The Many Faces of Denial
American addiction treatment gets a makeover
Most scholars agree that the therapeutic relationship between drug-using clients and the professionals who treat them profoundly affects the degree to which clients invest in addiction treatment. These relationships are built, in part, on counselors' characterizations of clients and theories about why they suffer. The simple assumption is that these ideas stem directly from clinical training and experience. But American cultural norms and values also profoundly affect the therapeutic relationship.
For my book Scripting Addiction: The Politics of Therapeutic Talk and American Sobriety, I spent more than three years at an intensive outpatient drug treatment program studying therapeutic transactions like group therapy sessions, attending program meetings, interviewing clients and staff, and examining program documents—all with the goal of uncovering the cultural and clinical assumptions that governed practice and program policy.
I found that it is not just counselors' ideas about addiction and sobriety that influenced their everyday practice. The staff I studied also mobilized mainstream American ideas about the nature and function of language. Counselors used slogans—like HOW (Honesty, Openness and Willingness) — to promote what they saw as healthy human communication. They even hung rules of speaking on the group room wall, which prohibited overlapping or "cross" talk, required public confession of relapses, and redirected social commentary by obliging individual speakers to "own" expressed ideas and feelings.
Given counselors' careful attention to and direction of clients' speech, I concluded that the familiar prelude "Hi, my name is X" and the structured tale that follows are not the natural outpourings of the addict in recovery. These narratives are instead the hard won products of a clinical discipline that assures that clients' speech refers only to speakers' pre-existing inner states. Interestingly, the study of American linguistic norms reveals that the many other things people regularly do with words—such as persuade, negotiate, critique and cajole—have long been considered morally as well as clinically suspect.
The Language of Denial
The concept of denial calibrates widely shared ideas about language with the clinical regimen that characterizes mainstream American addiction treatment. Since the 1930s, denial has stood at the ideological center of the field and has enjoyed a wide range of professional adherents across otherwise distinctive theoretical orientations. As in so many contemporary addiction treatment programs, the professionals I studied believed that addicts are—by definition—unable to clearly see themselves. By extension, they also believed that addicts are unable to speak about themselves and their problems authoritatively.
Given addicts' presumed propensity toward denial, a therapeutic program of "speaking inner truths" makes clinical sense. However, casting clients as "in denial" profoundly affects almost every aspect of treatment. Perhaps most troubling was the way denial drove a wedge between client and counselor. Counselors—assuming that addicts floundered in denial were quite suspicious of what clients said about themselves, their problems and even their reactions to treatment, especially in the early stages. In other words, therapeutic relationships were built on radical suspicion rather than trust.
Administrative routines and relationships were also affected. Despite the program's promise to funders to involve clients in program development, administrators and line staff resisted clients' efforts to establish a representative position on the program's Advisory Board, largely on the grounds that addicts were unable to see what they really wanted and needed from treatment.
In sum, professionals' efforts to help clients hinged on the claim that they could see and intimately know the inner states that their clients, as not-yet-recovered addicts, denied. Clients reacted in ways that, arguably, further troubled their relationships with program staff, including what they called "flipping the script"—discerning what their professionals expected them to say and saying precisely that, without necessarily investing in the content of what they said.
Collaboration and Communication
Imagine if this theory of denial was reworked, allowing counselors and clients to re channel their analytical energies in more collaborative ways. This appears to be precisely the goal of an innovative counseling method known as Motivational Interviewing, formulated in the mid-1980s for the treatment of drug users. MI is a directive, yet client centered approach that aims to elicit "change talk" and, hence, changed behavior from client interviewees.
MI proponents insist that denial is not an internal property of the addicted person, but a product of interactions in which participating parties disagree about the nature of the problem. Rather than getting clients to see what they once denied, the practice of MI involves exploring the parallel interpretations of counselors and clients.
My recent study of MI documents a very different language ideology at play, one that values the ability of spoken words to produce rather than reveal realities, regardless of whether the speakers are clients or counselors. It also underscores a basic lesson of Scripting Addiction— that is, that clinical heuristics, like denial, are never insulated from cultural precepts and profoundly affect both how clients and counselors engage.
E. Summerson Carr is an assistant professor at SSA. Her book, Scripting Addiction: The Politics of Therapeutic Talk and American Sobriety (Princeton University Press), was released this fall.