Modifying the Medication
New Therapist: What are some of the essential elements of good inpatient addiction treatment?
Edward J Khantzian: I have recently put “kindness” at the top of the list in several articles. This might seem so self-evident as to be superfluous, but in practice too often it is not readily honored. In addition I include elements of comfort, empathy, avoidance of confrontation, patience, and instruction.
Kindness is important because addicted individuals suffer with a sense of unworthiness that predisposes to and results from addiction. It is not apt to be present when unwittingly we operate with modes of impassivity or more strictly interpretive modes of interaction, traditions that linger and carry over from now passé styles of therapeutic detachment and neutrality.
Furthermore, given the problems of disbelief and distrust that problems of addictions can evoke in us, attitudes of kindness are often hard to adopt and maintain.
Given the problems of disordered emotions, discomfort, low self esteem and troubled relationships so often associated with addictive disorders, approaches that incorporate attitudes of comfort and empathy become crucial. addictive behavior can cause therapists to feel crazy and angry and thus evoke confrontations that can be injurious, but they must be done with restraint, when necessary, and done in a way that preserves self-esteem. Patience and instruction remain important therapeutic ingredients, since addicted individuals so often are confused, out-of-touch, and not knowing about their emotions. All these elements are important in assuring a strong therapeutic relationship and alliance.
NT: How can therapists be assisted in understanding, addressing and modifying addicts’ vulnerabilities that contribute to their using drugs?
EJK: I have advocated that clinicians need to adopt and flexibly maintain a focus to deal with the complexities and challenges associated with addictions. A basic reminder is that what goes on in the contexts of individual and group treatments in most respects reflects what goes on outside of the treatment relationship for the individual and is a powerful telltales of what their addictive vulnerabilities are about. Modern relational therapies instruct therapists to monitor the subjective reactions and emotions that patients evoke as a means to guide them about their patients' suffering and distresses and what needs therapeutic focus. I have discovered that maintaining a focus on four areas of vulnerability in self-regulation is fruitful and principally involved in addictions, namely difficulties in regulating affect life, self-esteem, relationship, and self-care.
NT: Working with addicts provokes powerful and intense feelings. How can therapists in these situations be aware of caring for themselves?
EJK: In addition to Freud’s dictum for mental health—“to love and to work” (lieben und arbeiten), I would add “spielen” (to play). This applies to ourselves as clinicians as much as it applies to our patients. Letting go and finding enjoyment elsewhere beyond the work can be re-invigorating and revitalizing for ourselves. As the recovery traditions also instruct, a sense of humor helps. Employing periodic gut checks as to what we are feeling, self-scrutiny, and reflection also help. But when the going gets rough, as well it can in this work, not bearing and suffering our reactions alone, but sharing them with colleagues and friends can make a significant difference.
NT: About 40 years ago you began to conceptualize your view of addiction as an attempt by the user to self-medicate painful and uncomfortable inner states. What were some of the responses of your colleagues?
EJK: Because one of the predominant paradigms at the time of publishing my self-medication hypothesis (SMH) was a psychodynamic one, and my ideas were grounded in that tradition, it was met with considerable interest and acceptance. Beyond that, in lay articles and in non-psychiatric journals it was positively reviewed and endorsed. Five years after the publication of the SMH in the American Journal of Psychiatry (1985), the associate editor of The Journal of the American Medical Association, in an editorial article on nicotine dependence said, “The notion of ‘self-medication’ is one of the most intuitively appealing theories about drug abuse” (JAMA, Glass, 1990, p. 1583). As anticipated in your next question, many in the recovering traditions were skeptical, including physicians of that persuasion, and would respond saying, “keep it simple”. One highly regarded colleague and academic was inclined to say, “Alcohol causes depression, depression doesn’t cause alcoholism.” As an aside, I never said depression causes alcoholism; rather the SMH emphasizes that painful feelings and psychological suffering, which may or may not be associated with psychiatric conditions, pre-dispose to addiction.
NT: How do you think the idea of addiction as self-medication, sits alongside the view held by some, especially AA, that addiction is a disease?
EJK: It depends upon whom you ask. As many as there are who debunk it, I find many, including those who endorse a disease concept, who feel the SMH is complimentary with the disease concept of addiction. A nurse one day quipped, “Addiction is a disease of disordered emotions.” More often, I find that clinicians are most comfortable with the paradigm. That is, in the clinical context, therapists and counselors find that it is an alliance- building approach to inquire and pursue what an individual’s drug-of-choice does for them. This is in contrast to the prevailing tendency to judge and shame individuals for what the drugs do to them and loved ones, this in addition to the shame and guilt addicted individuals shower on themselves. Needless to say, some are sharply critical and dismissive of the SMH—including some neuroscientists, who consider it a “primary disease”. As two authors recently put it, the SMH is “dangerously false and misleading” (DuPont and Gold, 2007).
NT: Many theorists believe that, for treatment to be effective, it requires an awareness of the underlying psychological processes and mechanisms. Psychodynamic theory does this. What elements and techniques do you think non-psychodynamic theories, such as cognitive behavioural therapy, Dialectical Behavioural Therapy and Motivational Interviewing might share with psychodynamic therapy?
EJK: Both as pre-disposing and resultant factors, addictions are disorders of emotion, cognition, and attitude. Therapies that work do so because they address these factors. Some individuals are more in need of addressing the pain residing in confused or overwhelming emotions or troubled self-other relationships. For others, the problems are rooted in cognitive distortions or beliefs. For yet others the need to examine issues of impulsivity and faulty decision making are the order of the day; and finally, who would argue against treatments that target motivational factors and disavowal of problems. In my opinion and experience, effective clinicians draw upon and integrate elements of all these paradigms to address the factors that emerge and become apparent in the course of treatment. If we can consider the various paradigms as different channels needing variable attention and attunement, the challenge then becomes one of picking the channel that best suits a given patient or client at any given time. Effective therapists flexibly switch and adopt approaches best suited for patients’ needs and issues.
NT: Some theorists view addiction as the pursuit of pleasure. How compatible is this view with the belief that drug use is an attempt at self-medication?
EJK: Pleasure is not unimportant, but it is not lasting or sustaining. Nor in my opinion is it a prime motivating factor in addictions. In my experience and that of relational therapists, we are more contact and comfort seekers than we are pleasure seekers. Furthermore, in my estimation, there is an undue and misleading emphasis on pleasurable reward as a major motivating factor in drug/alcohol dependency. Some of this resides in a misunderstanding of what substance-dependent people experience and achieve with their substance use and dependency. I have concluded that addictively prone individuals suffer with distressing states of anhedonia and dysphoria and substances provide temporary relief from these painfully vague and confusing states. Little wonder that, when these distressful and elusive feelings are changed or relieved, it is experienced or erroneously interpreted as euphoria or a “high.” This is principally what is “rewarding” about addictive drugs.
NT: You identify difficulties in self-regulation of feelings, self-esteem, self-care and relationships as contributing to an individual’s pain and distress that leads them to self medicate with drugs. What leaves individuals more or less equipped to self-regulate emotions?
EJK: In life we need our emotions to guide us in being in touch with our inner psychological terrain and to negotiate our relationships with the human- and non-human environment. We need to love and care about ourselves and we need connection to caring others in order to take care of ourselves. Adequate protection, nurturing, bonding, and affirmation in the growing-up years determines whether we are equipped to be aware of and know our emotions, like ourselves and trust others enough to ensure we avoid danger and harm, especially behaviors and relationships associated with the dangers associated with addictions. Addictively prone individuals more often have been subjected to traumatic abuse and neglect such that these capacities for self-regulation have been severely compromised or lacking. They self-medicate the pain associated with their difficulties in regulating their emotions, self-esteem, and relationships. Their deficits in being unable to use their emotions as guides for their behaviors causes major dysfunctions and deficits in self-care and leaves them in harm’s way, especially those involved with substance use and dependency.
NT: Jeffrey Roth, an addictions psychiatrist and group psychotherapist, has referred to addiction as a disease of isolation. How does this view tie in with your understanding of addicts struggles to manage their interpersonal relationships?
EJK: I totally agree. One of my patients in group therapy described his dilemmas with relationships as being a “born-again isolationist”. Recovering individuals reveal their difficulties and ambivalence about their connections to others in their aphorisms such as “we don’t have relationships, we take hostages;” or “we are relief-seeking missiles.” Too often, patients and clinicians are misguided by an outdated and erroneous conception of maturity as the capacity to be “autonomous and independent” when, more correctly, an essential aspect of maturity resides in the capacity for interdependence. Life problems are not best solved alone and least of all are the problems of addiction solved alone. Rather, problems are best solved in a context of mutual concern and care.
NT: Attachment theory has gained prominence over the past two decades in addiction treatment. When individuals struggle to behave in a caring way towards self, indulging instead in dangerous and harmful drug usage, might this arise from an early attachment failure between themselves and their primary caregivers?
EJK: I believe that the SMH and attachment theory are mutually enriching paradigms. I was recently honored by the Bowlby Center to deliver the 20th John Bowlby Memorial Lecture. In their invitation to deliver the lecture, the conveners of the conference, including Sir Richard Bowlby, the son of John Bowlby, indicated that the SMH and my ideas of addiction as a self-regulation disorder clearly linked up with Dr. Bowlby’s ideas of the disrupting and damaging nature of trauma, neglect, and broken bonds in early stages of development. That is, they leave such individuals prone to life struggles with regulating emotions, self-esteem, relationships, and self-care, thus making addictively prone individuals more likely to self-medicate their suffering with addictive substances. What is significant here, with relatively little specific reference to attachment theory on my part over the years in my publications, and independent of my work, the originators and adherents of attachment theory affirmed that the concepts of self-medication and self-regulation disturbances associated with addictions were entirely consistent with the addiction as an an attachment disorder.
NT: Mentalization-based therapy has gained prominence in many areas of mental health. Do you think it might be a useful way to assist patients to begin to identify and think about their overwhelming thoughts and feelings?
EJK: The principles and practice of mentalizing therapies are preeminently applicable to and efficacious for the dilemmas with which addictively prone individuals suffer. Helping drug dependent persons to identify, put into words and express their thoughts, feelings, and behaviors is to help such individuals use these processes to deal therapeutically with the issues of disturbed self-regulation problems that otherwise have been short-circuited into self-harmful addictive behavior. Psychoanalytic concepts of alexithymia, hypo-symbolization and disaffected states were identified by Krystal, Wurmser, and McDougal respectively as important factors in the development of addictions in the last half of the 20th century. These investigators appreciated the importance of helping individuals to understand how these factors contributed to their addictive problems. Mentalizing provides tools and approaches that specifically attunes to and addresses the affective deficits with which addicted individuals suffer.
About the author
Edward J. Khantzian is Clinical Professor of Psychiatry, Harvard Medical School. He is President and Chairman of the Board of Directors of Physician Health Services, a subsidiary of the Massachusetts Medical Society.
Dr. Khantzian is one of the founders of the American Academy of Addiction Psychiatry, is a past- president of that organization, and recipient of its Founder Award for his “courage in changing the way we think of and understand addictions.” His studies, publications, and teaching have gained him recognition for his contributions on self-medication factors and self-care deficits in substance use disorders and the importance of modified techniques in group therapy for substance abusers.
Important:
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