The Addiction Web Site of Terence T. Gorski

Best Practice Principles  - Articles  - Publications

Mission & Vision -  Clinical Model - Training & Consulting

Home - What's New - Site Map - Search - Book Reviews

 Links - Daily News Review 

  Research Databases  - Leading Addiction Websites -

Special Focus:  Mental Health, Substance Abuse, & Terrorism

Denial Management Counseling (DMC)
Bibliography & Abstracts   

<Return To DMC Description Page>

Updated:  August 7, 2000

1.          Addis-E-A. Alcoholic: ''But I Haven't Got A Problem, Doctor.''. AUST. FAM. PHYSN, 8: 976-981, 1979. (056422)

The attempts of alcoholics to conceal their drinking-related problems and the doctor's approaches to confronting them are discussed. Denial of an alcohol problem was found to be more common in persons living in a sub-culture of heavy drinking and in persons with acute or chronic impairment of memory and judgment. Confrontation is used to break the denial and to bring the patient to an understanding of the role of alcohol in his problem.

2.          Allan, C.A. Acknowledging alcohol problems: The use of a visual analogue scale to measure denial. Journal of Nervous and Mental Disease, 179(10):620-625, 1991. (113004)

The use of a visual analogue scale to measure denial is described. The research material included data collected from a random sample of 50 clients attending a Glasgow Council on Alcohol (GCA) and a matched group of 50 patients beginning treatment with an alcohol treatment unit (ATU). Using the visual scale, subjects from both groups acknowledged their difficulties with alcohol consumption, although there was evidence that, when compared with an interviewer, subjects underestimated the severity of their drinking. No relationship, however, was seen between denial and compliance with treatment. 28 Ref

3.          Allan, C.A. Does denial matter? A scale to measure denial and its links with attendance for treatment. 36th International Congress on Alcohol and Drug Dependence (36eme Congres International sur l'Alcoolisme et les Toxicomanies), Vol. I, Glasgow, Scotland, 16-21 Aug 1992, 861 p (pp 632-634) (123935)

A method of measuring denial using visual analogue scales (VAS) is described. Although denial is frequently mentioned in the literature, there is no consensus about its measurement. The research sample for this study included 50 clients attending a Council on Alcohol and 50 patients attending an Alcohol Treatment Unit. Subjects from both agencies acknowledged difficulties with alcohol and all subjects were assessed as having some degree of difficulty with alcohol by the interviewers. In a small group (11 of the 100) subjects, there was a large difference between the assessment of the subjects themselves and of the interviewers, with a small group of subjects who claimed to be having no problems at all with alcohol. Subjects whose scores fell one standard deviation below the mean of the differences between subject and interviewer scores were considered to be "denying" their alcohol problem. However, denial of alcohol problems did not appear to affect treatment compliance. 10 Ref.

4.          Altman-H; Evenson-R; Cho-d W. Predicting length of stay by patients hospitalized for alcoholism or drug dependence. J. Stud. Alc., 39: 197-201, 1978. (033581)

Data on demographic background and medical diagnosis as well as results of the Missouri automated mental status examination and items on the emergency room admission checklist were subjected to stepwise multiple regression analysis to determine their prediction of length of stay of 1,233 patients discharged from inpatient treatment programs in missouri during the years 1966 through 1971. The correlation between 20 predictor variables and length of stay was .38. Involuntary admission, admission while intoxicated, hostility and denial of problems were associated with early dropout, as were unemployment, younger age and having a spouse or someone else to live with.

5.          Amodeo, M.; Liftik, J. Working through denial in alcoholism. Families in Society: Journal of Contemporary Human Services, 71(3):131-135, 1990. (107440)

The role of denial in alcohol dependence syndrome is discussed, with a focus on counseling techniques for addressing denial. Headings within this article include: (1) resistance to acknowledgment of problem; (2) resistance to treatment; (3) resistance to recovery; and (4) working through denial. It is concluded that in dealing with entrenched denial, a practitioner must determine and accept the patient's view of reality perhaps by presenting alternative interpretations of events and by reorganizing problems to include repressed or rationalized issues. It is important to avoid power struggles that result in the therapist imposing abstinence on the client and to have the therapist and client conclude together that drinking is the problem that needs to be resolved. 12 Ref

6.          Barnes-H-N. Presenting the diagnosis: Working with denial. In: H.N. Barnes, M.D. Aronson, and T.L. Delbanco (Eds.), Alcoholism: A guide for the primary care physician. Frontiers of Primary Care Series, New York, NY: Springer-Verlag, 1988. 252 p. (pp 59-65). (103832)

Approaches to patient denial of alcoholism in the process of diagnosis and treatment are discussed. Headings within this chapter include: (1) obstacles to presenting the diagnosis; (2) strategies for presenting the diagnosis, including use explicit information, be empathic and helpful, educate about alcoholism, avoid arguments about a diagnostic label, be realistic about your role and the patient's response; (3) patient's responses to hearing the diagnosis, including patient agrees to the problem and desires help, patient acknowledges a problem but refuses help, and patient denies a problem with alcohol. It is noted that an understanding of denial is crucial in discussing the diagnosis of alcoholism with an alcoholic patient, and that by starting a dialogue with the patient, the patient's drinking patterns may be modified. 65 Ref.

7.          Batel, P.; Tkoub, E.M.; Pessione, F.; Lancrenon, S. Essai d'evaluation des attitudes de deni en clinique alcoologique (Evaluation of attitudes of denial in clinical alcohology) Alcoologie, 21(1):35-42, 1999. (149118)

The evaluation of denial and defensiveness can be improved by using The Denial Rating Scale (DMS) which objectively measures the progressive stages of an alcoholic subject's awareness of the implications of his disease. This study evaluates the French translation of the DMS in evaluating 1,982 alcoholic patients attending an alcoholism treatment center in France for the first time.  The DMS was used in conjunction with sociodemographic and clinical data. Only 9.4 percent of these first time patients were classified as having high level denial.  Univariate analysis of this large sample size identified a denial patient profile: a male, living alone, with low social and educational level, whose delayed access to alcoholism treatment is correlated with pressure from the work or family environment. These clients were more likely to leave treatment before completing Withdrawal and more likely to be referred to residential treatment. The blood pressure and heart rate of these denying subjects are significantly higher, even after taking into account other confounding factors, such as age, withdrawal, and gender. 12 Ref. Copyright 1999 - Societe Francaise d'Alcoologie.

8.          Bateman-Nils-I. Study Of Socially Adaptive Aspects Of Alcoholic Denial. Ann Arbor, MI: University Microfilms, 1965. (010088)

An investigation of socially adaptive aspects of denial of alcoholism among married alcoholic males revealed that denial of alcoholism was related to variables in the subject's social situation. Such denial, seen as a defense against the experiencing of shame, may be modified over a period of time either in response to sick/role accomodation or to social exposure experiences. 160 ref.

9.          Baughan D.M. Crisis precipitation in alcoholism. Western Journal of Medicine, 145(5):680-681, 1986. (089217)

The intervention approach (also known as confrontation or crisis precipitation) for breaking through denial is discussed. The approach operates on the assumption that problem drinking continues as long as an alcohol abuser perceives more benefit from drinking than from abstinence. Rather than waiting for this perception to reverse when the patient hits bottom, the intervention technique offers a person with alcoholism a powerful preview of "bottom" to compare with the caring and support of significant persons in his or her life. This approach works best when the index patient still has some intact, meaningful, positive relationships with people who recognize alcohol abuse as a problem for the patient. The steps undertaken in this approach are reviewed and a brief evaluation of the technique is provided. The role of the family physician in the intervention approach is also discussed briefly. 5 Ref. Berenson, D.; Schrier, E.W. Addressing denial in the therapy of alcohol problems. Family Dynamics of Addiction Quarterly, 1(4):21-30, 1991. (114281)

The role of denial in alcohol therapy is discussed. Headings within this review of the literature include: (1) denial of naming; (2) denial of emotion; (3) working with nondrinking family members first; (4) using 12-step meetings and sponsors or other support groups; (5) working with the Map of Emotional Recovery; and (6) addressing spiritual denial. It is concluded that successful treatment of alcohol- related problems requires resolving the patient's denial, which is thought to be maintained by personal and family factors and to operate at both personal and transactional levels. Recovery may begin once the problem has been named, following release of emotions, or following a spiritual awakening. 12 Ref

10.        Belkin, B.M.; Miller, N.S. Agreement among laboratory tests, self-reports, and collateral reports of alcohol and drug use. Annals of Clinical Psychiatry, 4(1):33-42, 1992. (123648)

A study was done to examine drug testing as a way to circumvent denial and to substantiate alcohol or drug dependence. The study's major hypotheses were that alcoholics and drug addicts deny and minimize drug use, that detecting the presence of alcohol and drugs in blood and urine is a more reliable indicator of addiction than reported histories, and that corroboration from family adds important diagnostic information. Self-reports of 18 individuals admitted to an inpatient alcohol and drug treatment unit were compared with reports obtained from family members and with results of blood and urine tests. The usefulness of self-reports increased when a structured interview form was used. Interviews with family members were not consistently helpful, but blood screens were positive when alcohol or drug use occurred within 7 hours of admission, and urine screens were positive when use occurred within 2 days. It is concluded that self-reports, family interviews, and laboratory screens should all be used in diagnosing alcohol or drug dependence. 41 Ref.

11.        Berry, G.W. Effect of denial on two alcoholism screening measures. Dissertation Abstracts International, 52(1):510-B, 1991. (112031)

This study explored the effect of denial on the Michigan Alcoholism Screening Test (MAST) and the MacAndrew Alcoholism Scale (MAC). Subjects were 191 male and 160 female alcoholics and non-alcoholics. The alcoholics included patients in detoxification treatment and outpatients in alcoholism treatment; the non-alcoholics were psychotherapy patients and university students. Denial was measured by the Little-Fisher Denial Scale (LFDEN) and Basic Personality Inventory Denial Scale BPIDEN). Results indicated significant correlations (p less than 0.001) between the MAST and both denial measures and between the MAC and LFDEN. The two denial measures accounted for variance not shared by MAST and MAC. Canonical analysis of all measures indicated a factor which could be labeled "alcoholic denial". Combining the denial scales with the alcoholism scale significantly (p less than .01) improved the accuracy of discrimination of alcoholics from non- alcoholics. Results support inclusion of denial measures in alcoholism screening batteries. Copyright 1991 - University Microfilms, Inc. This abstract was published with the permission of University Microfilms International ( UMI) and may not be reprinted without their consent. For permission, contact UMI, 300 North Zeeb Road, Ann Arbor, MI 48106. Copies of this abstract are also available from the above address; refer to order number DA9115481.

12.        Bishop, D.R. Clinical aspects of denial in chemical dependency. Individual Psychology, 47(2):199-209, 1991. (115692)

Clinical aspects of denial in alcohol and other chemical dependency are discussed. Headings within this review of the literature include: (1) tenets of individual psychology; (2) basic mistakes and the denial process; (3) safeguarding and the private logic; (4) purposes of denial; (5) characteristics of denial; (6) clinical management of denial; (7) confrontation; and (8) issues for future research. It is concluded that denial affects clinical diagnosis and treatment and must be addressed before recovery can begin. The model presented in this paper provides a clinical strategy for dealing with denial. 29 Ref.

13.        Blanchard, H.B., Jr. Using three measures of addiction severity to predict treatment continuance of outpatients and counselor-evaluated prognosis of post-treatment abstinence of inpatients. Dissertation Abstracts International, 56(9):5159-B, 1996. (132643)

This study sought to identify variables that predict subjects who achieve success (Continuers) in substance abuse treatment programs from those who did not (Dropouts). Research settings included two public outpatient substance abuse treatment centers and one public inpatient substance abuse treatment center. In the outpatient program, 52 clients were administered the tests and followed for 3 months. Forty-two remained in treatment. Ten subjects dropped out or were terminated for noncompliance. The Dropout group tested higher on measures of craving, social skills anxiety, antisocial behaviors, and self-reported cognitive impairment. The best predictors of dropping out were affective disturbance (emotional distress) along with the number of substance abuse-related arrests and low educational attainment. Forty inpatients were evaluated with the same tests and measures, but since the inpatient program was correctional there were no Dropouts, and a measure related to program success was used instead. At graduation, counselors rated patients for predicted success in maintaining abstinence. Subjects with clearly higher scores in motivation received better prognoses from their counselors. For the inpatient group, data analysis did not reveal significant relationships between the other study variables and the counselors' ratings of probability of success. Comparison of inpatient and outpatient groups found that inpatients had significantly more substance abuse-related arrests, lower levels of denial, less resistance to treatment, and acknowledged more addiction-related problems than outpatients. Results suggested that once subjects receive three substance abuse-related arrests, their beliefs about their addiction status seem to change towards recognition of the problem. Copyright 1996 - University Microfilms, Inc. This abstract was published with the permission of University Microfilms International (UMI) and may not be reprinted without their consent. For permission, contact UMI, 300 North Zeeb Road, Ann Arbor, MI 48106. Copies of this abstract are also available from the above address; refer to order # DA9602181.

14.        Breuer, H.H.; Goldsmith, R.J. Interrater reliability of the Alcoholism Denial Rating Scale. Substance Abuse, 16(3):169-176, 1995. (129764)

The interrater reliability of the Denial Rating Scale (DRS), a measure of alcoholic denial, was assessed with the hypothesis that the reliability of ratings would be enhanced with minimal training if a semistructured interview and a decision tree were used. Twenty interviews with alcoholic volunteers were videotaped. Seven investigators rated the denial level of the subjects. It was found that interrater reliability was improved by use of the semistructured interview and the decision tree model. Estimates of interrater reliability ranged from 0.827 to 0.966 (P < 0.001). 12 Ref.

15.        Brunson, M.D. Primary and secondary alcoholics and their use of denial and repression. Dissertation Abstracts International, 55(7):3006B, 1995. (126485)

This study investigated denial, repression, childhood problem behaviors, and neuroticism in alcoholic male Veterans receiving inpatient chemical dependency treatment. Background information and previous research findings were integrated into a model of alcoholic denial, where alcoholic subjects with deviations in genetically-mediated temperament trait or vulnerability characteristics (e.g., increased hyperactivity or neuroticism) were hypothesized as more likely to utilize certain defense mechanisms (i.e., denial and repression) and to describe a more rapid and severe course of alcoholism development compared to other alcoholics. Alcoholic subjects were separated into groups of primary or secondary alcoholics, based on drinking history and subjective response to alcohol, and completed a variety of paper-and-pencil measures. Contrary to the study's hypotheses, primary alcoholics and subjects reporting greater numbers of childhood problem behaviors were found to evidence lower levels of denial and repression compared to secondary alcoholics and subjects reporting fewer childhood problem behaviors (respectively). Consistent with previous research, primary alcoholics reported significantly greater numbers of childhood hyperactive behaviors and evidenced a nearly significant higher level of neuroticism, compared to secondary alcoholics. These results support the idea that there are inherited temperament trait deviations or vulnerability characteristics (e.g., childhood hyperactivity) which may predispose an individual towards earlier and more severe alcohol dependence in efforts to minimize aversive aspects of these temperament trait characteristics. These findings raised questions regarding the utility and impact of traditional psychoanalytic perspectives of alcoholic denial on the assessment and treatment of alcoholism. Copyright 1995. University Microfilms, Inc. This abstract was published with the permission of University Microfilms International (UMI) and may not be reprinted without their consent. For permission, contact UMI, 300 North Zeeb Road, Ann Arbor, MI 48106. Copies of this abstract are also available from the above address. Refer to order #DA9430778

16.        Burling-T-A; Reilly-P-M; Moltzen-J-O; Ziff-D-C. Self-efficacy and relapse among inpatient drug and alcohol abusers: A predictor of outcome. Journal of Studies on Alcohol, 50(4):354-360, 1989. (104048)

Monthly intreatment ratings of self-efficacy to avoid drug and alcohol abuse were examined among 419 substance abuse inpatients of a residential treatment community. Posttreatment interviews were conducted with 81 patients approximately 6 months following discharge to assess the relationship between self-efficacy and relapse. As expected, self-efficacy increased during treatment and was higher among abstainers than relapsers at follow-up. Contrary to expectations, low self-efficacy at intake was related to longer inpatient residence and more positive conditions of discharge. Furthermore, abstainers had slightly lower self-efficacy scores than relapsers at intake and increased their self-efficacy two-fold over relapsers during the course of treatment. Contrary to previous research with tobacco smoking, self- efficacy ratings at the end of treatment were not related to substance abuse at followup. It is proposed that the present findings are consistent with previous research in demonstrating a relationship between self-efficacy and outcome, and provide new information suggesting that low self-efficacy may be related to positive outcome under certain circumstances. Hypotheses are advanced regarding (1) the potential utility of intreatment change measures, (2) the role of underestimation in self-efficacy ratings and (3) the role of denial in substance abuse populations. 23 Ref. Copyright 1989 - Alcohol Research Documentation, Inc., Rutgers Center of Alcohol Studies, New Brunswick, NJ 08903. Author abstract provided with permission from Journal of Studies on Alcohol.

17.        Burns-J-D. Effects of self-efficacy training on coping skills of alcoholics. Dissertation Abstracts International, 45(5):1580B, 1984. (083537)

The effects of self-efficacy training on coping skills of 50 male alcoholics who were court-referred for outpatient treatment were studied. All had a score of five or greater on the Michigan Alcoholism Screening Test. Two experimental groups were led by an alcoholism counselor trained in the techniques of self-efficacy training, i.e., increasing subjects' expectations of success in coping with drinking- related situations of anger and anxiety. Two control groups were led by an alcoholism counselor trained in alcohol education and counseling as part of a standard program at the outpatient alcohol treatment facility. The groups met with their respective counselors once a week for 2 hours for a total of 12 hours. Prior to treatment and posttreatment, all subjects were administered the Situational Competency Test (SCT), a 16-item paper and pencil test asking what they would do in a drinking-related situation. The three hypotheses tested, namely that subjects in the self-efficacy group would exhibit (1) a significantly shorter response latency on the SCT, (2) a greater number of nondrinking behavioral alternatives on the SCT, and (3) a greater number of words on each drinking-related situation of the SCT were not supported. It is recommended that the program be extended to confront the subjects' denial, blaming, and externalization of problems before introducing self-efficacy training. Also, a different measure of competency, the Adaptive Skills Battery, should be used. 0 Ref.

18.        Cecero, J.J.; Karp, S.A. Denial and self denigration in the draw-a-person profiles of alcoholics. Current Psychology, 15(3):254-257, 1996. (152686)

A study was conducted to validate previous findings that alcoholics tend to engage in more denial and more self-demeaning behavior than control subjects as measured by the Apperceptive Personality Test. Outpatient alcoholics (n = 100) were matched on age, race, and social class to nonalcoholic controls (n = 100). A different measure of denial and demeaning behavior, the Draw A Person Questionnaire, was applied to all subjects. Results indicate that alcoholic subjects used more denial and were more often self-demeaning than controls, validating the earlier findings. 5 Ref.

19.        Chambers, G.T. Relationship of cognitive impairment and denial to alcohol treatment progress. Dissertation Abstracts International, 50(7):3147-B, 1990. (106943)

To investigate the relationship of alcoholic denial and alcohol-induced cognitive impairment to treatment progress, seven denial measures and 15 cognitive impairment measures were obtained for 59 alcohol inpatients (18 to 49 years of age). The specific instruments administered were the Shipley Institute of Living Scale (SILS), the Symbol-Digit Modalities Test (SDMT), the Rey Auditory Verbal Learning Test (AVLT), and the Balanced Inventory of Desirable Responding (BIDR). In addition, an alcohol quiz, a treatment survey, and two questionnaires and fact recall quizzes about hypothetical case vignettes were developed specifically for this project. It was found that cognitive impairment measures involving greater cue-utilization and oral responding showed the strongest relationship with self- deception as measured by the BIDR. Other cognitive impairment measures did not show a consistent relationship with the other denial measures used in this study. The clinicians' rating of denial was shown in multiple regression analyses to be the best single predictor of treatment progress. Other scores found to be significantly correlated with treatment progress, although not significantly reducing the variance in the multiple regression, were: an AVLT long-term memory score, the SDMT-Written Score, and a score assessing patient acceptance and satisfaction with treatment. It was concluded that the conventional wisdom of confronting alcoholics' denial may be justified based on the observed relationship of denial ratings to treatment progress. Copyright 1989 - University Microfilms, Inc. This abstract was published with the permission of University Microfilms International ( UMI) and may not be reprinted without their consent. For permission, contact UMI, 300 North Zeeb Road, Ann Arbor, MI 48106. Copies of this thesis are also available from the above address; refer to number DA 8914136

20.        Clark-D-E; McCarthy-E; Robinson-E. Trauma as a symptom of alcoholism. Annals of Emergency Medicine, 14(3):274, 1985. (076866)

A major obstacle in the therapy of alcoholism is denial of the problem by the patient and the patient's family. Blood alcohol levels provide objective evidence that is useful to break through the wall of denial. The crisis of trauma is an opportunity not to be missed to intervene in the progression of the patient's underlying disease--alcoholism or alcohol abuse. In this way, trauma can be viewed as a symptom of alcoholism and any traumatic episode should be viewed in this context, with special emphasis on blood alcohol levels and other objective evidence.

21.        Conigliaro, J.; McNeil, M.; Kraemer, K.; Conigliaro, R.; Joswiak, M.; Maisto, S. Are patients diagnosed with alcohol abuse in primary care ready to change their behavior? JGIM, 12(suppl 1):113, 1997. (142610)

The success of brief intervention (BI), involving structured advice and individualized feedback about drinking, in primary care settings has been attributed to the patient's readiness to change. Stages of change are defined as precontemplation or denial, contemplation or ambivalence, determination, action, and maintenance. This study determined the stage of change of alcohol abusers and hazardous drinkers in 6,635 primary care patients using the Alcohol Use Disorders Identification Test (AUDIT) and the SOCRATES-5A measure of stage of change. The findings can summarized as follows:  (1) Of the total patient population of 6,635, 741 (11.2 percent) screened positive for alcohol abuse;  (2) Of the 191 patients who underwent a baseline assessment, 65 (34%) met criteria for alcohol abuse or dependence,  (3) Of the 191 patients who underwent a baseline assessment, 126 (66%) were in the hazardous drinking group.  (The hazardous drinking group was at high risk of developing an alcohol use disorder due to their use of alcohol or other drugs, minor lifestyles disruptions related to alcohol or drug use, an absence of symptoms that meet the clear criteria for abuse or dependence);  (4) In the hazardous drinking group, 73 percent were in precontemplation, 8 percent in contemplation, 6 percent in determination, 4 percent in action, and 9 percent in maintenance stages. (5) In the alcohol abusing or dependent group, 45 percent were in precontemplation, 16 percent in contemplation, 15 percent in determination, 18 percent in action, and 7 percent in maintenance stages. These results indicate that primary care patients screening positive for hazardous drinking should receive treatment focusing on overcoming denial and ambivalence, and linking BI to enhancing patients' motivation and readiness to change.

22.        Criddle-W-D. Rational emotive psychotherapy in the treatment of alcoholism. In: N.J. Estes and M.E. Heinemann, Alcoholism: Development, Consequences, and Interventions. Second Edition, St. Louis, MO: C.V. Mosby Company, 1982. 385 p. (pp. 339-348). (090771)

Rational emotive psychotherapy (RET) is primarily a cognitive therapy, the basic principle of which is that most emotional and behavioral responses are determined by one's thoughts or evaluations. One's cognitions (or thoughts) determine both the type of emotion and the intensity of an emotion, and whether to act and what course of action to act. Rational, logical, reality-based thinking results in appropriate emotions and behaviors, whereas irrational, illogical, exaggerated thinking generally results in inappropriate and often destructive emotions and behaviors. The 10 basic irrational ideas that individuals use, introduced by Albert Ellis (founder of RET), are outlined. To aid in the difficult process of change, the therapist employs a number of adjunctive procedures: assignment of reading materials; and behavioral homework. The use of RET in the treatment of alcoholism is similar. With these procedures, therapists can confront the alcoholic and combat denial, breaking through the irrational and inaccurate beliefs about alcoholism. The RET therapist can then focus on the internal cues or motivations for the alcohol consumption. Utilization of RET techniques during withdrawal and at the onset of abstinence, as well as the maintenance of sobriety, is described. 10 Ref.

23.        Davis, S.K.; Lanz, J.B. Perceptions of denial among pregnant and parenting chemically dependent women enrolled in treatment. Substance Use and Misuse, 34(6):867-885, 1999. (148455)

This study combined both qualitative and quantitative methodologies to examine the perceptions of denial in a sample of pregnant and parenting chemically dependent women enrolled in treatment. Interview data revealed that the women in the study:  (1) recognized denial as a negative influence on the recovery process;  and (2) were highly critical of denial behaviors displayed by other women in treatment.  The participants identified learning opportunities, such as special focus groups that focused on denial recognition and anger management, as the most helpful strategies utilized by treatment staff in dealing with denial.  Perceptions of denial were compared across selected demographic and psychosocial variables. No significant differences emerged, with one exception: Women who reported recent histories of physical or sexual abuse were more likely to report positive feelings while in denial, such as feeling "normal" and "in control" than women who denied recent abuse histories. 28 Ref. Copyright 1999 - Marcel Dekker, Inc.

24.        Dicicco-L; Unterberger-H; Mack-J-E. Confronting Denial: An Alcoholism Intervention Strategy. PSYCHIAT. ANN., N.Y., 8 (NO. 11): 54-64, 1978. (038796)

Some of the approaches used to diagnose and treat alcoholism in the alcoholism program of the Cambridge-Somerville Mental Health And Retardation Center in Massachusetts are described. The ability of professional therapists to recognize alcoholism and to verbalize the diagnosis to the patient is stressed as the starting point of all recovery strategy. Seeking treatment is the ultimate result of a series of confrontations aimed at overcoming the alcoholic's denial: drinking ought to be perceived by the patient as a source rather than result of major problems in life. ''Motivation'' is an irrelevant concept and only precipitation of crises is useful in getting the patient into treatment. Three case histories of late-stage alcoholism in women are described. Helpful and unhelpful attitudes in understanding and treating alcoholics are tabulated.

25.        Duffy, J.D. Neurology of alcoholic denial: Implications for assessment and treatment. Canadian Journal of Psychiatry, 40(5):257-263, 1995. (128610)

Alcohol has neurotoxic effects that frequently result in significant sensorimotor and cognitive deficits. These cognitive deficits may have profound implications for the behavior and treatment of patients who abuse alcohol. In particular, the deficits in executive cognition that are typical of alcoholic dementia result in difficulties with planning, insight and impulse control. These deficits are frequently misinterpreted as alcoholic denial and are therefore assumed to have a psychodynamic basis. This paper reviews the neurological substrates for insight and self-monitoring and discusses a possible pathophysiology for a subgroup of alcoholic patients who exhibit alcoholic denial. Implications of this model for the evaluation and treatment of alcoholic patients are discussed. 30 Ref. Copyright 1995 - Canadian Psychiatric Association

26.        Eckardt-M-J; Rawlings-R-R; Martin-P-R. Biological correlates and detection of alcohol abuse and alcoholism. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 10(2): 135-144, 1986. (091849)

It is suggested that there has been a continuing interest in the biological correlates of alcohol abuse and alcoholism, in part because structured clinical interviews and questionnaire-derived data are vulnerable to deliberate falsification and/or denial. Although alcoholics often report a history of specific complaints and diseases, many clinicians do not think that early alcohol abuse can be detected by evaluating this self-reported data. Although the search for a single biological marker for alcoholism has so far proved unseccessful, several investigators have recentlly demonstrated that combinations of tests are more likely to identify alcoholics than single tests. Ideally, one would like to have a technique that would define when an individual is consuming too much alcohol, such that for one person it may be four drinks per day and for another it may be six drinks per day. Moreover, a clinically useful technique would identify binge drinkers as well as regular consumers, and would not be influenced by acute intoxication, age, other drug use, nonalcoholism-related medical conditions, or pathophysiology accompanying the alcohol withdrawal syndrome. 46 Ref.

27.        Edelman-S-E. Alcoholic denial. Psychiatric Annals, 9(8):387-388, 1979. (044615)

The psychotherapist's role in confronting denial of alcoholism and facilitating referral for alcoholism treatment is discussed.

28.        Fewell-Christine-H; Bissell-Leclair. Alcoholic Denial Syndrome: An Alcohol-Focused Approach. social casework, 59(1):6-13, 1978. (032061)

The authors examine the alcoholic denial syndrome and its implications for treatment, and describe an alcohol-focused approach to confronting and motivating the alcoholic to accept help. Denial is seen as a major obstacle to treatment, and it is believed that to approach alcoholism as merely a symptom of an underlying pathology would be an exercise in futility. Basic assumptions of the proposed treatment plan are centered around the Jellinek concept of alcoholism and the need for abstinence from alcohol. 11 ref.

29.        Fals-Stewart, W.; Shanahan, T.; Brown, L. Treating alcoholism and substance abuse: A neuropsychiatric perspective. Psychotherapy in Private Practice, 14(1):1-21, 1995. (139376)

Several studies have revealed the presence of subtle cognitive deficits in chronic abusers of alcohol and other psychoactive substances, which can be detected even after long periods of abstinence. The psychiatric sequelae of these impairments can include irritability, low frustration tolerance, impulsivity, depression, paranoia, and denial. The neuropsychological assessment of chemically dependent clients frequently provides valuable information as to the nature and extent of these cognitive deficits, all of which may be relevant to the therapeutic management and treatment planning. Clinical interventions that account for these neuropsychological decrements are recommended for those clients who abuse alcohol and drugs and have measurable cognitive dysfunction. To illustrate the potential impact of impaired cognitive functioning on the treatment of these clients, a case example is provided. 74 Ref. Copyright 1995 - Haworth Press, Inc.

30.        Forman-R-F. Interventions: Some guidelines for performing a denial-ectomy. Alvernia College Addictionary, 2(1):1-4,1986. (092321)

Discussion is presented on performing interventions with regard to guidelines for performing a denial-ectomy. The phases of the intervention or denial-ectomy are: (1) facing the facts and mobilizing, (2) co-dependency family education, (3) rehearsal, and (4) the intervention. An intervention is described as a process whereby the combined influence of a trained and concerned group of people is brought to bear on the defense of an active alcoholic or addict. 10 Ref.

31.        Galanter-M. Religious conversion: An experimental model for affecting alcoholic denial. In: M. Galanter, Ed., Currents in Alcoholism: Treatment and Rehabilitation and Epidemiology. Volume VI, New York, NY: Grune & Stratton, 1979. 345 p. (pp. 69-78) (046339)

It is noted that many alcoholics drop out of treatment at an early stage because of denial of their illness, and it is important to investigate effective means of achieving successful transformation in the alcoholic's attitudes. Results from a study of two religious sects ( the Devine Light Mission and the Unification Church) are reported, and the marked transformation in behavioral and attitudinal variables related to alcohol, achieved through religious conversion, is examined. Findings are discussed as they relate to the clinical management of alcoholic patients. 16 Ref.

32.        Galanter-M; Sofer-S-C. Systems view of treatment motivation. In: F.A. Seixas, Ed., Currents in Alcoholism: Psychiatric, Psychological, Social, and Epidemiological Studies. Volume IV, New York: Grune & Stratton, 1978. 498 p. (pp. 139-152) (034567)

This paper focuses on the motivational state of the alcoholic at the time of application for treatment. An instrument for the periodic assessment of patient status is described, and data obtained from a sample of alcoholic patients are presented to illustrate the utility of a systems model for patient motivation. The model is described as " highly inferential." It utilizes empirical data but has not been subjected to experimental validation. It does, however, serve to focus attention on the merit of an operational definition of the motivational state. It also defines a technique for rendering issues such as denial and craving into a format for dealing with quantitative interrelated measures. 28 Ref.

33.        Gibbs, V. Investigation of ego defenses in recovering alcoholics. Dissertation Abstract International, 54(9):4901B, 1994. (122452)

This study was an examination of improvement in psychological functioning during recovery from alcoholism. Specifically, it was hypothesized that those in early recovery would rely on immature defenses (denial, acting out); those in middle recovery would rely on neurotic defenses (reaction formation, idealization); and those in late recovery would rely on mature defenses (humor, anticipation). This hypothesis was derived from Vaillant (1983) and assessed with Bond's questionnaire (1984). Whether the recovery process is different for males and females was also examined. Finally, higher life-events- stress was expected to be associated with more immature defenses regardless of time in recovery, and time in recovery itself was expected to be a carrier variable for the effects of involvement in Alcoholics Anonymous BAA) and psychotherapy. The results revealed a significant relationship between time in recovery and defensive functioning. Subjects used a Greater proportion of immature defenses in early recovery than either middle or late recovery, and they employed more neurotic defenses in early and middle recovery than in late recovery. Mature defenses were most prominent in late recovery. There is no evidence that time in recovery is a carrier variable for involvement in AA and psychotherapy. The results were not noticeably affected by removing the effects of life-events-stress, and there were no gender differences in the main findings. These results are consistent with Vaillant, though less extreme, suggesting a refinement of his model of the recovery process. Copyright 1994. University Microfilms, Inc. This abstract was published with the permission of University Microfilms International (UMI) and may not be reprinted without their consent. For permission, contact UMI, 300 North Zeeb Road, Ann Arbor, MI 48106. Copies of this abstract are also available from the above address. Refer to order # DA9333086.

34.        Goldsmith-R-J; Green-B-L. Rating scale for alcoholic denial. Journal of Nervous and Mental Disease, 176(10):614-620, 1988. (101480)

Effective treatment is often significantly hindered by the alcoholic's denial of alcoholism. More effective interventions may be possible for practitioners who can concentrate on, and deal effectively with this denial. Alcoholics may deny the complete disorder or just some element of it -for example, loss of control over drinking. The authors describe and discuss their Denial Rating Scale (DRS), which was developed to help detect denial of alcoholism and to aid the specification of which feature(s) of the disorder the alcoholic patient is denying. Preliminary data on reliability and validity of the DRS are presented. It is concluded that preliminary interrater reliability is sufficient and that constructive and predictive validity apparently are indicated. Case histories illustrating three of the scale's eight levels of denial are included. An appendix contains brief conceptualizations of the eight levels. 19 Ref.

35.        Gorski Terence. Denial Process And Human Disease. 1(5):1-7, 1976. (038636)

Theories of denial are discussed in terms of (1) need (trigger) for denial, (2) the denial process, (3) the dynamics of denial, and (4) the interruption of denial as a primary step in dealing with an alcoholic patient. Methods are outlined for helping the patient interrupt denial. The individual must be consistently confronted with realistic alternatives to continued denial. It is contended that primary emotional, behavioral and situational problems of the alcoholic are not caused by any underlying pathology or major emotional difficulties and that the professional's responsibility is to help the patient to understand that he or she is reacting to a fatal illness by using denial.

36.        Gorski Terence. Denial Patterns: A System For Understanding The Alcoholic's Behavior. 1(6):1-6, 1976. (038637)

Six steps in the denial/acceptance process which an alcoholic must experience to be able to accept treatment are outlined. The steps include: (1) isolation, (2) denial, (3) anger, (4) bargaining, (5) depression, and (6) acceptance. Patterns associated with isolation and denial stages include avoidance, absolute denial, rationalization by intellectualization, and rationalization by comparison. The bargaining stage concerns minimizing, scapegoating, compliance, flight into health, manipulation, and consequential sobriety. The author makes special note of two denial patterns used by late, chronic stage alcoholics. These are (1) the democratic disease state, and (2) the diagnosis of self as beyond help.

37.        Grant, B.F. Barriers to alcoholism treatment: Reasons for not seeking treatment in a general population sample. Journal of Studies on Alcohol, 58(4):365-371, 1997. (140489)

This study describes the reasons that people with alcohol use disorders gave when asked why they did not seek alcoholism treatment in spite of their perceived need for such treatment.  A total of 964 people diagnosed with an alcohol use disorder (69.8 percent male, 93.5 percent non-Black) in a large representative sample of the United States population were evaluated. Data were derived from the 1992 National Longitudinal Alcohol Epidemiologic Survey, a national probability sample of 42,862 respondents, aged 18 years and older, from the non-institutionalized population of the contiguous states. Lack of confidence in the alcoholism treatment system and its effectiveness, stigmatization and denial were identified as significant barriers to alcoholism treatment at the aggregate level. In general, enabling factors such as lack of financial resources or facilities for child care were much less important barriers to care than were individual predisposing factors including attitudes towards alcoholism treatment. Important sociodemographic differences in identified barriers to care are discussed in terms of their minimization through proposed changes in education, screening, outreach, detection, and referral patterns in alcoholism treatment delivery systems. 21 Ref. Copyright 1997 - Alcohol Research Documentation Inc., Rutgers Center for Alcohol Studies.

38.        Griffin-P-P. Therapeutic processes affecting denial in alcohol groups. Dissertation Abstracts International, 49(10):4540-B, 1989. (103225)

This study was designed to investigate the therapeutic processes that occur in group treatment. Since denial is a major barrier to treatment, two processes that contribute to reduced denial were hypothesized: group acceptance leading to self-acceptance, and identification leading to reduced negativity of the label "alcoholic." Pre-and posttreatment measures of denial and weekly pencil and paper questionnaires were used to assess the therapeutic processes and their link to outcome. The hypothesis that group acceptance would lead to self-acceptance and self- disclosure was confirmed, and the link between self-disclosure and reduced denial was confirmed. The link between self-acceptance and denial also occurred, but contrary to prediction, self-acceptance decreased as denial decreased. The hypothesis that identification would lead to reduced negativity of the label alcoholic was not supported; instead, identification was directly linked to reduced denial. Unexpectedly, group acceptance was directly linked to reduced denial and reduced negativity of the label alcoholic. Copyright 1989 - University Microfilms, Inc. This abstract was published with the permission of University Microfilms International ( UMI) and may not be reprinted without their consent. For permission, contact UMI, 300 North Zeeb Road, Ann Arbor, MI 48106. Copies of this thesis are also available from the above address; refer to order # DA8827009.

39.        Griffith-P-R. "Learned helplessness" and ego defense mechanisms in alcohol treatment. Employee Assistance Quarterly, 1(4):87-92, 1986. (087742)

The role of learned helplessness and ego defense mechanisms in the personality of the alcoholic is discussed. Because of learned helplessness, the alcoholic is unable to perform a simple avoidance task--that of avoiding alcohol. Defense mechanisms used by alcoholics include denial, projection, rationalization, and intellectualization. Alcoholics show cognitive distortion. The concept of alcoholism is threatening to alcoholics, and it is this threat that the alcoholic defends against. A new way is needed to talk about alcoholism that does not threaten the ego of the person with the problem. Abstinence needs to be made a more acceptable choice. 2 Ref.

40.        Hoffman, N.G.; Ninonuevo, F.G. Concurrent validation of substance abusers self-reports against collateral information: Percentage agreement vs. k vs. Yule's Y. Alcoholism: Clinical and Experimental Research, 18(2):231-237, 1994. (123116)

The ability of chemical users to give an accurate self-report of substance use vs. abstinence has been questioned. This study investigated its concurrent validity, against collateral ratings. The results indicated that validity of reports of chemical use must be evaluated in the context of the validity of other types of information chemical use items were corroborated about as often as such nonchemical use items as reports of emergency room visits, arrests, and hospitalizations, thus arguing against the presence of a specific denial syndrome or overarching tendency toward self-misrepresentation. Relative concurrent validities seemed more a function of such factors as item salience and specificity. No consistent trend in patient over- or underreporting of chemical use was found. The choice of concurrent validation statistic is important and can influence interpretation of results. Current standards such as percentage agreement and k were seen as flawed; comparisons of results based on these two measures, as well as Yule's Y led to the conclusion that Yule's Y is the statistic of choice. 15 Ref. Copyright 1994 - Research Society on Alcoholism

41.        Howard, M.O.; Donovan, D.; Morse, R.M.; Flavin, D.K. Definition of alcoholism. JAMA : Journal of the American Medical Association, 269(5):586-587, 1993. (117717)

This letter comments on the definition of alcoholism provided by the Joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine. The definition includes denial as one of the distortions in thinking. The letter suggests that denial is a poorly operationalized concept used to explain the onset, progression and consequences of drinking. Experimental findings do not support the view that denial is a sine qua non of alcoholism. The response to this critique disputes that denial has inadequate empirical justification. It suggests that the difficulties have arisen more in the scientific attempts to define, delineate, describe, and measure the denial process. It also emphasizes that the definition of alcoholism provided in the original article was not vague and takes issue with the citation of a study which found low rates of denial in alcoholics. It is contended that no association between denial and treatment was found in the study because of the small sample size and the use of a little known " visual analogue scale" to measure rates of denial. 10 Ref

42.        Kofoed, L. Engagement and persuasion. In: N.S. Miller, Ed. Principles and Practice of Addictions in Psychiatry, Philadelphia, PA: W.B. Saunders Company, 1997. 567 p (pp. 214-220) (137785)

This article presents barriers that make it difficult for patients with substance abuse disorders to accept treatment, including patients with complications produced by comorbid substance abuse and other psychiatric disorders. These barriers include demoralization, denial, and fear. Specific treatment approaches that address individual and group engagement and persuasion techniques are discussed that modify denial and convince patients to accept a long-term abstinence-oriented treatment plan. Available evidence suggests efficacy of engagement and persuasion efforts and supports the benefits of subsequent specialized dual-diagnosis treatment. 22 Ref.

43.        Krueger-D-W. Neurotic behavior and the alcoholic. In: E. Pattison, and E. Kaufman, Eds., Encyclopedic Handbook of Alcoholism, New York, NY: Gardner Press, 1982. 1230 p. (pp. 598-606). (066872)

The author contends that supportive therapies, pharmacologic treatment, and insight-oriented treatment are encompassed by basic issues and principles. In this chapter, these basic issues and principles are discussed regarding the relationships of neuroticism and alcoholism, and the importance of recognizing neurotic mechanisms and behavior in treating alcoholic patients. Denial, anger, guilt, withdrawal from treatment, and assertions of omnipotence are described as commonly observed defense postures among alcoholics. Complementary and counterpart mechanisms in the therapist, called transference and countertransference, respectively, are also discussed as they relate to the therapist's ability to reorganize these issues and utilize them in successful treatment. It is concluded that these mechanisms, in both patient and therapist, can be used as tools for understanding the patient's mental processes, including the content, mechanism, and intensity of his or her mental life, and the role and function served by the alcoholic behavior. 11 Ref.

44.        Kufner-H. Zur Frage von Verleugnungstendenzen bei Alkoholabhangigen (Problem of denial tendency among alcoholics). Drogalkohol, 6(3):21-36, 1982. (067364)

An analytical review is presented of published empirical data obtained from: (1) reliability and validity tests of self-reports by alcoholic subjects; (2) the evaluation of denial tendencies in alcoholics, using an alcohol control scale, mainly the MMPI, and correlating the scale data with questionnaires to determine alcohol dependence; and (3) a direct evaluation of the defense tendency, using the Defense Mechanism Inventory test. The primary conclusions from this review are that: (1) the denial tendency depends heavily on the particular phase of treatment, and (2) the self-reports of patients may lead to overagreement or underagreement with diagnostic criteria, but on the whole, they have at least the same validity as anamnestic data from other sources.

45.        Landeen-R-H. Will power and denial: Clinical findings about these pervasive concepts. In: M. Galanter, Ed., Currents in Alcoholism: Biomedical Issues and Clinical Effects of Alcoholism. Volume 5, New York, NY: Grune & Stratton, 1979. 378 p. ( pp. 301-307). (080337)

Willpower and denial in alcoholism are discussed based on results of part of a multipurpose questionnaire administered to 41 patients admitted to a general psychiatric ward. Twelve were diagnosed as being alcoholic. As a potential measure of motivation, this question was included in the questionnaire: "In terms of help for my drinking behavior, I would rather (choose one) (a) just be 'dried out' and have a rest, (b) develop willpower, (c) actively participate in a therapeutic program, (d) have other people offer solutions for me, or ( e) I do not consider myself to have a drinking problem." Of the alcoholics only two denied having a drinking problem, but six reported a desire to develop willpower. It is suggested that the denial frequently mentioned in alcoholic programs may be mostly a function of the therapist-patient interaction, while the desire for willpower is a self-perception and may be an expression of alcoholics' concern about loss of control. 7 Ref.

46.        Lederer, G.S. Use of denial and its gender implications in alcoholic marriages. In: J.A. Lewis, Ed., Addictions: Concepts and Strategies for Treatment, Gaithersburg, MD: Aspen Publishers, 1994. 393 p (pp. 263-275) (123871)

Some degree of denial and invalidation of circumstances and feelings occurs in most marriages, whether or not alcoholism is present. What makes denial different when it occurs in alcoholic marriages is the overlay of dynamics attributable specifically to alcoholic systems. This chapter reviews the use of denial and its gender implications in alcoholic marriages. Issues addressed are: (1) Denial and invalidation; (2) Denial and overresponsibility; (3) Denial and entitlement; (4) Denial and validation; (5) Denial and power; (6) Denial and responsibility for self; (7) The presenting problem; (8) Claire's story; (9) Exposing denial; (10) Raising the gender issues; (11) Defining a self; (12) The sequel to Claire's story; and (13) Dilemma: personal or political? 25 Ref.

47.        Lehman-C-V. Alcoholic bottom: Problem recognition and help seeking by alcoholics. Dissertation Abstracts International, 45(7):1992-A, 1985. (083979)

The characteristics of alcoholics, factors associated with hitting bottom, and help-seeking behavior of alcoholics were studied in a cross- section sample of 150 selected Alcoholics Anonymous (AA) members. Responses to a self-administered questionnaire were analyzed by sex, income, and years spent drinking. Although the onset of alcoholism was found to be later for women than for men, women moved more rapidly through the progressive alcoholic symptomatology. Proportionately, the ratio of men to women was two to one. Lower income alcoholics, especially men, had more pronounced drinking histories. Hitting bottom, the experience in which alcoholics recognize their absolute dependence on alcohol, was a profoundly emotional, but individually perceived, phenomenon. Increased symptomatology and losses, culminating in a final erosion of self-esteem, contributed to hitting bottom, but did not cause it. Hitting bottom frequently preceded help-seeking, but it was not necessarily a prerequisite of help-seeking. Alcoholics delayed seeking help because of fear, denial, and pride. More men sought help than women. Formal helping sources were used more frequently than informal sources. Men preferred alcoholism treatment systems; women preferred psychological help. Lower income people sought help more aggressively than higher income people. Respondents gave low effectiveness ratings to helping sources outside of AA. Implications of the findings to increase effectiveness of professionals who work with alcoholics are discussed. 0 Ref.

48.        Levy, M. Psychotherapy with dual diagnosis patients: Working with denial. Journal of Substance Abuse Treatment, 10(6):499-504, 1993. (121374)

The author discusses a strategy of working with chronically impaired dual diagnosis patients who are in denial of their substance abuse problems. It is argued that due to a number of unique features among such patients, directly confronting denial and insisting on abstinence will not be effective for many of these patients. Instead, it is suggested that patients' continued substance use should be tolerated although at the same time be made a focus of treatment. Techniques are offered which can be utilized to broach the denial of this challenging patient population. Types of patients not suitable for this approach are also discussed. 15 Ref. Copyright 1993 - Pergamon Press Ltd.

49.        Loethen, G.J.; Khavari, K.A. Comparison of the Self-Administered Alcoholism Screening Test (SAAST) and Khavari Alcohol Test (KAT): Results from an alcoholic population and their collaterals. Alcoholism: Clinical and Experimental Research, 14(5):756-760, 1990. (109287)

This study examined the reports of patients and their collaterals on drinking practices, as measured by the summary scale of the Khavari Alcohol Test (the annual absolute alcohol intake, AAAI) and alcohol- related behavioral patterns as assessed by the Self-Administered Alcoholism Screening Test (SAAST). In-and outpatients from two Milwaukee area substance abuse treatment hospitals, and a number of their collaterals, participated in this study. Patients' and collaterals' responses on the AAAI and SAAST were compared through the use of a paired t test. Results indicated no significant differences between patients' self-reports compared with collateral reports, and demonstrated a direct relationship on the AAAI (two-tailed p < 0.001) and SAAST (two-tailed p < 0.001). Self-reports of patients who volunteered collaterals compared with self-reports of patients who did not volunteer collaterals also showed no signficant differences on the AAAI or the SAAST, demonstrating consistency of reporting whether the patients believed their reports would be compared with information provided by a collateral or not. The AAAI and the SAAST corroborated in their diagnoses of patients as suffering from alcoholism (r = 0.515, p < 0.001). Multivariate analysis revealed no significant effect of demographic variables on either the AAAI or the SAAST. This study shows: (1) impressive concordance between patient and collateral reports; (2) apparent intactness of memory, and little evidence of denial, as measured by the instruments; and (3) the efficacy of measures such as the AAAI and the SAAST, two vastly different scales measuring dimensions of alcoholism. 27 Ref. Copyright 1990 - The Research Society on Alcoholism

50.        Maisto, S.A.; Wolfe, W.; Jordan, J. Short-term motivational therapy. In: P.J. Ott, R.E. Tarter, and R.T. Ammerman, Eds., Sourcebook on Substance Abuse: Etiology, Epidemiology, Assessment, and Treatment, Boston, MA: Allyn and Bacon, 1999. 472 p. (pp. 284-292) (149143)

This chapter describes motivational therapy and its implementation in the treatment of substance abuse disorders. The importance given to the construct of motivation to behavioral change has been pivotal in the treatment of substance abuse as well as in the treatment of other disorders. Denial is a construct that is common to substance abusers and is manifested as a failure to acknowledge or to have concern about their patterns of substance use and related problems. The transtheoretical model of change has shown that each stage (preparation, action, maintenance) of behavioral change is associated with different processes of denial. Traditional models of substance use disorders are reviewed. Motivational interviewing is based on six keys to motivation to change called Frames: (1) Feedback, which is a comprehensive assessment given to the individual about his or her current status; (2) Responsibility, emphasizing the individual taking personal responsibility for his or her behavior changes; (3) Advice, which is a clear statement given to the individual to change his or her drinking;  (4) Menu, offering the individual different strategies to make behavioral changes; (4) Empathy, stressing the empathic nature of effective therapeutic relationships; and (5) Self-efficacy, reinforcing the idea that individuals are capable of making the changes. Procedures used in motivational interviewing are described. Based on the positive findings about brief interventions for change in alcohol use, it would seem that studies of the effectiveness of motivational interviewing would have a good chance of showing positive outcomes. A review of the effectiveness of motivational interviewing in four recent studies is presented. 39 Ref.

51.        Malik, R.; Washton, A.M.; Stone-Washton, N. Structured outpatient treatment. In: A.M. Washton, Ed., Psychotherapy and Substance Abuse: A Practitioner's Handbook, New York, NY: Guilford Press, 1995. 500 p (pp. 285-294) (129018)

The purpose of this chapter is to familiarize the reader with the philosophy, approach, and content of a specialized and structured outpatient treatment program for alcohol and other chemical dependencies. The Washton Institute (NY) outpatient program is described. The description covers program philosophy; patient eligibility; counselor attitude and stance; assessment; session format and content; typical session topics or themes; strategies for dealing with common clinical problems; strategies for dealing with denial, resistance, and poor motivation; counselor's response to slips and relapses; role of significant other in treatment. 6 Ref.

52.        Midanik, L.T.; Harford, T.C. Alcohol consumption measurement: Introduction to the workshop. Addiction, 89(4):393-394, 1994. (122931)

Six papers on measurement issues in alcohol consumption are introduced. The papers were originally presented at a workshop at the 18th Annual Alcohol Epidemiology Symposium of the Kettil Bruun Society of Social and Epidemiological Research on Alcohol, Toronto, Ontario, Canada, in the Spring of 1992. The introduction identifies three main sources of error in self-reported alcohol use: (1) errors arising in respondents themselves, from denial, deliberate deception, or faulty memory leading to overestimation or underestimation; (2) errors arising from the contexts in which the reports are obtained, which can lead to overestimation if, for example, admission to a treatment program is at stake, or to underestimation if, for example, keeping one's job is at stake; and (3) errors arising in the procedures investigators use to obtain self-reported alcohol consumption data. Copyright 1993 - Society for the Study of Addiction to Alcohol and Other Drugs

53.        Mayer, J.E.; Koeningsmark, C.P.S. Self efficacy, relapse and the possibility of posttreatment denial as a stage in alcoholism. Alcoholism Treatment Quarterly, 8(4):1-17, 1992. (114947)

This article reports the results of a study examining self-efficacy and relapse in patients treated in a substance abuse facility for alcoholism. Relapse was measured as a two-stage process of "Lapse" and " Relapse." The results did not support the previous findings that self-efficacy ratings measured post treatment were valid predictors of treatment outcome status. In examining the results, it is proposed that a condition of "post treatment denial" is operating among patients. 32 Ref Copyright 1992 - The Haworth Press, Inc.

54.        McMahon, J.; Jones, B.T. Change process in alcoholics: Client motivation and denial in the treatment of alcoholism within the context of contemporary nursing. Journal of Advanced Nursing, 17(2):173-186, 1992. (114629)

The process of change in the alcoholic patient is discussed, with a focus on motivation and denial. Headings within this review of the literature include: (1) role of client motivation; (2) different models of problem and treatment, including the medical model and the compensatory model; (3) the compensatory model and the importance of motivation; (4) the compensatory model and the importance of expectancy and beliefs; (5) changing expectancies through cognition; (6) the need to change negative expectancies of alcohol use; (7) changing expectancies within a nursing context; (8) process of assessment; (9) qualitative and quantitative information; (10) revised expectancy/ motivation hypothesis; (11) denial and the role of cognitive dissonance; (12) negative outcomes; and (13) case studies. It is noted that the revised expectancy/motivation hypothesis is a statement of the preconditions necessary for successful treatment, in which the nurse may permit the client to reinterpret past experiences. 60 Ref Midanik, L.T. Perspectives on the validity of self-reported alcohol use. British Journal of Addiction, 84(12):1419-1423, 1989. (106675)

The question of whether self-reports of alcohol consumption are valid is explored. Also examined is the denial by most alcohol researchers that overreporting of alcohol use may be possible. Researchers tend to assume that the question of self-report validity has an absolute answer, but the truth is unlikely to be neat or simple. There is a tendency to regard discrepancies of self-reported alcohol consumption as underreports, probably because the concept of denial is ingrained in the alcohol field. Overreporting is almost never considered possible, despite evidence that it appears in fields such as drug abuse and is related to how respondents choose to present themselves. Alcohol researchers who use collateral methods to validate self-reports assume that if such a method provides more of the behavior being studied it must be more accurate. Overreporting of alcohol consumption by respondents is rarely offered as an explanation for discrepancies with collateral reports or other external criteria. Several factors could account for overreporting, including how questions are asked, accuracy of instruments used to validate reponses, assumptions in estimating blood alcohol levels from self-reports, and the interview situation. 26 Ref. 26 Ref. Copyright 1989 - Society for the Study of Addiction to Alcohol and Other Drugs

55.        Metzger-L. From denial to recovery: Counseling problem drinkers, alcoholics, and their families. San Francisco, CA: Jossey-Bass Publishers, 1988. 326 p. (104417)

A guide to helping problem drinkers through the stages of recovery is presented, including methods for handling denial, confrontation, interviews, and case studies. Chapter headings include: (1) problem drinker or alcoholic? A framework for diagnosing alcohol abuse; (2) development of alcohol abuse: four aspects; (3) dealing with denial; ( 4) conducting the diagnostic interview; (5) creating a treatment plan; ( 6) treating the individual; (7) counseling children of alcoholics; (8) working with the family: interview and treatment; (9) substance abuse in the workplace; (10) the evolution of an attitude; ( 11) Alcoholics Anonymous: Twelve Steps; (12) and drug use: stages, patterns, and observable effects. The book is written for professionals and paraprofessionals who work with clients suffering from all degrees of alcohol abuse. 174 Ref.

56.        Midanik-L-T. Perceptual variables as factors in dropout for alcoholism treatment. 11th Annual Medical-Scientific Conference of NCA, Seattle, WA: May, 1980. 20 p. (049915)

This study examined factors in the initial intake interview which could identify those clients at high risk of dropping out of an alcoholism treatment program prematurely. Using a prospective study design, data were obtained from 68 new clients at the time of entrance in two sites ( emergency room and walk-in clinic) of a comprehensive alcoholism treatment program. Study respondents were asked about their drinking behavior, including alcohol consumption in the last twenty- four hours. After being interviewed, a breath test was administered to each respondent. The sample was followed for 28 days. Early dropout for emergency room entrants was related to client' s perception of a severe problem with alcohol, having had a problem with alcohol for a shorter period of time and over-reporting recent alcohol consumption. Dropouts from the walk-in clinic also reported having a shorter history of alcoholism and having a less severe alcohol problem. In addition these dropouts disagreed with their counselors concerning their problem severity and also over-reported their recent consumption. The findings in this study cast doubt on the generally accepted notion of denial as a "barrier to treatment." In fact, the data suggest that the over- reporter is at a higher risk of dropping out of treatment than the under-reporter. 20 Ref.

57.        Midanik L.T. Client's Perception Of Problem Severity And Client/Counselor Agreement Of Problem Severity As Factors In Early Dropout From Alcoholism Treatment(Abstract). Alcoholism: Clinical and Experimental Research, 4: 223, 1980. (055287)

Sixty-eight newly admitted alcoholics were studied to determine the risk of dropping out of a treatment program prematurely. Early dropout for those entering an emergency room was related to the client' s perception of a severe problem with alcohol, agreement with the counselor on the severity of the problem and over-reporting of recent alcohol consumption. Walk-in dropouts were more likely to disagree with their counselor about the severity of their alcohol problem and to report having had the problem for a shorter period of time. It is suggested that the over-reporter of alcohol use is at a higher risk of dropping out than the under-reporter; denial may not be a barrier to treatment.

58.        Miller, W.R. Enhancing motivation for change. In: W.R. Miller and N. Heather, Eds., Treating Addictive Behaviors: Second Edition, New York, NY: Plenum Press, 1998. 357 p. (pp. 121-132) (147748)

This chapter is based upon the beliefs that: (1) motivation is created by helping people to find what makes it worth their while to change;  (2) people with AOD problems will not change their patterns of AOD use until they find something they care about more than the use of AOD's.  This chapter reviews techniques for enhancing motivation for change in the treatment of addictive behaviors.  The chapter is organized around the general topics of therapeutic style, motivational techniques, and the broader context of behavior.  The section on motivational style discusses the ambivalence that often stalls the change process (avoid the confrontation-denial trap); basic assumptions (the processes of change, the locus of change, and the possibility of change); empathy; and support. The section on motivational techniques discusses practical steps to help ensure a client's continued participation; help the client see the discrepancy between a risky or harmful behavior pattern and important personal goals; and offering treatment options to the client.  The following recommendations are made for enhancing denial:  (1) focus the assessment and treatment process upon finding things that clients care about more than the use of AOD's;  (2) explore how AOD use becomes and obstacle to getting those things;  (4) provide positive reinforcement for constructive change whenever possible;  (5) involve of significant others in the problem solving and motivational process; (6) stop using therapeutic techniques to "trick people" into doing what they do not want to do;  (7) start using therapeutic techniques as tools for helping people to realize that their use of alcohol and other drugs (AOD's) is jeopardizing what is most dear to them. 41 Ref.

59.        Miller, W.R. Motivational interviewing: III. On the ethics of motivational intervention. Behavioural and Cognitive Psychotherapy, 22(2):111-123, 1994. (124916)

Motivational interviewing is a style of therapeutic intervention designed to strengthen and consolidate commitment to change. Its focus is on the resolution of ambivalence toward changing behavior. This article campaigns for the consideration of ethical issues in motivational interventions. Areas covered include: (1) Motivation and "denial"; (2) Motivating change - an ethical change; (4) What is manipulative?; and (5) Why does motivational interviewing work? 37 Ref.

60.        Miller W.R. Increasing motivation for change. In: R.K. Hester and W.R. Miller, Eds., Handbook of Alcoholism Treatment Approaches, Elmsford, NY: Pergamon Press, 1989. 292 p. (pp. 67-80). (103643)

Professionals in wide-ranging fields agree that client motivation is a vital issue in recovery from alcoholism. Denial has long been considered a defense mechanism inherent to alcoholics. More recently, however, it has been posited that such matters as high bottoms, enabling and codependence, interventions, the "alcoholic personality," and therapist effects are involved in this complex matter. The modern concept of motivation is discussed. The stages of change (precontemplation, contemplation, determination, action, maintenance, and relapse) are discussed. Ways in which therapists can increase clients' motivation are described and discussed. Motivational interviewing, a practical approach to combining tools to increase motivation, is described and discussed. Two of its components, contemplation strategies and determination strategies, are detailed. Treatment goals, including controlled drinking and abstinence, are considered. Research using an early intervention approach called the Drinker's Check-Up (DCU) is described and discussed. 77 Ref.

61.        MilleR F; Barasch A. Under-reporting of alcohol use: The role of organic mental syndromes. Drug and Alcohol Dependence, 15(4):347-351, 1985. (085793)

The role of organic mental syndromes in the underreporting of alcohol use was investigated. The underreporting of alcohol use has been viewed as the consequence of alcoholic denial. Alcoholic denial has been conceptualized as an unconscious ego defense. The Mini-Mental State ( MMS) was acquired on the first, third, fifth, and eighth days of the psychiatric hospitalizations of 13 men and women for alcohol detoxification. The MMS is a scored mental status examination designed to grade the cognitive state of patients. It assesses orientation, registration, attention, recall, and capacity to understand and perform written and verbal tasks. Results of this study suggest that the underreporting of alcohol use may, in some cases, be related to cognitive impairment rather than to unconscious ego defenses. It is concluded that alcohol-related organic mental syndromes tend to interfere with the collection of reliable information. The implication for treatment is the need for the physician to carefully evaluate the patient for the presence of an organic mental syndrome before assuming that the patient's underreporting of alcohol use is psychologically motivated. 9 Ref.

62.        Morgan, T.J. Behavioral treatment techniques for psychoactive substance use disorders. In: F. Rotgers, D.S. Keller, and J. Morgenstern, Treating Substance Abuse: Theory and Technique, New York, NY: Guilford Press, 1996. 328 p (pp. 202-240) (132594)

This chapter reviews behavioral treatment techniques for psychoactive substance use disorders (PSUDs). Major topics addressed include basic tasks of all behavioral interventions (developing a therapeutic relationship, enhancing motivation to change, thorough assessment by functional analysis, developing and implementing treatment goals, evaluating treatment progress and terminating treatment); specific behavioral treatment techniques and interventions (aversion treatments, cue exposure, behavioral self-control training, broad-spectrum treatments, contingency management); and specific issues in implementing behavioral treatment (sequencing of technique use, how and in what order problems are addressed, addressing denial, resistance, and lack of progress, how lapses and relapses are viewed and used in treatment, how to integrate other treatment supports such as self-help groups and medication). The case of a 35-year-old married white male who was referred for treatment by his attorney after a second conviction for driving while intoxicated is presented to illustrate the techniques discussed. The author concludes that the treatment approaches that have the most empirical support in the literature are behaviorally based. 76 Ref.

63.        Morgenstern, J.; Frey, R.M.; McCrady, B.S.; Labouvie, E.; Neighbors, C.J. Examining mediators of change in traditional chemical dependency treatment. Journal of Studies on Alcohol, 57(1):53-64, 1996. (131228)

Few studies have examined processes that mediate positive outcomes in the treatment of substance use disorders. The present study used a theory-driven approach to assess mechanisms hypothesized as curative by the traditional chemical dependency treatment approach. Several specific disease model processes such as accepting powerlessness over alcohol and two processes common to both the disease model and other treatment approaches (commitment to abstinence and intention to avoid high-risk situations) were studied. It was hypothesized that patients entering treatment would manifest high levels of denial, that there would be significant reduction of denial and increased endorsement of disease model and common processes as a result of treatment and that processes would mediate outcome. Patients (N equals 79; 54 men) in intensive traditional alcohol/drug treatment were assessed at entry into treatment, at the end of treatment and 1 month following treatment. Both self-report and clinician ratings of processes were assessed. Overall, results provide little support for study hypothesis. Subjects showed low levels of denial at treatment entry. Specific disease model, but not common processes, increased during treatment. Common processes, but not disease model processes, predicted relapse. Patients with higher levels of commitment to abstinence and greater intentions to avoid high-risk situations were at lower risk for relapse. However, greater commitment to Alcoholics Anonymous and belief in a Higher Power predicted reduced severity of relapse among those who did relapse. Findings do not support prevailing practitioner views regarding how traditional treatment works and suggest that interventions in these treatments may be mismatched to patient needs. 51 Ref. Copyright 1996 - Alcohol Research Documentation, Inc., Rutgers Center of Alcohol Studies, New Brunswick, NJ 08903. Author abstract provided with permission from the Journal of Studies on Alcohol.

64.        Mulder, R.T.; Joyce, P.R.; Sellman, J.D.; Sullivan, P.F.; Cloninger, C.R. Towards an understanding of defense style in terms of temperament and character. Acta Psychiatrica Scandinavica, 93(2):99-104, 1996. (142271)

The relationship between a model of personality based on defense mechanisms and style and Cloninger's psychobiological model of personality was investigated using 128 adults (59 with alcohol dependence and 11 with alcohol abuse) from 11 families with at least two first-degree alcohol-dependent relatives. Subjects completed the self-report Defense Style Questionnaire (DSQ) and the Temperament and Character Inventory (TCI). The DSQ measures the cluster A defenses of isolation, denial, projection, and fantasy; cluster B defenses of splitting, acting out, devaluation, dissociation, displacement, and unreflectiveness; and cluster C defenses of reaction formation, passive aggression, and somatization. The TCI measures the temperament dimensions of novelty seeking, harm avoidance, reward dependence, and persistence and the character dimensions of self-directedness, cooperativeness, and self-transcendence. Low reward dependence was correlated with cluster A defenses, high novelty seeking with cluster B defenses, and high harm avoidance with cluster C defenses. Regression analysis indicated that cluster B and C defenses were more related with low character scores, while both character and temperament scores contributed to cluster A defenses. Overall, results show that low character scores explained immature defenses, and neurotic defenses were explained by both temperament and character scores. It is concluded that an ego defense model of personality can adequately be integrated with Cloninger's psychobiological model. 17 Ref.

65.        Newsome, D.; Ditzler, T. Assessing alcoholic denial: Further examination of the denial rating scale. Journal of Nervous and Mental Disease, 181(11):689-694, 1993. (120930)

The Denial Rating Scale (DRS) for substance abuse is re-examined in this study. This replication study presents the results of applying the DRS in an inpatient treatment setting to assess further the scale's utility to predict outcome as well as its heuristic value for clinical practitioners. It is concluded that the DRS is a useful tool in alcoholism treatment that can be used in prioritizing admissions, in targeting intervention for high risk of early discharge patients, and for assessing treatment progress. It is recommended that treatment centers examine the potential utility of the DRS as a means of improving the precision of treatment plan decisions and facilitating staff focus on the primacy of addiction. 4 Ref.

66.        Obert, J.L.; Rawson, R.A.; Miotto, K. Substance abuse treatment for "hazardous users": An early intervention. Journal of Psychoactive Drugs, 29(3):291-298, 1997. (139788)

A six-session cognitive behavioral protocol has been developed for substance abusers who meet the description "hazardous users." This category includes individuals evidencing mild to moderate use of alcohol or other drugs, whose lifestyles are minimally disrupted, or who are displaying signs of problem use or abuse, but are unwilling to enter intensive treatment. The treatment model is nonconfrontational and is designed to motivate the individual to recognize the problems associated with his or her substance use and initiate treatment-seeking behavior. The intervention may be particularly useful in situations where employees have tested positive for substances but deny having a problem, where friends or family members report help is needed but the individual denies any problem, or where an alcohol or other drug problem is clearly evidenced but the individual does not acknowledge a problem. A positive outcome is indicated by the client taking action which is consistent with an increased awareness of the problem as conceptualized by J.O. Prochaska and C.C. DiClemente (1982). This model is an alternative to the traditional confrontational models of "breaking through denial." The philosophies employed by W. Miller and associates and by the Matrix treatment models form the basis of this intervention. 14 Ref. Copyright 1997 - Journal of Psychoactive Drugs.

67.        Oleary Michael R; Rohsenow-Damaris J; Schau-Edward-J. Defensive Style And Treatment Outcome Among Men Alcoholics. Journal Of Studies On Alcohol, 38(5):1036-1040, 1977. (029325)

The relationship between scores on the defense mechanism inventory (DMI) and treatment outcome in alcoholics was studied in 54 male alcoholic patients in a 1-year outpatient therapy program. The results of the study appear to challenge the concept of confrontation, generally accepted as an article of faith in rehabilitation programs. Of the 54 subjects, 26 quit the program before completion, 19 were rehospitalized for alcohol-related relapses, and 25 were employed at follow-up. Patients who completed the program had significantly higher scores on reversal than those who dropped out or who were hospitalized. On the other hand, the rehospitalized patients had higher turning- against-an-object scores. The high levels of denial on the reversal scale of the dmi may reflect an adaptive component of the recovery process. It is concluded that reduction of anxiety may be more beneficial to the rehabilitation of the alcoholic than confrontation and breakdown of denial mechanisms. 13 ref.

68.        Owen-P-L. Measurement of the concept of denial among alcoholics. Dissertation Abstracts International, 45(8):2698-B, 1985. (084176)

A study was designed to measure and validate the concept of denial, the tendency of some alcoholics to disavow or distort variables associated with their use of alcohol despite evidence to the contrary. Items indicative of denial that had been submitted by counselors were administered to 114 alcoholics in inpatient treatment. After estimates of reliability had been established, the resulting questionnaire of 74 items was administered to a new sample of alcoholics upon admission to and discharge from treatment. Correlations were computed between questionnaire scores and external criteria. High scores on the questionnaire, which were interpreted as reflecting high levels of denial, correlated positively with counselors' ratings of level of denial and Minnesota Multiphasic Personality Inventory (MMPI) A-scale scores. They correlated negatively with number of prior treatments, prior Alcoholics Anonymous involvement, brief Michigan Alcoholism Screening Test (brief-MAST) score, and MMPI K scale. Denial scores decreased over the course of treatment. Results suggest that the questionnaire measures a concept that is seen as denial by counselors, and is a complex phenomenon that includes a large component tapping patients' level of information on alcoholism. 0 Ref.

69.        Paredes-Alfonso. Denial, Deceptive Maneuvers, And Consistency In The Behavior Of Alcoholics. IN: F. Seixas and R. Cadoret, EDS, The Person With Alcoholism, New York: Academy Of Sciences, 1974. 177 P. (PP. 23-33). (015598)

Alcoholic behavior is defined in terms of: (1) physical tolerance and drinking capacity; (2) denial and prevarication; (3) deception; and (4) the contributory role of brain damage. The author lists a number of supportive networks that promote deviant drinking, noting that the need for alcohol is not compelling if the social demands placed on the problem drinker are structured and restricted. 43 ref.

70.        Pursch-J-A. Lab test for denial. Alcoholism The National Magazine, 5(4):11, 1985. (077558)

The use of the blood alcohol level (BAL) test to rule out other diseases in diagnosis and to break through the patient's denial of alcoholism is discussed.

71.        Rabold, D.E. Differentiating between psychogenic and neurogenic denial in persons with TBI and substance abuse. Dissertation Abstracts International, 57(7): 4771-B, 1997. (136925)

This study investigated the differences between psychogenic and neurogenic denial in a population of individuals who have been diagnosed with substance abuse following traumatic brain injury (TBI). Forty subjects from the TBI Network participated and four groups emerged: those with pure neurogenic denial, those with pure psychogenic denial; those with both denials; and those with neither denial. Selected neuropsychological assessments and emotional status inventories were administered to each subject. Principal hypotheses were: that individuals exhibiting neurogenic denial would perform more poorly on measures of neuropsychological functioning than individuals exhibiting psychogenic denial, and that individuals with psychogenic denial would display greater emotional maladjustment and less life satisfaction than individuals with neurogenic denial. A significant result was found between pure psychogenic and pure neurogenic groups on the depression measure. There were three limitations to this study. The first was the small size. The second was the operationalization of the subject groups by means of rating scales only. Future research may benefit from incorporating a combination of self-rating scales, questionnaires, structured interviews, and observations. The final limitation was in the choice of neuropsychological instruments. This study chose neuropsychological measures based on their lateralization potential which was not significant. Future studies may benefit from neuropsychological measures that assess verbal and executive function skills that may be more reflective of the diffuse nature of TBI. Copyright 1997 - University Microfilms, Inc. This abstract was published with the permission of University Microfilms International (UMI) and may not be reprinted without their consent. For permission, contact UMI, 300 North Zeeb Road, Ann Arbor, MI 48106. Copies of this abstract are also available from the above address. Refer to order # DA9639332.

72.        Rebelo, F.R. Denial level and coping style in a substance abuse treatment population. Dissertation Abstracts International, 60(6):2958-B, 1999. (152185)

This study examines:  (1) how coping styles are related to the severity of alcohol and other drug (AOD) abuse problems; and (2) the relationship between denial level and AOD abuse problem severity. Archival data from 346 adult males receiving substance abuse treatment at an urban Veterans Affairs Medical Center were analyzed. Alcohol and drug problem severity was assessed with the Addiction Severity Index. Level of denial for both alcohol and drugs was measured with the Denial Rating Scale (DRS). The Coping Strategies Inventory was used to measure coping style.  This study showed that:  (1) High levels of problem solving skills were associated with low levels of AOD problem severity.  (2) Low levels of problem solving skills were associated with high levels of AOD problem severity. (3) The use of Social Withdrawal as a predominant coping style was positively associated with AOD problem severity.  (4)  Higher levels of denial of AOD problems was positively associated with lower levels of AOD problem severity.  The results suggest that treatment of both alcohol and drug users should include skills in active problem solving, and that treatment of drug users should also focus on preventing social isolation.

73.        Rhoads-G-A. Preferred psychotherapist style of highly denying alcoholics: An Ericksonian hypnotherapy model. Dissertation Abstracts International, 48(7):2107-B, 1988. (100854)

Several hypotheses were tested regarding initial rapport between psychotherapists and their clients, particularly in respect to gaining rapport with highly denying alcoholics. This process is generally referred to as creating a therapeutic alliance, and more specifically defined by hypnotherapists as meeting the client at the client's model of the world. The major hypotheses predicted an interaction effect where low denying clients (n=20) would show a preference for an intuitive/experiential style of therapist and high denying clients (n= 40) would show a preference for a rational/analytic style of therapist. An analog experimental design provided no statistical support for the major hypothesis, however, a multiple regression equation did provide strong evidence that the demographic background of clients predicted their choice or rejection of the therapist regardless of level of denial or therapist style. When the subject sample, which consisted entirely of mandated clients (n=60), was divided into two equal groups, welfare referred black subjects indiscriminately accepted therapists regardless of style, whereas blue collar court referred white subjects indiscriminately rejected therapists regardless of style. This result supports the contention that social and cultural variables are critical in their effect upon psychotherapeutic relationships. In regard to the theoretical concept of denial, the results of the study question the accepted clinical understanding of denial as a trait variable. Further research is recommended to clarify the nature of the status of denial as a state or trait variable. Copyright 1988 - University Microfilms Inc. This abstract was published with the permission of University Microfilms International ( UMI) and may not be reprinted without their consent. For permission, contact UMI, 300 North Zeeb Road, Ann Arbor, MI 48106. Copies of the thesis are also available from the above address; refer to order # DA8722908.

74.        Richardson, D.R. Effects of a videotaped family intervention on the denial level of alcoholics and cocaine abusers. Dissertation Abstracts International, 53(11):3806A, 1993. (119030)

The purpose of this study was to examine the effects of a videotaped family intervention on the denial level of alcoholics and cocaine abusers. The sample consisted of 60 alcoholics and 60 cocaine abusers randomly selected from the adult, inpatient, chemical dependency unit at St. Francis Hospital. The Denial Rating Scale (DRS), was administered to each subject on a pre-and post-basis to measure the level of change of denial. The researcher hypothesized that there would be no difference in denial ratings between alcoholic controls and experimental alcoholics, between cocaine controls and experimental cocaine abusers, and between experimental alcoholics and experimental cocaine abusers. In addition, the researcher hypothesized that there would be no correlation between the experimental alcoholics' denial rating and their rating of the effectiveness of the videotaped family intervention in reducing their denial. Denial reduction across treatment was significant for both the control and experimental groups of alcoholics and cocaine addicts. However, the experimental alcoholics' level of denial reduction was significantly less than the control group of alcoholics. In addition, the level of denial reduction was significantly less for the experimental group of alcoholics than for the experimental group of cocaine abusers. Data analysis revealed a small, positive correlation between the discharge denial rating of the experimental alcoholics and their rating of the videotaped family intervention. A small, positive correlation was also found between the discharge denial level of the experimental cocaine abusers and their rating of the videotaped family intervention. Copyright 1993. University Microfilms, Inc. This abstract was published with the permission of University Microfilms International (UMI) and may not be reprinted without their consent. For permission, contact UMI, 300 North Zeeb Road, Ann Arbor, MI 48106. Copies of this abstract are also available from the above address. Refer to order # DA9259627

75.        Ritson, E.B. III. Alcohol, drugs, and stigma. International Journal of Clinical Practice, 53(7):549-551, 1999. (153504)

This article explores the public and professional attitudes that prevent substance abusers from seeking help.  These attitudes include:  (1) the belief that AOD problems are self-inflicted, (2) the belief that AOD patients with AOD problems will have serious behavioral problems that cannot be handled treatment, (3) the belief that AOD patients will have serious problems with denial that cannot be hanlded in treatment;  (4) the belief that AOD patients will have serious problems with relapse during treatment. 15 Ref.

76.        Rollnick-S. Value of a cognitive-behavioural approach to the treatment of problem drinkers. In: N. Heather, I. Robertson, and P. Davies, Eds., Misuse of Alcohol: Crucial Issues in Dependence Treatment & Prevention, New York, NY: New York University Press, 1985. 284 p. (pp. 135-147). (087987)

The traditional treatment process is analyzed and it is argued that the problems of lack of motivation, denial, and resistance are not resolved by focusing treatment mainly around enhancing willpower among problem drinkers. In suggesting the use of a more dynamic model of motivation, it will be seen that there are a number of constructive strategies that can be used both to engage clients in the treatment process and to promote behavior change. Among these are the problem-solving strategies derived from social learning theory that are described in this chapter. It is suggested that the prevailing pessimism about the effectiveness of alcoholism treatment is not unlike a state of learned helplessness. This chapter argues that it should be possible to produce better outcomes by adopting an active cognitive-behavioral approach to treatment. To begin with, this would involve avoiding the use of a static model of motivation in which treatment centers around whether or not clients have sufficient willpower to stop drinking. A more dynamic model would entail dealing with two motivational problems in treatment: in the early stages of treatment, ambivalence about the abstinence goal should not be overlooked by clinicians or used to question a client's motivation or attitude to treatment. Instead, this should be regarded as normal and acceptable and some time should be spent examining the pros and cons of abstinence in a nonjudgmental atmosphere. This is likely to be a more successful method of engaging clients in the treatment process. In a later stage of treatment, attention could then be turned to the other major problems, that of actually achieving the abstinence goal. Although many of the cognitive-behavioral strategies derived from social learning theory remain to be properly evaluated, they offer the promise of producing greater behavior change than verbally based treatment methods. Until these possibilities have been fully explored it would be premature to conclude that treatment does not work. 34 Ref.

77.        Rothschild, D. Working with addicts in private practice: Overcoming initial resistance. In: A.M. Washton, Ed., Psychotherapy and Substance Abuse: A Practitioner's Handbook, New York, NY: Guilford Press, 1995. 500 p (pp. 192-203) (129013)

In this chapter, the author defines and discusses areas of resistance and techniques for working with resistances to treatment shown by drug-addicted patients. This is done to show why traditional approaches, which include rationalization for confrontation, prescription, and even argumentative opposition on the part of the therapist, cannot work. The discussion looks at: (1) Resistance versus denial; (2) Characteristics of addicts; (3) Beginning treatment; and (4) Specific situations. 10 Ref.

78.        Rugel, R.P.; Barry, D. Overcoming denial through the group: A test of acceptance theory. Small Group Research, 21(1):45-58, 1990. (108985)

Denial of drinking problems and decreases in psychopathology as a result of group counseling were studied, with a focus on acceptance theory. The study group included 28 males, ranging in age from 25 to 48 years, from four separate treatment groups, all of whom had been convicted of driving while intoxicated (DWI) and had been referred to an alcohol safety action program (ASAP). The subjects received 4 weeks of alcohol education followed by 12 weeks of group counseling in which they discussed their drinking histories. The study results revealed an increased admission or decreased denial of drinking problems following treatment, along with a general decrease in psychopathology. Use of a modified version of the Yalom curative factors scale revealed a positive relationship between hope and self-acceptance and a negative relationship between catharsis and self-acceptance. 17 Ref. 17 Ref.

79.        Runge, E.G. Intervention: Raising the bottom. Journal of the South Carolina Medical Association, 86(1):19-21, 1990. (107394)

The traditional view that an alcohol-or drug-dependent patient cannot be helped without first having to "hit the bottom" is critically examined. This view, which assumes that persons sick in mind and body are as competent to make a decision to seek treatment as they would be if they were well, is potentially as harmful to a chemically dependent patient as it would be to any patient with a chronic, progressive, and life-threatening disease. Current knowledge indicates that addiction responds to treatment at any point in its development, and that patients who are treated early have a better chance of responding favorably. Intervention can be most effective in a highly structured confrontation made by family members and other caring individuals. Before the intervention, family members must receive training about chemical dependence, the dynamics of denial, the intervention process, and their own resistances and defense mechanisms. At the confrontation, which must occur without warning to the patient, family members present, objectively and in a manner that does not arouse defensiveness, the incidents in which the patient's illness caused them suffering. It is very important that family members explicitly state the consequences if the patient refuses help and that they are prepared to follow through on those consequences. Intervention should not be made without help from a trained individual, however. It is tempting to physicians to avoid confrontation, but at least they should avoid making matters worse by diagnosing only secondary damage and failing to address the primary illness of chemical dependence. 2 Ref

80.        Saunders, B.; Wilkinson, C.; Towers, T. Motivation and addictive behaviors: Theoretical perspectives. In: F. Rotgers, D.S. Keller, and J. Morgenstern, Treating Substance Abuse: Theory and Technique, New York, NY: Guilford Press, 1996. 328 p (pp. 241-265) (132595)

This chapter presents theoretical perspectives on motivational approaches to the treatment of addictive behaviors. Major topics addressed include the psychology of motivation (drives, learning, decision making, emotion); and motivation and the addictions field (the myth that clients who persist in drinking have "no motivation," therapeutic intervention and motivational direction, denial as cognitive conflict, contrasting counseling styles and perspectives, motivation and giving up addictive behaviors). 59 Ref.

81.        Shaffer, H.J. Denial, ambivalence, and the countertransferential hate. In: J.D. Levin and R.H. Weiss, R.H. (Eds.), Dynamics and Treatment of Alcoholism: Essential Papers, Northvale, NJ: Jason Aronson, Inc., 1994. 456 p (pp. 421-437) (127248)

This chapter considers the natural history of addictive disorders and the common mechanisms of change that characterize this process as a context for understanding the emergence of ambivalence and countertransference. A stage change model is offered as a template to describe the emergence of addiction and the three phases of recovery. Furthermore this discussion focuses on the psychological events associated with stage change and the transitions between them. Of particular interest to the author is the role that addiction ambivalence plays in energizing the denial that sustains the status quo. The dynamic interaction between (1) the emergence and maintenance of addictive ambivalence and denial, and (2) countertransference hate serves as the centerpiece of this chapter. 31 Ref.

82.        Segal-B. Causes of therapeutic failures in alcoholics. Alcoholism: Clinical and Experimental Research, 5(1):167, 1981. (063464)

It was concluded that well organized aftercare and social rehabilitation had the greatest impact on the success of treatment of alcoholics. Treatment outcome was studied among 1118 alcoholics (103 women). The period of abstinence varied between 10.4 and 15 months in 70 percent of the cases. Failures were related to resistance to treatment accompanied by denial and attempts to drink in moderation. Intensive psychological dependency and stressful situations were other factors. Those with characteristics of poor adaptation, immature ego, inability to express emotions adequately, tension, anxiety and anger were more conducive to early relapses. Treatment failure was slightly higher in patients of lower social and educational status but this was not statistically significant.

83.        Shore-J-J. Use of paradox in alcoholism treatment. 1980, 21 p. (045314)

According to the author, paradoxical orientation and specific paradoxical strategies are particularly effective in dealing with the alcoholic's denial of alcoholism and resistance to treatment and recovery. The paradoxical approach allows the therapist to maintain an empathic stance while putting the responsibility for change upon the alcoholic, thus reducing therapist burnout. Issues discussed include: ( 1) theory of paradox, (2) use of Alcoholics Anonymous and Al-Anon, (3) power dynamics of the therapeutic process, (4) specific strategies, and (5) ethics. Clinical examples are presented. 17 Ref.

84.        Smith, M.B.; Hoffmann, N.G.; Nederhoed, R. Development and reliability of the Recovery Attitude and Treatment Evaluator-Questionnaire I (RAATE-QI) International Journal of the Addictions, 30(2):147-160, 1995. (126759)

A reliability study was performed on a new 94-item true-false report instrument called the Recovery Attitude And Treatment Evaluator-Questionnaire I (RAATE-QI). The RAATE-QI consists of five dimensions which assess a patient's status in five clinically relevant areas for making admission assessment, treatment placement/matching and planning decisions, and discharge/follow-up outcome assessments. The five dimensions measure: resistance to treatment (treatment motivation and denial), resistance to continuing care (long-term denial), biomedical acuity, psychiatric/psychological acuity, and social/family environmental support status. Data on 143 inpatients who completed the RAATE-QI from a public sector chemical dependency/dual diagnosis treatment unit demonstrated test-retest reliabilities in the range from .73 to .87, and internal consistency reliabilities in the range from .63 to .78 across the five dimensions. These preliminary data suggest that the RAATE-QI may be a clinically reliable assessment/placement tool. 12 Ref. Copyright 1995 - Author abstract provided with permission from Marcel Dekker, Inc., 270 Madison Ave., New York, NY 10016.

85.        Smith, M.B.; Hoffman, N.G.; Nederhoed, R. Development and reliability of RAATE-CE. Journal of Substance Abuse, 4(4):355-363, 1992. (118181)

The Recovery Attitude And Treatment Evaluator-Clinical Evaluation ( RAATE-CE) utilizes a brief, structured clinical interview that assesses five key dimensions that produce a clinically relevant and useful severity profile of the patient for making placement, continued stay, discharge, and treatment-planning decisions. The RAATE-CE also measures treatment progress. These five dimensions are: (A) degree of resistance to treatment (including denial of addiction problems); (B) degree of resistance to continuing care (including self-help groups); (C) acuity of biomedical problems; (D) acuity of psychiatric-psychological problems; and (E) the degree to which the psychosocial environment is supportive or detrimental to recovery. Data on 139 publicly funded, high-severity subjects suggest that the RAATE-CE demonstrates an interrater reliability across the five dimensions between 0.59 and 0. 77, and an internal consistency reliability range between 0.65 and 0. 87. 6 Ref Copyright 1993 - Ablex Publishing Corporation

86.        Sjoberg, L. Risk perception of alcohol consumption. Alcoholism: Clinical and Experimental Research, 22(7 suppl.):277S-284S, 1998. (145635)

A review is given of general principles of risk perception, with some historical highlights of the field. It is pointed out that the risk target is of great importance (i.e., that personal risks are almost always perceived as smaller than risks to others). The implications of perceived personal and general risks are different, with general risks being more important for policy attitudes. The concepts need to investigate risk perception are different, depending on what kind of risk is studied. Alcohol consumption risks give rise to uniquely strong risk denial, closely tied to control notions. Consumption of alcohol is found to be related to personal alcohol risk in a positive manner; the larger the consumption, the larger is the perceived risk. However, no such relationship is found for general risk. At the societal level, alcohol was the most common explanation that people gave for the prevalence of violence. 94 Ref. Copyright 1998 - The Research Society on Alcoholism

87.        Trice-H-M; Sonnenstuhl-W-J. Constructive confrontation and other referral processes. In: M. Galanter, Ed., Recent Developments in Alcoholism, New York, NY: Plenum Press, 1988. 411 p. (pp. 159-170). (100821)

The use of constructive confrontation by supervisors, peers, unions, and occupational groups as a strategy to identify alcoholic employees and motivate them to change their behavior is described. The term " self-referral" is also examined. Historically, constructive confrontation has been used as a management strategy, but occupational and professional association and labor unions can also use the strategy, either alone or with management. The method has been frequently evaluated and consistently found to be quite successful when used as intended. The combination of constructive confrontation and receiving treatment outside the company, however, generates larger improvements in performance than either alone. It is noted that self- referrals have experienced varying degrees of constructive confrontation from family, friends, co-workers, supervisors, and medical personnel. Job performance continues to act as a powerful lever, breaking through the psychodynamics of denial and motivating problem drinkers and alcoholics to change their behavior. 65 Ref.

88.        Twerski Abraham. Alcologia: A "Logical" Paralogia. American Journal Of Psychoanalysis, 34:257-261, 1974. (020825)

The coined-term, "alcologia," is used to describe the pathological thought processes of the alcoholic person. Alcologia consists of 3 prime ingredients: denial, rationalization, and projection. Denial is called the keystone of the pathological defense system in alcoholism, while rationalization and projection buttress and defend denial. The function of denial is reviewed and a dynamic psychiatric approach to confronting this problem is outlined. The dangers of prescribing tranquilizers are stressed.

89.        Vabret, F.; Cognard, C.; Davy, A. L'arret de l'alcool: difficile separation (Stopping alcohol: A difficult separation) Alcoologie, 20(4):329-333, 1998. (146746)

Interviews of former drinkers were conducted to examine the difficulty such individuals have when they attempt to stop drinking alcoholic beverages. The methods used in separation from alcohol were analyzed, in order to evaluate the steps that are involved in stopping drinking. Cessation of alcohol consumption was compared with bereavement of the alcohol products. The authors propose an approach to separation from alcohol based on observations of hospitalized patients. The authors consider certain steps in this rational method particularly important. These steps are denial, relief, emptiness, destruction, and reconstruction. Therapies based on these elements can be organized to assist alcoholic patients who are negotiating the steps that lead from pathological abuse of alcohol to abstinence. 11 Ref. Copyright 1998 - Societe Francaise d' Alcoologie

Wallace-J. Critical issues in alcoholism therapy. In: Sheldon Zimberg, John Wallace, and Sheila Blume (Eds.), Practical Approaches to Alcoholism Psychotherapy. Second Edition, New York, NY: Plenum Press, 1985. 406 p. (pp. 37-49). (079089)

Alcoholism psychotherapy is shown to consist of a number of strategic choices in the presence of multiple hazardous alternatives. The alternatives include: denial versus premature self-disclosure; guilt versus sociopathy; self-blame versus blaming others; rebellion versus compliance; acting out versus repression; obsession with the past versus refusal to consider it; indiscriminate dependency versus stubborn independence; compulsive socializing versus alienation; perfectionism versus inferiority; self-obsession versus obsession with others; and pessimist versus pollyanna. An attempt is made to indicate the most reasonable compromise between each alternative. 1 Ref.

90.        Ward, L.C.; Rothaus, P. Measurement of denial and rationalization in male alcoholics. Journal of Clinical Psychology, 47(3):465-468, 1991. (111325)

Two hundred male alcoholics were given 94 true-false items constructed to characterize alcoholic defensiveness, and a factor analysis revealed two strong factors. The first factor (Denial) was correlated with items that asserted an ability to control one's drinking, denied being an alcoholic or needing treatment, or minimized the consequences of alcohol abuse. Items that loaded the other factor (Rationalization) gave reasons, justifications, and excuses for drinking. Two derived scales were examined in a replication sample of 66 male alcoholics, and alpha coefficients (.84 and .85) from the first sample did not show undue shrinkage in the second (.86 and .77) 3 Ref. Copyright 1991 - Clinical Psychology Publishing Company, Inc.

91.        Watten, R.G. Coping styles in abstainers from alcohol. Psychopathology, 29(6):340-346, 1996. (136582)

The aim of this research was to study the distribution of basic coping styles among abstainers from alcohol (N=55) and age-matched moderate drinkers (N=176). Factors compared included basic coping styles, mental absorption, sensation seeking, and affect inhibition. The abstainers scored significantly higher than the moderate drinkers on one of the repressive coping styles (respectful) and significantly lower on sociability. The two groups did not differ on the other basic coping styles. No significant differences were found between abstainers and drinkers in mental absorption. These findings suggest that abstainers may have adopted an affect-inhibiting, passive-ambivalent coping style associated with denial of hostility, rigid impulse control, and social conformity. 27 Ref.

92.        Weinberg Jon R. Why Do Alcoholics Deny Their Problem?. Minnesota Medicine, 56(8):709-711, 1973. (009833)

The author clarifies the factors which produce and maintain the denial system of alcoholic persons. The moral stigma provides the cultural stimulus for denial. A tendency for family and friends to overlook the alcoholic person's drinking problem in its early stages is the social environment for denial. Finally the alcoholic person's inability to cope with internal conflicts leads to a denial of reality. Until changes occur in the cultural, social, and intrapsychic environments of the alcoholic person the pattern of denial will persist. 2 ref.


93.        Weinstein, B.A.; Raber, M.J.; Slaght, E.F. Reexamining the clinical response to denial in alcoholics. Employee Assistance Quarterly, 14(4):45-52, 1999. (150664)

This article presents a number of obstacles that tend to make denial a major obstacle in the successful treatment of alcoholism.  These are:  (1) the current unidimensional approach to conceptualizing denial;  (2) the failure to take into account all potential causes for the denial during the assessment and screening process;  (3) The lack of comprehensive intervention strategies that incorporate all components of denial.  (4) the lack of coordinated interdisciplinary approaches for managing denial.  A new theoretical model of denial is discussed that could be used to overcome these obstacles. 27 Ref. Copyright 1999 - The Haworth Press, Inc.

94.        Williams, S.A. Therapeutic factors affecting denial change in substance abuse treatment groups. Dissertation Abstracts International, 57(4):2892-B, 1996. (135500)

The present study investigated the relationships between addiction treatment group and change in denial. The sample consisted of 50 substance abusers in a private inpatient treatment facility. Although group acceptance, ability to self disclose in the group, self acceptance as a result of group membership, identification with group members, therapist empathy, and therapist unconditional positive regard were related to each other in the predicted direction, none predicted denial change. Confrontation and identification as a repressor showed the least denial change. Treatment implications are considered.  Copyright 1996 - University Microfilms, Inc. This abstract was published with the permission of University Microfilms International (UMI) and may not be reprinted without their consent. For permission, contact UMI, 300 North Zeeb Road, Ann Arbor, MI 48106. Copies of this abstract are also available from the above address. Refer to order # DA9625604.

95.        Wing, D.M. Transcending alcoholic denial. Image: Journal of Nursing Scholarship, 27(2):121-126, 1995. (144468)

The internal processes experienced by alcoholics as they transcend alcoholic denial are described. The constant comparison methods and grounded theory, a systematic method of collecting, recording, organizing, and analyzing data collected through qualitative means, guided the collection and analysis of the data used in this report. The author lived in an alcoholism inpatient treatment facility for 28 days for the purpose of learning about the recovery process. Denial was identified as one of four stages of recovery. Discharged patients were then followed for three years. The research sample included 30 male and female participants in an inpatient treatment program, who agreed to follow-up interviews. Over the three-year follow-up period, patients in the group were interviewed from 1 to 14 times. The findings revealed that the process of transcending denial has five stages: (1) reacting to a critical event; (2) role disaffiliation; (3) ambiguous anticipation; (d) peer affiliation; and (3) acceptance. Relapsing patients either stayed in denial or started the process over. Nurses can have an impact on patient response to treatment, specifically in helping patients overcome the third stage, ambiguous anticipation. The results of the study provide a theory of the transcendence of alcohol denial. Through an understanding of the stages of denial, health professionals can help the patient during the recovery process. 25 Ref.

96.        Wing, D.M.; Hammer-Higgins, P. Determinants of denial: A study of alcoholics. Journal of Psychosocial Nursing and Mental Health Services, 31(2):13-17, 1993. (136784)

It is generally taken for granted that at some time or another, alcoholics will experience denial of their addiction. Among nurses and other health professionals, the effective confrontation of denial is considered to be the first and most crucial step of treatment. In a study of problems in the treatment of alcoholics, nurses frequently cited denial as a factor that made providing care difficult. The purpose of this article is three-fold. First, the authors discuss selected literature on denial in alcoholism to conceptualize denial from the standpoint of its role in recovery. Second, the authors present findings of their study that corroborated the determinants of denial with previous research findings. Finally, the authors discuss implications of research results for the treatment of alcoholic patients in denial.

97.        Wiseman, E.J.; Souder, E.; O'Sullivan, P. Relation of denial of alcohol problems to neurocognitive impairment and depression. Psychiatric Services, 47(3):306-308, 1996. (132111)

Forty-six participants in an alcohol rehabilitation program were assessed to determine whether neuropsychological impairment was associated with a higher level of denial of alcohol-related problems and whether depressive symptoms were associated with a lower level of denial. Denial was measured based on the discrepancy between patients' rating of their alcohol-related problems on a visual analogue scale and a psychiatrist's rating. The neuropsychological function of the 15 patients in the group who denied alcohol problems was similar to that of the other patients. A modest inverse correlation was found between the level of depressive symptomatology and the level of denial. 7 Ref.


98.        Zimberg-S. Individual therapy. Clinical Management of Alcoholism, New York, NY: Brunner/Mazel, 1982. 251 p. (pp. 70-80). (067156)

The stages of alcoholism therapy and the termination of treatment are discussed. The defense structure of the alcoholic is outlined, including denial, projection, conflict minimization, rationalization, nonanalytical modes of thinking, passivity, and obsessional focusing. Critical issues in alcoholism therapy and techniques of individual therapy are described.

99.        Wallace J. Critical Issues In Alcoholism Therapy. IN: Practical Approaches To Alcoholism Psychotherapy, New York: Plenum, 1978, VOL.XIX. 288 P. (PP.31-43). (039526)

It is suggested that alcoholism psychotherapy consists of a number of strategic choices in the presence of multiple hazardous alternatives; the most difficult task is to lessen denial and to encourage increased self-awareness and disclosure while simultaneously keeping anxiety at minimal levels. Techniques are discussed for dealing with patients' dilemmas of guilt vs sociopathy, self-blame vs blaming of others, rebellion vs compliance, acting out vs repression, obsession with the past vs refusal to consider it, indiscriminate dependency vs stubborn independence, compulsive socializing vs alienation, perfectionism vs inferiority, self-obsession vs obsession with others and pessimism vs a pollyanna (excessive optimism) attitude.

100.     Wallace J. Working With The Preferred Defense Structure Of The Recovering Alcoholic. IN: Practical Approaches To Alcoholism Psychotherapy, New York: Plenum, 1978, VOL.XIX. 288 P. (PP.19-29). (039525)

It is proposed that alcoholics have a ''preferred defense structure'' ( pds) and that this structure can be utilized in achieving and maintaining sobriety. The pds is an outcome rather than antecedent of alcoholism, and its components include denial, projection, all-or-none thinking, conflict minimization and avoidance, rationalization, self- centered selective attention, preference for nonanalytical modes of thinking and perception, passivity and obsessional focusing. Recovery programs successful in producing abstinence recognize that the alcoholic's pds is to be protected and capitalized upon rather than confronted and radically altered. These defenses must be gradually removed, and psychotherapists must recognize that recovery from active alcoholism is a long-term process and requires different therapeutic behaviors at the various stages.


101.     Zimberg-S. Principles of alcoholism psychotherapy. In: Sheldon Zimberg, John Wallace, and Sheila Blume (Eds.), Practical Approaches to Alcoholism Psychotherapy. Second Edition, New York, NY: Plenum Press, 1985. 406 p. (pp. 3-22). (079087)

A psychiatrist's understanding of the sociopsychological factors relating to alcoholism and the approaches for successful psychotherapy of the condition in a significant number of alcoholics is presented. The underlying psychodynamics of alcoholism consist of conflict with excessive dependent needs leading to the defenses of denial and reactive grandiosity. Alcoholism can be treated psychotherapeutically in individual or group therapy based on two principles: (1) efforts must first be directed at producing abstinence; and (2) there must be an understanding of the transference and countertransference aspects of the treatment process by the therapist. Principles of psychotherapy with alcoholics are outlined as are the three stages of treament. 28 Ref.

102.     Zimberg-S. Office psychotherapy of alcoholism. In: J. Solomon, Ed., Alcoholism and Clinical Psychiatry, New York, NY: Plenum Medical Book, 1982. 238 p. (pp. 213-229). (070241)

Basic principles of office psychotherapy of alcoholism are discussed, based on a literature review and an outcome study of 23 alcoholic patients. Alcoholism can be treated in individual or group psychotherapy. The underlying psychodynamics of alcoholism consist of conflict with excessive dependency needs leading to the defenses of denial and reactive grandiosity. The use of alcohol serves to reinforce these defenses. A current approach to alcoholism psychotherapy involves eliminating the use of alcohol by directive approaches and helping the alcoholic to learn to live without alcohol in the face of stress and unpleasant feelings. During the initial evaluation of the alcoholic, it is important to evaluate the patient's social circumstances as well as areas of psychological conflict and psychopathology. To assure successful psychotherapeutic treatment of the alcoholic, abstinence from alcohol must be achieved, and the therapist must understand the transference and counter transference aspects of the treatment process. Psychotherapy with alcoholics has been observed to progress through three fairly distinct stages, reflecting the patient's change in status from "I can't drink" (need for external control) to "I won't drink" ( internalized control) to "I don't have to drink" (conflict resolution). Results of a 2 year outcome study of 23 alcoholic patients treated in individual psychotherapy in an office setting indicate a 61 percent success rate in the total group and a 78 percent success rate among patients who remained in treatment beyond six sessions. Thus, alcoholism was found to be eminently treatable in a psychiatric office setting, contrary to the common experience of most psychiatrists. Patients with long drinking histories who do not respond to this psychotherapeutic approach may have organic brain damage. 19 Ref.

103.     Zweben-J-E. Recovery-oriented psychotherapy: Patient resistances and therapist dilemmas. Journal of Substance Abuse Treatment, 6(2):123-132, 1989. (103469)

This paper examines patient resistances, especially in early recovery and explores some therapist's dilemmas and hazards arising from personal issues and gaps in professional training. To some extent, these vary according to the route by which the practitioner became involved in treating addiction. The vulnerabilities of the conventionally trained mental health therapist are contrasted with difficulties often seen among those whose training and primary experience base is in substance abuse treatment. Emphasis is given to the patient in denial and in early recovery and to the frustrations and power struggles common at those stages. The paper briefly addresses problems manifested by insulated treatment systems and other obstacles to open inquiry and dialogue among professionals. 31 Ref. Copyright 1989 - Pergamon Press plc.

104.     Zimberg-S. Principles Of Alcoholism Psychotherapy. IN: Practical Approaches To Alcoholism Psychotherapy, New York: Plenum, 1978, VOL.XIX. 288 P. (PP.3-18). (039524)

A conceptual schema applying psychotherapeutic principles to alcoholism treatment is presented, which uses notions of childhood rejection, oral fixation, dependency needs, anxiety, denial and '' reactive grandiosity.''  Six principles of psychotherapy with alcoholics are discussed: direct intervention to stop drinking; transference (intense ambivalence, testing, denial and gradiosity); countertransference ( intense feelings of frustration and anger; therapist's need for omnipotence); support for and redirection of the alcoholics' defense mechanisms rather than their direct removal; therapeutic leverage; and therapy in stages to achieve control over impulse to drink. Serious depressions and psychoses should be dealt with first, but achieving and maintaining abstinence are essential.

105.     Zung B.J. Factor Structure Of The Michigan Alcoholism Screening Test. J. STUD. ALC., 39: 56-67, 1978. (033569)

The Michigan Alcoholism Screening Test (MAST) was administered to 1000 motorists (mean age 42; 67 women) arrested for driving while intoxicated (dwi). The mast item scores of the entire sample and of subgroups of alcoholics (mast scores of 5 or above) and nonalcoholics were factor analyzed. A principal-components analysis of the entire sample yielded 4 independent dimensions of alcoholic symptomatology which accounted for a maximal proportion of the individual differences on the mast: help-seeking, discord, alienation and denial. Six independent factors were found for the alcoholic subgroup (54 percent of the entire sample): denial, debilitation, marital discord, work problems, help-seeking and social discord. No consistent patterns were found in the nonalcoholic subgroup. The multidimensionality of the mast in the sample as a whole and in the alcoholic subgroup indicates the wide variety of drinking problems in the DWI population which must be taken into account in diagnosis and treatment.

<Return To Top Of Page>  <Return To DMC Description Page>


Home - What's New - Site Map - Search Gorski's Site - Articles - Book Reviews

Mission & Vision - Training & Consultation Services - Publications - Links

Daily News Review  -  Addiction Databases  - Leading Addiction Websites

GORSKI-CENAPS Clinical Model --- Research-Based Best Practice Principles

Special Focus:  Mental Health, Substance Abuse, & Terrorism

Terry Gorski and Other Members of the GORSKI-CENAPS Team are Available To Train & Consult On Areas Related To Recovery, Relapse Prevention, & Relapse Early Intervention

Address: 6147 Deltona Blvd, Spring Hill, FL  34606;,,