Diagnosing Addiction by Daniel Linder MA, MFT as featured in September, 2007 issue of Recovery Today.
When it comes to
treatment, “rule of thumb” is: The sooner addiction is detected the more
favorable the prognosis. The goal is always to intervene as early as possible.
The reasoning is simple – addiction worsens over time, related problems mount
and it becomes more entrenched and impervious to treatment.
However, more
times than not, by the time the addict enters treatment, the addiction has
progressed to middle or advanced stages, when there is already an abundance of
objective evidence pointing to an addiction; i.e. significant and irrefutable
functional impairment. In these later stages, the addict is likely to be
motivated, or at least receptive to seeking help because there is more pressure
to do so, something calamitous has brought him or her face to face with the
addiction. It’s usually an occupational, relationship, legal, financial or
health crisis that precipitates treatment.
Given that the
onset of the dependency is never immediately known to the addict, or to anyone
else for that matter, there is no way to predict who will fall prey until long
after a full-blown dependency has developed. If only there was a way to detect
the existence of a dependency, before it becomes full-blown!
Even though there
may be no irrefutable evidence, i.e. symptoms pointing to an addiction, there
are signs of its existence nevertheless. These signs, subjective in nature, are
manifestations of denial. To detect such manifestations, the clinician must
utilize his or her intuitive radar to scan for subjective manifestations such
as subtle distortions, absolutes, grandiosity, minimizations, even outright
lies during an assessment.
Assessing for
denial requires skill and ability that comes from understanding the theoretical
basis for using denial as diagnostic criteria as the intricacies of
denial.
Based on Linder’s Relationship
Model of Addiction, the ‘pathological dependence’ is a pathological
relationship, one that can be likened to a secret love affair, one
predicated on deception and secrecy. As the addict becomes increasingly
involved in this relationship, s/he becomes increasingly isolated and
disconnected from him/herself and the rest of the world. The dynamics always
operating are dependency and denial.
Denial works to protect and preserve the
dependency by eliminating all internal and external conflicts of interest. Any thought, concern, apprehension, fear, or
recognition of consequences, in short, anything that poses a threat or
deterrent to the dependency is wiped from consciousness. It includes any means
of deception, whether deliberate, or unconscious, as in self-deception. Denial
operates unconsciously; that is, the addict has no awareness that s/he is in
denial or that denial has insulated some chunks of experience from
consciousness. Denial is what makes it
possible to function without adequate emotional nourishment. The addict could
be starving to death and yet be unaware of anything out of the ordinary.
The addict doesn’t notice any changes – no
diminishment in functioning, no risk of serious consequences and exhibits
little or no concern regarding excessive and escalating behavior; that is, none
s/he would attribute to his/her use. The pain of (emotional) withdrawal is
either attributed to other causes or denied altogether. The addict’s judgment or ability to assess what is
happening accurately and realistically is severely curtailed.
The theoretical basis for using denial as diagnostic
criteria is that dependency and denial go hand in hand; one doesn’t exist
without the other. Denial is a “smoking gun.” Where there is denial, there is dependency. There would be no
defense if there were nothing to defend. Consider dependency and denial equal
and synergistic. The dependency is as strong as denial is effective. Denial
becomes increasingly sophisticated to keep up with the demands of the
developing dependency.
In order to make
the earliest possible diagnosis and therapeutic intervention, the clinician can
take a ‘subjective’ approach when conducting the initial assessment. S/he can
no longer afford to limit the scope of inquiry by relying solely on objective
signs, (as most clinicians are trained to do) i.e. substance or activity,
frequency of use, how long using, prior attempts to stop, prior treatments, functional
impairments, family history, co-morbid conditions. The clinician can also be
looking for manifestations of denial to latch on to, either to inquire or
discuss further.
This requires some
special skills training on the therapist’s part -- attunement to non-verbal
communication and being able to quickly interpret their meaning and not take
verbal communication at face value. The longer the counselor engages the
patient about his or her relationship to the source of relief and to clarify
further regarding statements s/he made, the counselor will be better able to
determine or interpret whether denial, delusion, deception or concealment of
his or her secret love affair are manifest. The clinician’s intuition or gut
sense will often signal some kind of discrepancy.
Diagnosing
addiction by interpreting manifestations of denial is an art form. Detecting
gaps in your patient’s reporting and focusing on inconsistencies in his/her
communication and perception are clinical challenges of the highest order.
Consider the addict capable of covering his tracks, misrepresenting reality, of
lying and deceiving, and doing so righteously, to the point of believing
his/her own lies. We’re talking about antenna that picks up on the most subtle
and nuanced non-verbal communication. While the addict might tend to discount
their importance, the clinician must be careful not to do the same.
We know that
medically oriented professionals tend to dismiss such subjective “symptomology”
as being open to interpretation and futile
debate, which may be valid from a purely science-based perspective. But what
has become a prevailing tunnel vision approach has left treatment professionals
vulnerable to
getting derailed by denial. We can see that an approach that relies only on physical evidence to make a diagnosis has inherent
limitations. When physical evidence is lacking, the tendency is to conclude
that there is insufficient information to make a diagnosis, and therefore,
there is nothing to treat.
In order to
understand inherent challenges and necessary skills involved in relying on
denial, the following distinctions must be made: between an objective and
subjective diagnosis and between an objective and subjective
dependency. A diagnosis based on
subjective information, i.e. manifestations of denial is a subjective diagnosis; and one based on
objective evidence is an objective
diagnosis. When there are no visible signs, yet there are (subjective)
indications of an addiction, we’ll call this a subjective dependency. Clear cut
and irrefutable indications, therefore, translates to an objective dependency. Early stage
dependency in which denial is detected will likely be a subjective dependency; and mid-later stage dependency when there are
objective indications we’ll naturally call an objective dependency.
Identifying manifestations of denial and
turning them into inquiry or discussion points can lead to the Mother Lode of
therapeutic opportunities. Dialog about what an addiction is before it
becomes problematic or observable, about the dynamics of dependency and denial
can help towards building rapport. It can help gain credibility and respect,
and can easily become the heart and soul of the therapy. You can also have the
opportunity to address denial pro-actively and cut through layers of
stigma-based shame related to being addicted. Continuing dialog could also
serve to disarm the addict subliminally and circumvent denial.
Daniel Linder is a
licensed Marriage and Family Therapist, Addiction Specialist and Relationship
Trainer in the San Francisco Bay Area; Author: Demystifying Addiction (The
Relationship Model of Addiction), Relational Recovery, just released; Intimacy, The Essence of True Love,
Online Addiction CEUs and numerous related articles.
Addition
recovery relationship blog: http://www.sober.com/blogs/relationship_recovery/
E-mail: Daniel@RelationshipVision.com
