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