Looking in the mirror and accepting what we see can be one of the hardest things we ever do. It's especially hard when the image staring us in the face is painful or doesn't fit with how we want to see ourselves. Sometimes, the truth is so painful that we avoid it at any cost.

Refusing to accept a painful reality that alters the perception of ourselves is a psychological defense called denial. As human beings, we may use denial to protect ourselves from knowledge, insight or awareness that threatens our self-esteem, mental or physical health, or security.

The term "denial" is often used in the chemical dependency field to describe people who deny substance abuse problems. "Denial is the tendency of alcoholics or addicts to either disavow or distort variables associated with their drinking or drug use in spite of evidence to the contrary," said Patricia Owen, PhD, a licensed psychologist and Director of the Butler Center for Research and Learning at Hazelden in Center City, Minn.

It's a common misconception that all alcoholics and addicts are in denial. In fact, people have various levels of awareness of their chemical use problems and readiness to change behavior. "People may recognize certain facts concerning their use, such as number of arrests or how often they drink," Owen said. "At the same time, they may woefully misperceive the impact their use has had on the people around them, their relationships, how they feel about themselves, or the implications of their drinking history."

Some common statements made by alcoholics who deny their disease include: "I could quit anytime I wanted to." "I'd quit using if people would quit ragging on me." "If you were in my situation, you'd drink, too." Typically, the more severe the addiction, the stronger the denial. This is often baffling and frustrating to family members and others who care about the addicted person.

"If a person doesn't recognize that his or her behavior is creating problems, then he or she wouldn't see the need to change or seek assistance," said Barbara McCrady, PhD, professor of psychololgy and clinical director of the Center for Alcohol Studies at Rutgers University in New Brunswick, NJ. "They are also likely to react negatively to people who believe they have a problem."

Also feeding denial is the stigma and shame associated with alcoholism. Unfortunately, much of society still perceives alcoholism as a moral failure.

There are many barriers to overcoming denial. In some cases, the alcoholics behavior may be similar to his or her peers -- it's hard for them to understand that anything is wrong. Other people don't think they can be successful in making changes in their lives, so they refuse to recognize there is a problem.

Chemically dependent people don't have a monopoly on denial. The defense is also employed by many people with chronic illnesses such as diabetes, heart disease, cancer and AIDS. People with these diseases may use denial to avoid accepting their mortality, giving up fantasies of control or invincibility, or dramatically changing lifestyles.

An article in the Dec. 14, 1994 issue of the "Journal of the American Medical Association" notes that "denial may constitute a barrier to the patient's sharing of essential information; it may also interfere with the patient's ability to hear and accept medical advice." Examples of denial include not reporting chest pain or other potentially life-threatening symptoms and denying the impact of chronic or disfiguring illnesses.

It is a myth that harshly confronting a person with the consequences of his or her behavior helps people break through denial. "In most cases, it builds up the defense even more," Owen said. "People fear coming into treatment because of the shame and stigma associated with alcoholism; they fear rejection and confrontation and facing up to their guilt and low self-esteem. A more effective way is to help people learn more about their disease and get support from others who also have the disease."

Family members can help by allowing the chemically dependent loved one to experience the consequences of his or her drinking or drug use. "If someone passes out in the yard -- unless it's a life-threatening situation -- they should be left there," McCrady said. "The person will begin to recognize that there are consequences for his or her actions. If family members give feedback, it should be when the person is sober or straight and it should be expressed in a caring rather than confrontational manner."

Alive and Free is a chemical health column created by Hazelden Foundation, a nonprofit agency that provides a wide range of services relating to alcohol and drug dependence. Address questions to Alive and Free Editor, P.O. Box 11, BC 10, Center City, MN 55012-0011 or email to Marty Duda.