Denial

Today I will lecture to my students in my Alcohol and Drugs class on denial.  We had a provocative discussion of the topic last Thursday, building off our reading of the wonderful and powerful memoir Drinking: A Love Story by Caroline Knapp. 

A group of students opened last Thursday’s class with a presentation that framed denial in the two ways it is generally discussed in addiction (in the US).  As I wrote to this group to help in preparing their presentation, “There is a basic debate in the addictions field (particularly alcoholism) on the role and importance of denial in addiction and recovery.  On the one side, denial is seen as a defining feature of addiction and breaking through denial as a core component of successful recovery.  On the other side, denial is seen as a marginal feature of addiction, likely the result of some other internal problem or even of social relations.  In this approach, attacking denial can backfire, causing anger in the substance abuser while not addressing either addiction itself or the promotion of therapeutic change.” 

After the students gave their presentation, I wanted to encourage class discussion, and used a technique I often employ, getting them to reflect on their own everyday lives and what that can tell us about ourselves.  I asked the class to write down an example of someone they knew “in denial,” and then give their gut reaction about why they think that person reacted that way.  In other words, I wanted some ethnographic data and some culturally-framed “explanations” to generate discussion.  It worked. 

Here’s one great example: 

One of my best friends, she has some eating issues (which she adamantly denies).

-When confronted about the problem, she first becomes defiant (“I just eat healthy”) and then self-conscious; sinks deeper into problem, avoids eating around friends, hides the problem

-Refuses to acknowledge that starving herself is problematic; denies the problem: “look at me, do I LOOK anorexic? I’m not stick thin so I can’t be anorexic”

-Tunnel vision: she wants to be thin so badly that she’s willing to ignore the negative consequences that come from starving herself

-Constructing an ideal world– ignoring the issue, living in her own little universe where everything is perfect and not eating is the key to happiness.

This may be silly, but this idea and some other comments that were made about “counter personalities” in class reminded me of a line from the most recent episode of the TV show Gossip Girl– Serena to Blair: “Whenever something happens that’s not a part of your plan you pretend like it doesn’t exist. You act like you’re in this movie about your perfect life then I have to remind you the only one watching that movie is you.” To me, that’s a pretty good description of denial…This description—with its emphasis on an idealized world created through language and imagination; on sinking deeper into problems through the combination of awareness and avoidance; and the role of confrontation and defiance in social relations—captures something about denial that is not in a disease view nor in a psychological view of addiction.   

Put differently, it is a view of denial that is at a significant distance from anything seen in neuroscience, where denial is often reduced to cognitive dysfunction or to ambivalent emotions.  For example, the first article that pops up in Google Scholar under “denial addiction” opens its abstract with: “This study explored the proposition that denial of addiction is often more a product of cognitive failure due to cerebral dysfunction than an emotion-driven rejection of the truth (Rinn et al. 2002).”  For many interested in cognitive neuroscience, the discussion of psychological and neurological functions seems sufficient, with the arguments over the weight to assign one or another (say, cognitive failure versus emotional rejection).  

Yet this psycho-biological approach leaves out two main causal forces in our lives, forces that reach down and shape the very cellular functioning of our brains: (1) language, meaning, and thought, and (2) self and social relations.  (For the first, see the post on Language and Color, and for the second, on Loneliness and Health.)  For example, in my class some students emphasized aspects of how people talk and talk to convince themselves and others of something.  Other emphasized the role of pride and humiliation in why some people kept pushing to “keep up appearances.” 

In reviewing the students’ descriptions, I saw repeatedly how the act of confrontation, struggles over what counted as “real”, and the assigning of blame and responsibility infused “denial” with incredible social and symbolic relevance.  Cognitive dysfunction might have come in with off-hand comments of, “yeah, it’s so stupid” and ambivalence and emotion-driven rejection of the truth in why people did not want to accept blame. 

But the real action, it seemed to me, was in the realm of negotiating meanings and social relations and how these informed behavior—accusing someone of being in denial over an eating problem, a father pushing his son to play and play, denying an injury until something catastrophic happens. 

Really, I wish to end with two points.  As I told my students, our American culture (and most Western cultures, I’d argue) emphasize the “scientific” as our way to explain—the production of rational categories, the importance of biological causes, the role of universal psychological features.  Yet the students’ own data and explanations were at the level of meaning and relationships.  At this level, we have tools to think about two other formative causes in our being human.  One is language, meaning and thought, and the other is self and social relations.  These are good levels for neuroanthropology, good levels to look for integration to more macro concepts like culture, inequality, and ideology, and good levels to reach down to emerging trends in “social neuroscience.” 

For the second point, about denial itself, I will admit I still don’t have much clarity.  But what did come clear to me is that for denial, it’s the transition from singular acts and situations to social definitions of people that most marks “denial.”  The transition from telling “white lies” to “living a lie.”  But there is no absolute line there.  It is similar with trying to diagnose addiction—there is no definitive line.  Indeed, clinicians rely on the violation of social roles and responsibilities, and not on some abstract definition of biological function (just look at the DSM-IV criteria, e.g., “failure to fulfill major role obligations” and “recurrent social or interpersonal problems” linked to on-going substance use).   

So if there is not an absolute category, I would say we should speak in terms of processes and outcomes.  With denial, I see two joint processes that lead to one outcome. 

The first is based on that description “becomes defiant, then self-conscious, sinks deeper into the problem”—denial is about ambivalence and truth and awareness and defiance and what you tell yourself over and over until it just has to make sense. 

The second is the continued effort to convince others, often through self presentation and in conversation, that there is no problem—proving and demonstrating that it is so, a literal enactment of “the truth.” 

As those two processes widen—a deepening problem full of greater ambivalence and pain (hence avoidance), and continued effort at “keeping up appearances”— the negotiation of “denial” in confrontations, accusations, responsibility and blame becomes more potent.  The wider the gulf in those two processes, the closer we might come to saying someone is in denial.   

So that’s where my thoughts are right now.  I would encourage people to note down their own examples and knee-jerk explanations of someone “in denial.”  To note any literature that touches on the multiple nuances of this everyday phenomenon.  And to share their own reflections.

4 thoughts on “Denial

  1. A friend wrote me an email about denial, saying, “For me, denial is a strategy, a way of protecting yourself or not moving, to put your head in the sand like an ostrich, to stay in the same situation, to change nothing while making as if all the world believed that.”

    So just thought I’d throw that out there. Another view is on display at Human All Too Human blog: http://human-alltoohuman.blogspot.com/2007/09/basic-principles-03-deception.html

    The most interesting part. Lying is simply something humans do, based on a study in the US: “[T]he work by Bella DePaulo, Ph.D., a psychologist at the University of Virginia, confirms Nietzche’s assertion that the lie is a condition of life. In a 1996 study, DePaulo and her colleagues had 147 people between the ages of 18 and 71 keep a diary of all the falsehoods they told over the course of a week. Most people, she found, lie once or twice a day —- almost as often as they snack from the refrigerator or brush their teeth.”

    Next, cognitive dissonance is a related phenomenon to denial with its emphasis on presenting a consistent world view and thus “denying” contradictory information. Here’s a recent consideration at PsyBlog: http://www.spring.org.uk/2008/02/when-cognitive-dissonance-doesnt-matter.php

    Some related material on the imposter syndrome (thinking yourself a fraud) and self presentation, over at Mind Hacks: http://www.mindhacks.com/blog/2008/02/impostors_and_the_su.html

    And finally a good article on Denial at the NY Times, with comments, “Denial Makes the World Go Round”: http://www.nytimes.com/2007/11/20/health/research/20deni.html

  2. Pingback: It’s Our Fault: Denial, Disease and Addiction « Neuroanthropology

  3. Hello, I’m trying to put together some information to provide a definition and examples of “denial” to a teen population. This is proving to be more difficult than I imagined. Any ideas? Thanks for your time…I will keep working on it!

  4. One of the best examples that came up in my class was actually the story of a father denying that his son was injured, insisting that the boy could continue playing whatever sport it was. That lead to a catastrophic knee injury.

    Tara Parker-Pope discussed another interesting example recently, involving denial and heat stroke, or people insisting they are all right until they collapse. Here’s the link: http://well.blogs.nytimes.com/2008/06/09/a-common-symptom-of-heat-illness-denial/?scp=1-b&sq=denial+heat&st=nyt

    I like these sorts of examples because they show denial as something people in general do, not something specific to addicts because of some psychodynamic or prefrontal cortex problem. I suggest you look at Motivational Interviewing as a way to work with everyday issues of denial–empathic listening and rolling with resistance help you get closer to the other person, and thus overcome the initial denial that everything might be all right.

    Here’s a recent book, Motivational Interviewing in Health Care, that is a useful introduction.

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