What Is Denial

Denial when defined in a behavioral health context has become widely used among lay persons in every day discussion. Someone who seems to be willfully ignoring an obvious problem is referenced, usually behind their back, as “he’s in denial”. As is many times the case, the more a topic is in public parlance the less well understood it becomes.

A 2020 study of individuals with alcohol use disorder (UAD) found that two in three of the participants who clearly met the criteria for AUD in the Diagnostics and Statistical Manual V5 reported that they did not have an alcohol problem. The study concludes that these individuals are deliberately and consciously lying to avoid negative views from others or consequences of the behaviors. This would meet the classic view that the person with an alcohol or other drug abuse and addiction is fully aware but denying this fact to others.

The authors also conclude that denial may result from cognitive difficulties in correctly appraising the dangers of the substance use. This perspective of denial may reflect a less than conscious defense mechanism where persons facing substance-related psychological stressors subconsciously “defend” themselves by denying that the substance problem or adverse event occurred. In addition to lying to others they, essentially, lie to themselves.

In a 2024 paper Steven Rose, Ph.D. describes forms of denial and their basis.

·       Minimization is a process of psychologically diminishing the severity of an issue attempting to convince others or oneself that the situation is less difficult than it is

·       Optimization consists of an unrealistic belief that things will be OK in an attempt to justify to oneself continuing the behavior

·       Normalizing is a form of optimism bias, diminishing a sense of personal responsibility by concluding that their behavior is common

·       Avoidance is a matter of purposefully not focusing on distressful thoughts or emotions rather than effectively dealing with them. On the one hand addictive substances serve as a way to avoid other difficulties in the short-term. This may become an issue in itself without other purposes where further drug use is used to avoid the negative effects from drug use in the first instance. This is often a form of self-medicating

·       Control fallacies are a form of cognitive distortion where the individual either hopes or actually believes that they can control the drug or alcohol despite repeated failures to do so.

·       Another form of cognitive distortion is where one justifies or believes that they live under a dark cloud where bad things happen to them because of their nature where other people live without these bad outcomes. It is fate, not their alcohol and drug use

·       Externalization is a form of avoiding responsibility by blaming others. It is other people impinging on self in negative ways that cause the alcohol or drug use.

In a 2025 article Good Landing, a substance use treatment organization, notes that denial is not just an unwillingness to accept reality but often a subconscious coping mechanism that shields individuals from emotional distress. Factors that contribute to denial might include:

• Fear of the change that admitting to addiction means facing withdrawal and lifestyle changes

• Shame and stigma associated with being discovered to have a substance use disorder

• Actual brain change where long-term substance abuse makes it harder to recognize the consequences of addiction

• Selective focus on those who tolerate if not encourage use instead of those who are pointing out the difficult results from one’s substance abuse

 It is often difficult for the person with the disease and for their loved ones to consider whether or not they have developed a mental health disorder. The continuing stigma surrounding mental health drives people to avoid those labels. It is easier then to consider addiction as a habit that is reinforced by the body and denial as a natural but mild occurrence resulting from withdrawal and lifestyle changes.  

 A study from 2019 summarizes the mental health issue from the standpoint of evolutionary biology. They conclude that over time addiction creates a pathological limitation to rational exercise of personal, free will and capacity to recognize and adapt healthy choices. The choices available become increasingly limited to a narrow set of behaviors dedicated to acquiring and using. As addiction progresses the decision-making that is needed to perform adaptive change is progressively limited.  Addiction becomes a trap in which healthy, productive, socially responsible behavior is constrained in favor of a focus on the drug often at the expense of everything else in the person’s life. Yes, changes to mental capacity, even brain structure occur in alcohol and other drug abuse and addiction that lead to and increasingly limit the range of options available to the person with substance use disorder.

 In twelve step programs the Second Step encourages that successful members “Came to believe that a power greater than ourselves could restored us to sanity”. Many recoil at the suggestion that at some point they were “insane”. Likely they suffer the stigma that says that physical diseases such as cancer are legitimate occurrences in life but behavioral health diseases such as depression and substance use disorder are moral failings. Given this description of denial, and years of repeated, destructive alcohol and drug use, the individual in recovery eventually has little choice but to accept the implication of the Second Step.

 Although it is not our purpose in this article to recommend action, it seems unfair to not offer suggestions to those who are thinking about this issue anew and have someone close to them suffering this condition. A 2024 article on Marriage.com discusses ways in which a loved one may react to someone with denial about a substance use issue.

 ·       Educate yourself about denial. It’s unfair to get angry at a depressed person in denial without understanding their situation

·       Given this additional information try to consider the situation from what is going on with the afflicted person. Easier said than done given the pain the codependent experiences

·       Develop compassion further. Your loved one is not acting out of malice but afflictions

·       It is essential to be an active listener to know how to deal with someone in denial 

·       Express that compassion and support

·       Avoid using I as it expresses your situation as opposed to theirs

·       Develop acceptance. This situation is likely beyond your control and your attempts at help may go rebuffed early and maybe always

·       Validate your loved one’s experience and feelings

·       Be prepared to act if the moment presents. Don’t wait until the moment arrives as it may pass as quickly

·       Set boundaries. Often this behavior has little to do with you. Hopefully change will come but until then it is in your interest and theirs to set boundaries. Set them and stick with them

·       Recommend treatment. You are not a mental health professional and are too close to the situation if you are. There is treatment. Educate yourself about that and be prepared to recommend that treatment

·       Consider what you will do if they refuse your help. Sadly, this is a very real possibility. Your wellbeing and especially the wellbeing of children who may be involved may become the paramount issue.

As denial enters everyday lexicon we tend to consider its meaning superficially. Your understanding of what is happening in denial as experienced by you or a loved one may not be very well informed. Our attempt here has been to provide a better understanding.

There are many sources you may research that will debate whether or not denial is or becomes a mental health issue. In our view this is a reaction to stigma that, sadly, still surrounds mental health issues including substance use disorder. It is not a worthy debate. It seems clear that continuing substance use and addiction creates increasingly limited options and capacities to engage those behaviors that might overcome the substance use disorder. Whether or not one considers that a mental health issue, which we do not engage here nor are we qualified, the fact is that the results can be deadly.

Gene Gilchrist

August 2025