Does progressive stage transition mean getting better? A test of the Transtheoretical Model in alcoholism recovery," Addiction, Oct 2007;102(10):1588-96.

Cohen 2007

Cohen, J., R. et al., "A league of their own: demographics, motivations and patterns of use of 1,955 male adult non-medical anabolic steroid users in the United States," J International Society of Sports Nutrition, Oct 2007; 4(12).

Collins 2007

Collins, R. L. et al., "Early adolescent exposure to alcohol advertising and its relationship to underage drinking," J Adolescent Health, Jun 2007;40(6):527-34.

Di Noia 2005

Di Noia J., S. et al., "Application of the Transtheoretical Model to Fruit and Vegetable Consumption Among Economically Disadvantaged African-American Adolescents: Preliminary Findings," Am J Health Promotion, 2006; 20(5): 342–348.

Gerard 2001

Gerard, J. C., D. M. Donovan, and Carlo C. Di Clemente, Substance Abuse Treatment and the Stages of Change, 2001.

Flores 1996

Flores, P. J., Group Psychotherapy with Addicted Populations, 1996.

Franco 1995

Franco, H, et. al., "Combining behavioral and self-help approaches in the inpatient management of dually diagnosed patients," J Subst Abuse Treat. May-Jun 1995;12(3):227-32.

Goldstein 2007

Goldstein RZ et al., "Subjective sensitivity to monetary gradients is associated with frontolimbic activation to reward in cocaine abusers," Drug Alcohol Depend, Mar 2007; 87(2-3):233-40.

Julian 2005

Julian, R. M., A Primer of Drug Action, 10th edition, 2005.

Klein 2007

Klein, J. D., R. K. Thomas, and E. J. Sutter, "History of childhood candy cigarette use is associated with tobacco smoking by adults," Prev Med, Jul 2007, 45(1):26-30.

Longshore 2006

Longshore, D., and C. Teruya, "Treatment motivation in drug users: a theory-based analysis," Drug Alcohol Depend, Feb 2006; 81(2):179-88.

McGlothlin 1971

McGlothlin W.H. and D.O. Arnold "LSD revisited. A ten-year follow-up of medical LSD use,"  Arch. Gen. Psychiat, 1971; 24:35‑49.

Migneault 2005

Migneault J. P., T. B. Adams, and J. P. Read, "Application of the Transtheoretical Model to substance abuse: historical development and future directions," Drug Alcohol Rev, Sep 2005; 24(5):437-48.

Miller 2002

Miller, W. R., and S. Rollnick.  Motivational Interviewing: Preparing People for Change, 2nd Ed, 2002.

Minuzzi 2005

Minuzzi, L., et al., "Interaction between LSD and dopamine D2/3 binding sites in pig brain," Synapse, Jun 2005; 56(4):198-204.

NA 1988

Narcotics Anonymous World Services, Narcotics Anonymous, fifth edition, 1988.

Prochaska 1979

Prochaska, J. O., Systems of psychotherapy: A transtheoretical analysis, 1979.

Prochaska 1994

Changing for Good : A revolutionary 6 stage program for overcoming bad habits and moving your life positively forward, Prochaska, Norcross & Di Clemente, 1992.

Prochaska 2004

Prochaska, J. M., "The Transtheoretical Model of Change for Mutli-Level Interventions for Alcohol Abuse on Campus," J Alcohol and Drug Education, 47(3); 34-51, Mar 2004.

SAMHSA 1999

TIP 34: Brief Interventions and Brief Therapies for Substance Abuse, SAMHSA/CSAT Treatment Improvement Protocols, 1999, Chapter 4:  Brief Cognitive-Behavioral Therapy.

Valins 2005

Valins, S., "Persistent effects of information about internal reactions: ineffectiveness of debriefing," Integr Physiol Behav Sci. Jul-Sep 2005; 40(3):161-5.

West 2004

West, S. L. and K. K. O'Neal, "Project D.A.R.E. outcome effectiveness revisited," Am J Public Health. Jun 2004; 94(6):1027-9.