I Don’t Believe in Denial

By Edward M Paul 02/12/15

How an experienced addiction psychiatrist helps patients navigate the bumpy road to recovery.


Although some physicians in addiction medicine concentrate chiefly on prescribing medications, renowned addiction psychiatrist Edward Paul believes in a more holistic approach. As seen below, Dr. Paul fastens his therapeutic seat belt and uses a multimodal approach to help his patients navigate the “peaks and valleys” that often characterize the path to recovery. Psychotherapy, family sessions, medications and creative interventions, all delivered in the context of a therapeutic alliance that allows full expression of his patients’ ambivalence about substance use, are some of the methods used by Dr. Paul as he helps patients navigate the “gradual learning process” of recovery. —Richard Juman

For every person at an NA meeting who says, “I kicked on my own,” there are nine who are dead and can't share their side of the story. 

When I was a young addiction fellow, I was called to consult in the hospital for a man being treated for the medical complications of alcoholism. In those days, I wore a white coat.  As I walked into his room, I could detect the faint smells of spilled urine and “liver breath." I was determined to see if I could find a way to connect with and get through to this man who others on the unit had told me was a “lost cause.” The feeling among the staff was that he was destined to die of his alcoholism and that he was “in denial.” I decided that I wasn’t going to become yet another person confronting him, eliciting the familiar, “Oh, no, not again. I don’t have a problem!” So, I decided that I would deny his denial, that I would bypass it, rather than repeat a pattern that had been played out scores of times by previous doctors and other providers. So, I bypassed it by gently telling him, “You know, there is hope.” 

 In those days, it was standard procedure to refer all such patients to AA. Going on a hunch, I added, “And you don’t have to go to AA to do it.” He responded with a look of wonder, hope, fear and puzzlement. 

“Really?” he asked. 

“Really” I told him.

“Everyone told me I was going to die. I thought it was too late.” 

“It isn’t.”

I elaborated, and we got to talking. Soon, he was receiving cognitive behavioral therapy and on medication for his drinking, having deciding it was possible to live.

This clinical example illustrates something that I think is critical: The patient wasn’t “in denial,” he was scared to death! He was hopeless, and he needed to hear that his life wasn’t over, that change was possible and that there were tools available to help him. It has been my long experience that all of the admonitions in the world only serve to make matters worse. People need to see that there is a way forward—that there is hope. The exact reasons for his fear of AA weren’t touched, and they didn't need to be. Sometimes “meeting the patient where he is” turns out to mean “meeting the patient where he is, once he’s been thoroughly interrogated about why he is where he is, since we know that where he is must be wrong!” To me, this was simply a case of a patient who hadn’t responded to a recommendation that he’d heard hundreds of times. I wasn’t interested in being the hundredth person to tell him to go to AA. So, I just left it alone.

Another reason that people appear to be in denial is that they are simply stalling. While I’m an addiction psychiatrist, I often treat patients with other problems. Once, I was treating a patient for an elevator phobia. The strategy was for her to first simply stand in front of the elevator, watching the ominous doors close in on others that she felt were doomed to certain death. Eventually, the plan was for her to ride one flight up and walk back down. From there she would endure longer trips, a technique known as exposure therapy, in which a patient gradually faces their fears a bit at time. But, even this was too much for her.

On the way to the elevator, she said, “I don’t think I really have a problem with elevators, in fact, I can really get on one any time that I want. I just don’t feel like it right now.” She sounded awfully like an alcoholic, whose “denial” may really be fear that the consequences of detoxing and remaining abstinent will be horrific. Many people are simply afraid to be without their drug of choice. “How will I cope?” “How bad is the withdrawal?” “Who will I socialize with if I am not drinking and using drugs?” My experience has demonstrated that telling someone that these are invalid concerns only makes things worse. It is only when they have learned that drugs and alcohol are causing more harm than good that they change—and it’s an accumulation of many small instances, sometimes culminating in the famous “hitting bottom,” and sometimes not. “How will I have fun?” “My boyfriend is a dealer and I love him!” “I have business dealings in China and you can’t do business there without drinking.” These are all extremely valid concerns to the patient, as self-defeating as they might be, and in the context of a solid therapeutic alliance they all deserve a fair hearing. It can take a long time to learn what works and what doesn’t.

So, I conceptualize overcoming addiction as a gradual learning process—that is the paradigm that I see repeated in my work with this population. It’s one thing to know there’s a problem—and I have never met an injecting heroin user who said they didn't have an addiction—and another to learn what helps in the long run. Although there are many people who overcome addiction without treatment, in my experience those who do enter treatment usually have a “peaks and valleys” process to recovery. 

The opioid use disorders highlight the benefits of ongoing and gradual progress towards recovery. I have seen too many opioid patients relapse, often with tragic consequences, because they come out of an inpatient setting and try to remain abstinent by only going to outpatient treatment and 12-step programs. Without Vivitrol, Suboxone or methadone, the chances of maintaining abstinence are less than 1 in 10. For every person at an NA meeting who says, “I kicked on my own,” there are nine who are dead that can't share their side of the story. Talk about the definition of insanity—how many detoxes does somebody addicted to heroin have to go through before they learn that something else is needed? And all along they are being told that “denial” is leading them astray. Telling someone that they are in denial, besides being absurd at face value, assumes that a patient’s own experience and struggles are to be ignored.

It’s not about denial, which is black and white—there is always ambivalence in addiction.

I think denial is really useful when applied to an acute phenomenon: your wife just died in a car accident, you have metastatic cancer—“It can’t be!” Then, all of the Kubler-Ross stages follow: denial, followed by anger, bargaining, depression, and acceptance. Or, we could map a similar process onto the Prochaska and DeClemente stages of change model. What I hear in session is: “I don’t want to be on Suboxone for the rest of my life, is being on heroin the rest of my life OK?” I have met with countless families in which the following scenario is enacted: 

Mom (addressing me)  “She just doesn’t want to get better!” 

Daughter (screaming) “I do, you just don’t see it!” 

Mom: “Then why are you still using?” 

Daughter: “Because it’s hard! But that doesn't mean I don’t want to stop!”

I can see the desperate look on the patient’s face. She wants to get better, but this addiction is too powerful—she needs more help. Coming at it from another angle, I’m reminded of a recent comment from the representative of a managed care company I spoke with on behalf of a crack-smoker seeking inpatient rehab: “We can’t admit him, he’s obviously not motivated because he’s still using.” 

In my experience it is very rare to find someone who is completely committed to abstinence, or completely committed to continuing their substance use. For one thing, the extended amygdala wants to keep using, but the pre-frontal cortex wants to stop. It’s not about denial, which is black and white—there is always ambivalence in addiction.

To come at this from a completely different angle, I will share a personal experience that I have come to think of as my “Colonoscopy Epiphany.” I was told by my doctor that I would not be able to work after having the procedure, but afterward I felt fine. I figured that I would take the opportunity to write and return some emails. As I was about to hit “send” on the first one, something told me to proofread my communication. I found that what I’d been about to send was complete and utter gibberish! “That’s interesting,” I thought. I was completely “under the influence” but I had no real awareness of it. Was it because I was “in denial”of the fact that my functioning was negatively impacted by anesthesia? Obviously, not. It was just that my brain was malfunctioning in a way that didn't let me know it was malfunctioning. 

I believe that this paradigm is descriptive of my patients who are dependent on alcohol or benzodiazepines. Many of them feel fine and believe that they’re operating well, even though they’re not. Of course, this scenario is much worse in someone with unrecognized brain trauma, or alcoholic dementia, or Wernicke-Korsakoff’s syndrome, a form of alcohol dementia from B-vitamin deficiency in which someone creates false memories to fill the vacuum of what’s missing. With such patients one can say, “I knew you in the Navy,” and you might hear back: “Yes, I was an admiral in The Seventh Fleet.” Or you might say, “I knew you in the circus,” and hear the patient respond: “Yes, I auditioned for the flying Wallendas.” Of course, this is brain damage, plain and simple, but something of this ilk happens in more subtle ways. I had a patient with bipolar disorder, who was becoming manic and a bit disruptive in group. He was accused of being in denial about his personality problems!

Telling someone they are in denial takes the voice of wanting to heal, and steals it from the patient, leaving the addictive voice behind. It is saying, “I know how you should live— I know more about your life than you do.” It is the opposite of understanding that, for example, doing crack blocked out the memories of sexual abuse, but that now it’s causing its own problems. Hopefully, this all water under the bridge, and all addiction professionals have learned that listening, caring, helping resolve ambivalence and offering practical suggests when asked is the way to go.

Dr. Paul is a Columbia- and Harvard-trained, Board Certified Psychiatrist in New York who has long been recognized as a leading expert in Addiction Psychiatry. He is a perennial Castle Connolly Top Doctor and is Clinical Associate Professor at the NYU School of Medicine. 

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Edward Paul, MD., has been working in addiction psychiatry for almost 3 decades (unless you count his eighth grade talking a friend out of trying heroin.) He is trained in several forms of psychotherapy as well as the pharmacology of addiction and co-occurring psychiatric disorders. You can find Dr. Paul on Linkedin.