Denial - of Reality and of Freedom - in Addiction Research and Treatment - Denial — of Reality and of Freedom — in Addiction Research

Written by Stanton Peele

Yet treatment for substance abuse (or chemical dependence) has become more coercive than ever before (Weisner & Room, 1984). Most referrals now come from the court system or employee assistance programs, where treatment is offered as an alternative to prison or job loss. Treatment is almost always geared toward the disease model, abstinence, and 28-day hospital programs, so that, for example, a drunk driver under court-ordered treatment may be put in jail for showing any alcohol in a follow-up blood or urine test. The largest single category of such referrals is DWI; consider this analysis by the President of the Insurance Institute for Auto Safety: "the best research to date has found that drivers convicted of alcohol-related offenses have fewer crashes after their licenses have been suspended or revoked than after being sent through present types of rehabilitation" (Ross, 1984, p. xvii).

The person with a drinking problem who is directed to treatment by his company or the courts in fact infrequently qualifies as alcoholic. Nonetheless, he or she—like most people who present themselves for treatment—are often hospitalized and invariably instructed in abstinence and other disease-based recommendations (Hansen & Emrick, 1983). If people like this resist such diagnosis and treatment, they have proven their denial and thus that they are suffering from the disease of alcoholism! It is not surprising that most people—even those who acknowledge they may be abusing a substance—refuse to seek treatment. If they do seek treatment that contradicts their self-assessment, they frequently drop out or fail to benefit from therapy (Miller, 1983).

In this sense, the largest source of denial is the therapy itself and the belief systems of those who conduct it (Fingarette, 1985). When therapists gainsay the ideas that people can improve their drinking or drug-taking status without abstaining, or that people can use a drug regularly without abusing it or risking addiction—as has repeatedly been established by epidemiological research—we may say that it is therapists and addiction and alcoholism experts who are practicing denial. Thus we refuse either to support nonproblematic substance use or to help people with their problems before these are completely out of hand. As indicated by the type of person who voluntarily calls an 800 hotline, when people are finally willing to commit themselves to standard treatments they have usually progressed to the point where their life has collapsed and therapy is a stop-gap, emergency measure rather than a path to health and an ordinary lifestyle.

The failure of our policies to prevent the rapid rise in cocaine use or addiction, to eliminate high levels of problem drinking among young people (large numbers of whom seem destined to grow into alcoholism), or to help most alcoholics or addicts would seem to be severe indictments of these policies. Instead, the policies are apparently reinforced by their lack of success as we up the ante of military interventions against the production and importation of cocaine and we increasingly recommend drug-testing of athletes, young people, and practically everybody else. Consider that the 1986 deaths of athletes using cocaine occurred with one whose school was already aggressively drug-testing athletes and another whose club boasted the most active treatment program in the NFL—the two most popular methods for responding to drug abuse among athletes and others.

Is it really true, as our current model of addiction and its treatment suggests, that our only hope for keeping people from drowning in drugs is to blockade our shores and coerce people into therapy? Have we given up on the possibility of self-control, so that addiction and denial are concepts that require us to take control over more and more people's lives? If we accept this view, have we not already lost the war on drugs? It is fascinating, though not wholly unpredictable, that in this atmosphere alternative views of drug use and abuse, alcoholism, and treatment have all but been eliminated. For example, despite the repeated failure to show the efficacy of conventional treatment for DWI referrals, the Attorney General of New York recently petitioned the State Supreme Court to have a nondisease program for drunk drivers placed under the control of the State Division of Alcoholism and Alcohol Abuse, which disapproved of the program's approach (State of New York Supreme Court, 1986). Is it possible that our programs are designed primarily to preserve and support conventional wisdom and those who are emotionally committed to it rather than for their actual effectiveness in dealing with the problem?

Advocates of traditional treatment approaches are undaunted by reports like Vaillant's that treated alcoholics did no better than untreated alcoholics and Helzer et al.'s that 93% of inpatient alcoholic patients either died or were still alcoholic after five to eight years. An editorial based on the Helzer et al. study warned that "Any treatment professional who holds out controlled drinking as a reliable option ... ought to consider getting very good malpractice insurance" ("Rx—Abstinence: Anything Less Irresponsible, Negligent," 1985). Responses to an article on moderate drinking in the Washington Post (November 27, 1985, p. 6) averred the discussion "has significant potential for causing great harm and even death to alcoholic persons" and that acceptance of this point of view "could, indeed, be fatal." A woman who drew the quite legitimate conclusion that the controlled-drinking "approach doesn't work for me" prompted Joseph Pursch (1986) to announce in his national column that "any program which prepares an alcoholic for controlled drinking is dangerous and should be condemned."

This is not an easy time to oppose the prevailing disease-oriented wisdom of alcoholism and addiction. I could hardly recommend that a person practice controlled-drinking or drug-use therapy; what if patients later joined AA or NA and decided to make a cause celebre of their previous treatment or sue their former therapists? Nor is it surprising if professionals tilt their views (or at least those they express) in the direction of the prevailing wisdom. In her review of my book The Meaning of Addiction in The New England Journal of Medicine, Dr. Margaret Bean-Bayog (1986) wrote in part:

But this book worried me. Dr. Peele is widely read outside the scientific community. The distortions are subtle, the writing is slick, and to a person unfamiliar with the literature, the arguments are very seductive....First Amendment rights and a free press guarantee that such books be protected, like any other, but if [such] a book pretends to scientific neutrality..., what then? This is obviously different from a case of fraudulent data. Is there any court of appeal from slur and innuendo [Dr. Bean-Bayog refers here to my reinterpretation of Dr. George Vaillant's work]? I would be delighted to hear from readers who have thought about these issues.

I don't recall ever reading a review before in an important scientific publication which requested like-minded readers to contact the reviewer for possible action against a book's author. Perhaps it is not too late for me to recant and to endorse disease views of alcoholism and addiction.