So you don’t think that you are an alcoholic. Chances are that you are not, but this is the thought that many who are unknowingly addicted to alcohol or other mind-altering agents. This denial barrier is the first of many hurdles to overcome when they are identified as having an addiction disorder. Although all denial isn’t bad most of the time, addicts are often the last to recognize their disease, pursuing their addictions into mental illness, the degeneration of health, and ultimately death. This paper will explain the concept of denial, its consequences, and the implications it has for nursing care.
Denial, in the psychological/psychiatric vernacular, is a defensive strategy to minimize anxiety. It is defined and conceptualized in a number of ways, which differ according to theory. In classical Freudian terms, denial is a defense mechanism invoked by a person when there is a danger that he or she will become aware of or act on unconscious primitive impulses that are unacceptable. We defend against such impulses, it is said, by unconsciously limiting our awareness of them, or perhaps attributing them to others. A murderous rage, for example, may be repressed or obscured from our awareness, or it may be attributed to others (p. 2).
Sometimes denial can be constructive and adaptive, according to R. Davidhizar, V. Poole, J. N. Giger, and M. Henderson the authors of When your patient uses denial. For example, there have been studies of people with terminal illness that have suggested that denying the seriousness of the condition may help postpone death. It is true that overwhelming anxiety can hamper coping, and that screening out anxiety-provoking stimuli can help prevent this kind of paralysis. In general, it must be observed, the world is full of terrifying possibilities that we could never completely comprehend (1998).
Denial is the refusal to believe or accept the reality that certain events have happened, are happening, or will happen. To accept the reality would bring emotional pain, so the events are denied. Related to denial is the defense called minimizing. Events are accepted, but only in a watered down version. “Sure I drink once in a while. Everybody does. It’s no big deal. Once in a while I might get carried away, but it really isn’t a problem” (USDHHS, 1994).
Denial is the primary psychological symptom of addiction. It is an automatic and unconscious component of addictions. Addicts are often the last to recognize their disease, pursuing their addictions into mental illness, the degeneration of health, and ultimately death. Sadly, many addicts continue to act out on their addictions while their world collapses around them blaming everything but the addiction for their problems (USDHHS, 1994)
Denial is one of the reasons that recovery from addictions is seldom effective if the chemically dependent person is forced into treatment. You cannot work on a problem unless you accept that it exists (USDHHS, 1994).
Active alcoholism and addiction are characterized by a struggle to control use. Addicts resent the suggestion they are powerless until things get so bad they are forced to face their addiction. Sadly, some alcoholics never break through their denial, and continue use to the point of insanity and death (USDHHS, 1994).
The concept of denial plays a key role in the twelve-step addiction treatment model, where denial of addiction is seen to be the chief hindrance to any kind of realistic treatment of the problem. This is no easy task because addicts have developed an “elaborate network of denial” (McCracken, 1998). Not only of addictive events, but also of the meanings and consequences of those events, whose seriousness they try to minimize with rationalizations (McCracken, 1998).
The twelve step programs also recognize that any one person’s denial can expand into a group denial, most immediately, perhaps, to the family system. Family members play along with the addict’s behavior, assume the addict’s guilt, and maintain a secretive united front with the outside world (McCracken, 1998).
Step One of Alcoholics Anonymous deals with working through our denial, allowing us to accept our powerlessness over addictions and the chaos and unmanageability they bring into our lives. This is just one of the curious and beautiful things about recovery. The acknowledging of the powerlessness the addict is empowered to lead a healthy life (USDHHS, 1994).
There are several defining characteristics that identify the possibility that a patient may be in denial. Some examples include pretending something does not exist when in reality it does. Being willing to admit there is a problem, but unwilling to see the severity of it. Seeing the problem as being caused by something or someone else. The behavior is not denied, but its cause is someone else’s responsibility. Offering excuses, alibis, justifications, and other explanations for behavior. Dealing with the problem on a general level; avoiding personal and emotional awareness of the situations or conditions. Changing the subject to avoid threatening topics. Becoming angry and irritable when reference is made to the condition. These defining characteristics help to avoid the issue at hand (Whitfield, 1994).
Denying disease is a well-recognized phenomenon in medicine. Every year thousands of people with treatable illnesses die because they don’t take prescribed medicines properly, or at all (Davidhizar, Poole, Giger, & Henderson, 1998). Even the healthiest among us are sometimes prone to denial, such as putting off annual checkups for fear of finding some illness. Some people even contribute to illnesses by their denial, most commonly by smoking.
In some cases the denial impulse can have a positive effect. In order to be a normal functional being, you must deny death. Healthy denial allows you to keep going. It’s when it interferes with survival that it seems to cause a problem. What we call denial is often really suppression, which is “the conscious or semiconscious decision to avoid attending to the conflict” (Davidhizar, Poole, Giger, & Henderson, 1998). We know that we are ill but we choose not to do anything about it. The most common reason for that behavior is fear, though not always fear of death. People make their life-and-death decisions based on what makes their lives worth living, for them. It is the author’s belief that most likely almost every oncologist can tell stories of women that lost their lives because they rejected recommended treatment. However, women who define their self-esteem through their body image may have a difficult time following through when treatment includes mastectomy. Doctors acknowledge that, for some, conventional medicine simply does not fit in with their personal belief system.
Implications for Nursing Care
The implications for nursing care are centered on the identification of a patient’s denial and to take steps to help the patient identify that they have a problem. It is especially important to help the patient identify that there is a possibility that they may have a problem to try to convince to them that they need help.
The concept of identifying denial can be used in the author’s nursing practice in such a way that it helps to identify a nursing implementation. This implementation will be necessary to be collaborative with other specialties, such as with a psychiatric specialist, along with including the family. This collaborative effort will help insure that the patient will receive proper help along with a supportive environment.
In conclusion, denial can be a serious and potentially lethal state of mind. Although denial can prevent illness, for the most part it hinders it. Remember that denial is the primary symptom of addiction. It is important to note that there are programs out there that can help individuals overcome their denial and get the proper treatment they need and deserve.
List of References
Davidhizar, R., Poole, V., Giger, J. N., & Henderson, M. (1998). When your patient uses denial. Journal of Practical Nursing, 48, 10-14.
Simpson, J. A. & Weiner, E. S. C. (1989). Denial. In The Oxford English Dictionary (Vol. 4, p. 456). Taunton, MS: Clarendon Press.
Knatz, H. (1999). Getting On. [On-line]. Available: http://www.awa.com/w2/getting_on/go-3.9.html.
U. S. Department of Health and Human Services. (1994). Signs of effectiveness 2: Preventing alcohol, tobacco, and other drug use: A risk factor / resiliency-based approach (DHHS Publication No. 94-2098, p 93-94). Washington, DC: U. S. Department of Health and Human Services Publications.