Cambridge College Program on
Alcohol and Drug Counseling
November 19, 2007
Reconciling Clinical and
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.
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
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
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
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
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.
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