As reported recently in this column, current research data has not been supportive of commonly held beliefs concerning denial. According to the research, denial was no more common in substance abuse populations than in normal populations, and confronting denial appears to contribute to relapse not recovery (Miller & Rollnick, 2002).

Lately, more research has come to light about denial. Once again, the data is not in line with commonly held perceptions. And, as with the first, this current information has implications for counseling strategies.

The new denial data
This new research indicates that people who have addiction problems seem to know it, but take a long time to do something about it (Simpson & Tucker, 2002). On average, they take about 10 years before they seek help (treatment or Alcoholic Anonymous, AA). A rough sequence of problems seems to happen before individuals seek help. That sequence roughly is as follows:

An interesting extrapolation from this data is that it parallels the old Jellnick progression of alcoholism scale. Certainly many folks who are currently in recovery voice that they were at one time in denial. Many of those testimonials indicate that they knew they had a problem but turned their back on the issue — a traditional definition of denial: “I realize there is a problem, but am not admitting it, and/or doing nothing to change things.” The new data, if you think about it, is not that much different from the old viewpoint, except to say that, deep down, people who abuse chemicals know there is a problem. In line with this wrinkle, the new research supports the use of non-confrontational strategies.

A few problems with tradition
The traditional strategies call for counselors to confront clients about their denial. This may be a bit off target. The traditional approach expects denial in clients and thereafter the need to confront the denial in order to break its hold on the client. A problem with this approach lies in expectation that clients are in the denial state — such an expectation may cloud clarity in the assessment phase of treatment. And of all the times you need to have a clear picture of things, it is at the beginning of treatment.

The central indication of the new research — that clients already know they have a problem — challenges the traditional approach. Rather than confront the client about something they already know, it would seem the better method is to get the client to come clean with their current situation, and most importantly to encourage them to act differently.
Simpson and Tucker (2002) identify a different treatment approach, called lower threshold interventions. What follows are an extrapolation of those suggestions.

Lower-threshold interventions
What sounds like a new buzz phrase for the field — lower-threshold interventions — has been around for a while in the form of the harm reduction philosophy. These interventions generally do not demand a high level of initial client expectancy (i.e., they start where the client is and don’t have an obligatory requirement for staying in treatment found in many traditional forms of addiction counseling). Often those traditional goals are high in terms of treatment thresholds. For example, they expect or demand total abstinence, and expect the client to verbally identify himself or herself as an alcoholic or other such labels.

On the other hand, most all goals in the low-threshold mold come from the client. Even though such goals do not originate from a counselor or program, they are considered worthy of consideration. Harm reduction purportedly reaches addicts early in the stages of change who are at the precontemplation or contemplation levels (Volpicelli & Szalavitz, 2000). One way to reach such clients is to keep them in treatment where you can work with them on daily or weekly basis. This is not to say that a client’s goal, especially if it is continued drug use (even if decreased), is the final goal of addiction counseling. It is just that the starting point is generally the client’s — not the program’s — starting point. Certainly, as treatment progresses, goals can be modified (Rubin, 2003); but, according to the harm reduction approach, at least the client stays engaged in some sort of treatment. That’s low-threshold intervention.

Now, I am aware of the contention between harm reduction and traditional forms of therapy. The traditionalists accuse the harm reductionists of enabling, while the harm reductionists accuse the traditionalists of inflexibility. Certainly, extreme forms of harm reduction might well be enabling, but many harm reductionists would indicate that their ultimate form of treatment is abstinence.

Research-to-practice key
The idea behind both the low-threshold and new denial research is to get people to take action about abusive drinking before waiting the average 10 years noted for most individuals cited in the study.

Specific low-threshold interventions can include listening and clarifying. Simply listening without judgment and clarifying certain parts of a client’s story are considered by many as the main condition for change (Miller, Duncan, & Hubble, 1997). In addition, the counselor can ask a few pointed low-threshold questions (e.g., “Where do you think you have to go in terms of progression before you begin to do something about your abuse issue?” Or, “What has to happen in your drinking life in order for you to ask for help?”) These curiosity-oriented questions (not demanding types) are designed to place a seed of change in the mind of someone who knows they have a problem already.

The “try it yourself” section
The low-threshold to therapy often entails aspects of harm reduction. As noted, that philosophy, according to some, is considered enabling the addict and is to be discouraged (DiClemente, 2003). However, this conflict between the traditional camp and the harm reduction camp presents all kinds of interesting questions, as does any good conflict. And if there are interesting questions, there are interesting research possibilities.

Here is your chance to do some basic survey research to help answer a few such questions. For our purposes, the main question is what will happen with certain key variables noted with clients assigned to either a traditional or harm reduction group. Your dependent variables can be attendance records, levels of compliance, drop out rates, and levels of drug and or alcohol use. Your research can follow these steps:

1. Randomly assign new clients to a low-threshold oriented group and others to a matched traditional low- and high threshold group.

2. Conduct counseling according to the basic principles of each orientation (independent variable) for the course of your program.

3. Track the dependent variables during and sometime after treatment in order to collect a data set.

4. Compare the dependent variables from the low- and high-threshold groups both during and sometime after treatment is over for the respective groups. Either there will or will not be a difference from the treatment approaches on the selected dependent variables.

This is not a sophisticated or clean research design. But, you might begin to get some useable data that can lead to another research design that is tighter and less fraught with internal/external threats to validity. I would really be interested in seeing any initial results, because if this basic research design is placed in a strong research design, it has a good potential to be published and add valuable information to our field.

Michael J. Taleff, PhD, CSAC, MAC, is the Coordinator of the Center for Substance Abuse for the University of Hawai’i at Manoa. He can be reached at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
DiClemente, C. C. (2003). Addiction and change: How addictions develop and addicted people recover. New York: Guilford.
Miller, S. D., Duncan, B.L., & Hubble, M. A. (1997). Escape from Babel: Toward unifying language for psychotherapy practice. New York: Norton.
Miller, W. M., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd Ed.) New York: Guilford.
Rubin, E. (2003). Integration of theory, research, and practice: A clinician’s perspective. In F. Rotgers, J. Morgenstern, & S.T. Walters (Eds.). Treating substance abuse: Theory and technique. (2nd ed., p. 343-363). New York: Guilford.
Simpson, C. A., & Tucker, J. A. (2002). Temporal sequencing of alcohol-related problem recognition, and help-seeking episodes. Addictive Behaviors, 27 (5), 659-674.
Volpicelli, J. & Szalavitz, M. (2000). Recovery options: The complete guide. New York: John Wiley & Sons.

This article is published in Counselor,The Magazine for Addiction Professionals, June 2004, v.5, n.3, pp. 61-62.

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