Whether you have had a personal experience with a substance use problem or not, you have likely heard the term denial used to describe someone who uses substances heavily, but tells others they don’t have a problem. Maybe you have a friend or family member you feel drinks too much or you know to be a heavy drug user, and you’ve thought they have a problem and are in denial of the problem. Or perhaps you’ve had others tell you that you have a problem, and you’ve disagreed and then been told you’re in denial. It’s time to challenge the denial myth with respect to substance use and show it for what it really is.
The theory of denial was first identified by Dr. Sigmund Freud to describe how an individual rejects something they find too painful to accept such as the death of a loved one, a terminal illness, or a traumatic experience. Like many of Freud’s theories, denial has been controversial. Unscrupulous therapists have used psychoanalysis and the denial theory to convince people of traumatic experiences that never happened such as molestation, incest and rape. More recently the denial theory has been used by the treatment industry to ensure even those who reject the idea that they have a disease called addiction can be coerced into treatment.
While it is understandable that a person may go through a period of “denial” when facing the death of a child or their own terminal illness, there is no data to support the idea that people are unaware of their own behaviors or of the consequences of their behaviors. As substance use requires prior thought, planning and action to fulfill, like all behaviors, the idea that a person is unaware they are partaking in the behavior is absurd.
So if denial is not referring to the person being unaware of the behavior, then what is it with respect to substance use? A substance user who is in denial is said to be unaware of the problems their substance use has caused them. Let’s look at an example from a man that came through our retreat some years ago, John. One night John drank approximately 8 drinks over the course of an hour and drove home. On the way home he crashed his car and was charged with DUI. In this case John knew that he drank. He knew that he drove after drinking, and he knew that his ability to drive was compromised which led to the accident. He initially denied these things to the police and his family, but that wasn’t denial, that was lying for obvious reasons. As part of his sentence John was required to attend an outpatient treatment program that where a counselor told him that he must accept that he is an alcoholic. John admitted to her that he drinks an average of 5 or more drinks most nights. He admitted that he used poor judgment to get behind the wheel while intoxicated but he rejected her assertion that he is an alcoholic. He told her he planned to continue drinking but will ensure he does not drive after more than 2 drinks. His counselor diagnosed John as in denial and required him to attend an inpatient treatment program. What do you think?
Those who believe the disease theory of alcoholism will say that of course, John is an alcoholic. They will say that drinking 5 or more drinks nightly is excessive. And to them, the fact that John got a DUI is proof positive for that he must not be in control of his drinking. Those who buy into the disease theory also think John’s assertion that he won’t drive after drinking is unrealistic. They believe that the disease of alcoholism renders him incapable of making the choice to drink less, and not drive.
It is true that John may or may not choose to keep his commitment to not drink and drive, but if he does doesn’t, this certainly does not mean he can’t, it just means he didn’t. The truth is, based on data, one of the most common ways people change their drinking behavior is through a brief intervention such as getting into legal trouble, having marital issues, employment issues or health issues. Contrary to popular belief, the majority of first time DUI offenders never get a second offense and instead modify their behaviors to ensure it won’t happen again. Using this data, the chances are far greater that John won’t repeat his offense and that he is perfectly capable of making the decision to not drink and drive.
In another example, Kate was a 4.0 student preparing to graduate from an Ivy League school. When her mother called us she was very concerned. She explained that Kate was an over achiever with respect to academics she found out from her roommate that Kate was secretly using heroin on a daily basis. She supported her habit by working at the campus bookstore part time. She got her heroin from another student on campus, but didn’t not hang out with people she considered to be “low-life junkies.” When Kate’s mother spoke to her about it, Kate told her that she knew she shouldn’t be doing it but she felt it was helping her deal with the stress of school. She promised she would quite when she graduated. Kate’s mother didn’t buy it and forced her into a treatment program. What would you have done? Do you think Kate could quit once she graduated?
When asked this question nearly everyone predicts that Kate wouldn’t be able to quit once she graduated. In this example you would say that Kate is not in denial that she’s using heroin or that her heroin usage may be wrong or dangerous, but that she is in denial of her “addiction”. Like John she believes she has control and therefore can stop when she wants to stop. Treatment providers used her belief that she could stop as evidence that she needed extensive treatment. They told Kate and her mother that Kate was in denial of her inability to control her behaviors, and then spent a few months convincing her that she was powerless to stop using heroin as a means to help her to stay off it once she left treatment.
To explore this concept more deeply, ask yourself the following question: is it better for Kate to believe that she can quit using heroin, or that she can’t quit using heroin? Is it better for her to believe that heroin is a tool she is using temporarily to help her with a situational issue, or is it better for her to believe she has a progressive, incurable brain disease that will make her crave and want heroin for the rest of her life? In these questions we have captured the root problem with the idea of powerlessness and disease. Whether people believe they can quit or can’t quit, they are right. I chose heroin use for this example because there is a strong belief in our culture that heroin and other opiates are patently addicting and people become hopelessly addicted for life from their first usage, yet data shows that most opiate users whether prescribed or recreational users, are occasional users and also that more than 96% of those who were once heroin dependent, no longer are. (Wu, et. al., 2011)
Based on this data it would stand to reason that if Kate was left alone and continued to use heroin after graduating it is because she wanted to continue using heroin not because she couldn’t stop. Kate continuing drug use even after she said she would stop is not evidence of a disease or of her lack of knowledge of her disease, rather it is only evidence that she decided to keep using heroin. Treatment professionals at all levels, even those who are former “addicts” themselves, built the theory of denial based on egocentric judgment rather than sound scientific research. If you take the moral judgments away and look at Kate’s life, by all other accounts she appears to be high functioning and successful, much like the vast majority of opiate users. Prior to being forced into treatment she stated she had no plans to keep using heroin forever, and at some point planned to set aside that behavior in favor of what she viewed as more mature behavior. Kate is like the majority of college students who spontaneously change their behaviors and in essence, mature out of problematic substance use after college.
In these examples both Kate and John reject the idea of powerlessness and SAHMSA substance use data that has been collected over the past 30 years shows that it is likely that both Kate and John will moderate or discontinue these behaviors as part of the natural maturation process.
It is important to understand that assessments given by treatment providers are specifically designed so that all participants fit the criteria for addiction and/or problem substance use and therefore need their programs and services. In this respect the theory of denial fits their marketing and sales needs perfectly. Whether you agree with their assessment that you are an addict or you disagree, you still need their treatment.
The concept of denial turns out to be not only wholly inaccurate, but an expedient way of exerting control over people. Denial is seen as a “symptom” of a non-existent disease that systematically allows the substance user’s thoughts, desires, and personal beliefs to be summarily dismissed by those trying to “help” them. And furthermore, it is the first step in the dehumanizing and devastating process used by the addiction recovery system to convince people they are powerless.
Wu, L. T., Woody, G. E., Yang, C., Mannelli, P., & Blazer, D. G. (2011) Differences in onset of abuse/dependence episodes between prescription opioids and heroin: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Substance Abuse and Rehabilitation, 2011 (2), 77-88. https://doi.org/10.2147/SAR.S18969
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