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

Written by Stanton Peele

What seems most remarkable about these alarmist campaigns is their lack of notable success. In 1982, 22 million people were found to have used cocaine—less than 4 million of whom were current users. Since that time, which marked a major escalation in various campaigns against the drug, cocaine use has continued at a remarkably high level (as indicated by the national student survey) and expert commentators have described epidemic levels of cocaine addiction (Peele, 1987a). At the same time, "'Crack has become in a very short time the drug of choice in New York City" (Kerr, 1986). Apparently, users do not believe the lurid depictions of cocaine's effects, or else they choose to use it anyway. The latest survey of young drug users finds nearly 40% of current high school graduates use cocaine before they are 27. These users report not believing the dangers typically attributed to cocaine, primarily because they and their friends have not experienced them (Johnston et al., 1986).

Treatment, Denial, and Our Failure to Stem Alcohol and Drug Abuse

Many observers are forced to juxtapose these data showing massive exposure to cocaine with the idea that cocaine use invariably becomes compulsive. Some argue that young users don't know what they're talking about when they describe their own casual use, that inevitable tragic consequences await many of these, and that many already suffer these consequences but are not aware of them because they are so bound up in their drug addiction. Are we a massively addicted society, only many of those affected don't realize it? The clinical concept that expresses this viewpoint is "denial," or the incapacity of drug and alcohol users accurately to perceive themselves and their substance use.

This alleged denial is then often used to justify treatment interventions with unwilling clients, particularly the young. On May 20, 1985, CBS Evening News ran a segment in which a CBS employee posing as a father called a treatment program to report his daughter for using marijuana and for dating an older boy. Based on no other information, the daughter (also a CBS employee) was placed in residential treatment. She wore a hidden microphone, and when she told a counselor she didn't have a drug problem, he replied that most of their patients made similar claims. In other words, they were all practicing denial. Admissions like these, according to CBS, had caused hospitalizations of adolescents to more than quadruple between 1980 and 1984.

CompCare Medical Director Joseph Pursch was presented in an interview on the news segment with a case scenario like that which had actually occurred; he denied such a case would be admitted to inpatient treatment. In a later debate on this case and related issues, CompCare Vice President Ed Carels took an aggressive stand toward those involved in the CBS program: "I don't know why you think that when you're done, the mafia, NORML and all those supporting drug abuse in the world won't have you and Mr. Schwartz [referring to those who arranged the case in which the girl was committed] as their champions." Mr. Carels noted that parents weren't concerned "about treatment professionals doing something wrong with their child. 'They are worried about their kid dying because of lack of professional help'" ("Adolescent Treatment Debate Rages," 1986).

The idea of death as the progressive end state of untreated alcohol or drug abuse derives from the disease-theory notion of addiction as an inevitable and irreversible process. The recent best-seller, The Courage to Change, relies on the personal testimony of recovered alcoholics and others to point up the pervasiveness of alcoholism and the urgent need for treatment. Dr. S. Douglas Talbott indicated "22 million people have an alcohol problem related to the disease of alcoholism." The possibilities for any such person "are these three: he or she will end up in jail, in a hospital, or in a graveyard" (Wholey, 1984, p. 19). Naturally, according to this model, it is imperative to get anyone abusing alcohol into treatment.

Epidemiological data systematically dispute the disease model. Most young people outgrow substance abuse, even its severe forms. The most powerful data on the return to controlled drinking do not come from studies of treatment outcomes, but rather from surveys of drinkers who do not enter treatment at all. The Cahalan-Berkeley group have regularly found problem drinkers to attenuate their drinking with age, and only rarely to abstain (Roizen et al., 1978). Similar natural remission over the course of the individual's life appears regularly even among severe cases of alcoholism (Gross, 1977). Indeed, Room (1980) discussed the repeated finding that only those who enter treatment display the full array of alcoholic symptoms, which include inevitable loss of control and the impossibility of regaining control of the drinking function. Treatment here seems to be necessary for the development of the classical alcoholism syndrome.

The commonplaceness of the natural correction of drinking problems over time comes through even in research like George Vaillant's The Natural History of Alcoholism, which sets out to defend the disease view of alcoholism. The majority of the over 100 inner-city alcohol abusers the Vaillant study followed for 40 years ceased abusing alcohol, in nearly all cases without treatment. Twenty percent returned to moderate drinking and 34% abstained. However, Vaillant defined abstinence as drinking less than once a month (he also allowed his abstinent—but not controlled—drinkers the leeway of up to a week of alcoholic drinking during the year). As Vaillant (1983) indicated, "relatively few men with long periods of abstinence had never taken another drink" (p. 184).

Of course, all alcoholics do not recover on their own. Along with the inaccurate notion that alcohol abuse inevitably worsens without treatment, the medical model insists that treatment of the disease significantly enhances the recovery rate for alcoholism. Although Vaillant's case descriptions emphasize the requirement of AA membership, he actually found 37% of those who achieved a year or more of abstinence relied an AA (the controlled drinkers obviously had almost no contact with AA). Just as the Rand investigators discovered, Vaillant (private communication, June 4, 1985) found that long-term AA membership was associated with long periods of abstinence, but that those attending AA also relapsed more often than those who quit drinking on their own. Meanwhile, analyzing remission in 100 alcoholic men and women treated in a medical program he supervised, Vaillant found their progress after 2 and 8 years "no better than the natural history of the disorder" (pp. 284-285). Vaillant reported 95% of his patients relapsed. One emerges deeply puzzled by Vaillant's insistence that medical treatment and AA attendance are imperative for alcoholics.

An even more outstanding case of rationalizing conventional treatment verities in the face of almost total lack of treatment success was presented in a much-noted study in the New England Journal of Medicine, which found only 1.6% of treated alcoholics returned to moderate drinking (Helzer et al., 1985). What, then, were the outcomes of this hospital treatment where controlled drinking has been so thoroughly discouraged? Overall, treatment for alcoholism in this study produced results decidedly inferior to the natural remission rates for alcoholism Vaillant (1983) summarized (cf. p. 286). Moreover, of the four hospital units Helzer et al. examined, inpatient alcoholism treatment showed the lowest remission rate, one half the remission rate (among survivors) of that for patients treated in a medical/surgical hospital. Only 7% of those treated in the hospital alcoholism ward survived and were in remission at a follow-up period of from 5 to 8 years! It might seem that self-congratulations for the dominant views of alcoholism and addiction treatment are somewhat premature.