Reflections on understanding and treating addictive disorders, Edward Khantzian
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Edward Khantzian
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Reflections on understanding and treating addictive disorders, Edward Khantzian
- 1. Edward J. Khantzian, MD Clinical Professor of Psychiatry, Harvard Medical School Cambridge Health Alliance 1
- 2. Perhaps it took a little time, but it seemed to happen instantly. He could feel his body relaxing, a stiffness going out of his shoulders as he sensed the warm glow seeping through him in all the distant forgotten corners of his being . . . It was a miracle. There was no other word. A miracle that was affecting him mentally, physically, and, as he would soon learn, spiritually. Bill W.’s first experience with alcohol as reported to his biographer, Robert Thomsen 2
- 3. A half century of study by clinical investigators The importance of understanding the human psychological underpinnings for addictive behavior If you don’t understand it you can’t fix it To understand and to be understood is a powerful remedy for the confusion, chaos, and suffering associated with addictions AA is a special place where such understanding develops Psychoanalytic influences on the beginnings of AA and the “Big Book” 3
- 4. First, what addiction is not: – Pleasure seeking – Human self-destructiveness – Oral dependency More than anything, addiction is about fundamental problems in self-regulation Individuals self-medicate the distress and pain associated with self-regulation problems 4
- 5. As humans we are governed less by instincts and more by coping skills and capacities acquired from the caretaking environment. Requirements for human survival and adaptation place a lifelong challenge on humans for self-regulation. Regulating emotions, self- esteem, relationships, and behavior, especially self care, are among the main functions upon which our survival depends 5
- 6. Involves (based on practice based evidence): An inability to recognize and regulate feelings An inability to establish and maintain a coherent, comfortable sense of self and self-esteem An inability to establish and maintain adequate, comforting, and comfortable relationships An inability to establish and maintain adequate control / regulation of behavior, especially self- care 6
- 7. Drugs enhance or contain feelings Drugs effect ones sense of self, wellbeing and self-esteem Drugs effect our ability or inability to care about or to connect to others Experimentation with and dependence on drugs are influenced by ones capacity for self- care 7
- 8. Feelings are experienced in the extreme: They are absent , vague, and confusing or they are overwhelming and unbearable Developmental deficits or regression – Affects have a normal (or abnormal) developmental line Krystal 1988 Affects are inaccessible, vague or confusing – The problem of alexithymia, disaffected, non-feeling responses Sifneos et al 1977 The problem of anhedonia – do addictive drugs produce pleasure or do they relieve displeasure? 8
- 9. Inner states of well-being and cohesion are elusive or lacking Feelings of inadequacy, impoverishment, insecure Kohut 1970, 1977 Feelings of helplessness and rage Dodes 1990 Narcissistic defenses of omnipotence Director 2005 Problems of dissociation Burton 2005 9
- 10. “If only they could be dependent” – “We don’t have relationships, we take hostages” anonymous – The challenge of interdependence Khantzian & Mack 1989 Creating the capacity for attachment Walant 1995 Addiction as an attachment disorder Flores 2005 10
- 11. The primary motivational drives in all mammals along lines suggested by Bowlby and Fairbairn are not pleasure seeking or self-destruction (as some old and modern theories would suggest EJK italics); rather our drives are object (i.e. relationship) seeking and comfort seeking. 11
- 12. Addictively prone individuals think and feel differently around danger and harm Anxiety, fear, or apprehension are absent or fail to guide such individuals in risky situations There is a failure to draw cause/consequence relationship in the face of risk Shame and guilt more often comes after the fact than before it – e.g. “I felt stupid and bad when I did that” [rather] “I will feel stupid and bad if I do that” 12
- 13. Consists of: An investment in caring about or valuing oneself – sufficient self-esteem to feel oneself to be worth protecting The capacity to anticipate dangerous situations and to respond to the cues which anxiety provides The ability to control impulses and renounce pleasures whose consequences are harmful Pleasure in mastering inevitable situations of risk, or in which dangers are appropriately measured 13
- 14. Knowledge about the outside world and oneself sufficient for survival in it The ability to be sufficiently self-assertive or aggressive enough to protect oneself Certain skills in relationship, especially the ability to choose others who, ideally, will enhance one’s protection, or at least will not jeopardize one’s existence Khantzian and Mack 1983, pp. 210-211 14
- 15. Khantzian EJ, Mack JEM (1994). How AA works and why it is important for clinicians to understand. J. Substance Abuse Treatment; 11:77-92 Khantzian, EJ (1995). Alcoholics Anonymous – Cult or corrective: A case study. J. Substance Abuse Treatment; 12:157-165 15
- 16. Because addicted individuals are overwhelmed or confused by their feelings, because their self-esteem is shaky, because relationships are elusive or absent, and because their self-care is undeveloped or inadequate, practitioners should be guided by the following essential elements for their work with patients: This slide and the following one are intended to guide staff, counselors, and facilitators in working with patients in rehab 16
- 17. Kindness (just in case this sounds obvious or preachy …) Comfort Empathy Avoid confrontation (unless the devil makes you – but …) Patience (remember the problems with alexithymia, action, avoidance) Instruction (e.g., help individuals to learn about emotions and self-care) Self-awareness (therapist/patient) Climate of mutual respect (the therapeutic alliance) Balance – talking/listening 17
- 18. ■ AA offers human contact, understanding, and self-expression for individuals who are or have become unaccustomed to availing themselves of these basic human experiences and needs ■ Storytelling is the main vehicle ■ Telling and listening to stories help people to learn and appreciate they are not alone in their suffering and that there is hope ■ It helps people who have been out of touch with or unaware of feelings to attend to and take charge of them 18
- 19. ■ “Alcoholism is a disease of disordered emotions” ■ An AA attendee said, “You switch from pills and booze to people and feelings … it makes you feel better … lot of laughter … the common bond is suffering (Robertson 1989)” ■ Not uncommon to hear, “We didn’t do feelings growing up” ■ Members begin to appreciate how they substituted action or drugs instead of feeling their feelings 19
- 20. AA as a group experience counters the predisposing and resulting self-absorption and interpersonal isolation associated with alcoholism The group dynamics of AA compels the appreciation that one is not alone with their problems 12-step programs are a natural vehicle to address the shattered self-esteem and relational issues that predispose to and result from the ravages of a life immersed in alcohol 20
- 21. The storytelling traditions and the sharing of experiences stimulates self-reflections, especially forcing the realization that one must live life on life’s term rather than one’s own terms Group psychology, including the group dynamics of AA, counters feelings of shame and guilt and thus fosters meaningful and comforting connection to others In doing so, the defenses of counter-dependency and self-sufficiency are gently challenged and gradually replaced with genuine care for and about others 21
- 22. The 12-step traditions implicitly appreciate that what is “solved” with alcohol involves a desire or search for something beyond self for comfort and a better sense of well-being The problem is the person went to the wrong address (“where do we aim what we thirst for”) AA is a re-locating experience where the comfort and connection that was discovered with alcohol is replaced with the hope and promise that is provided with the human connections and relationships that the program provides 22
- 23. The story telling traditions in AA directly and indirectly address the problems of behavioral dysregulation, especially self-care They do so in that the stories constantly focus on the unthinking and unfeeling behavior involved in persistent drinking and relapse Although not labeled as such, the stories cause recovering alcoholic individuals to think and talk about their mindless and thoughtless behavior, often with passion and healthy doses of humor 23
- 24. ■ AA works because it not only addresses uncontrolled drinking, but transforms the life of alcoholic individuals emotionally and spiritually ■ The attachment that had been made to substances in place of attachment to people is reversed ■ With abstinence and recovery, self-absorption and preoccupation with alcohol and drugs are replaced by genuine concern for others 24
- 25. ■ AA provides a forum to address the human tendency for self-centerdness and psychological denial ■ Members are reminded that they suffer with a disease, are powerless to control it, and can get better by going to meetings, ask for help, and not using today (my italics for emphasis) ■ When slips occur members are not scolded or banished, but are encouraged to remember that they are vulnerable and to learn from their mistakes 25
- 26. Beyond the specific elements reviewed here, as with any beneficial therapeutic program, there is the essential ingredient of hope that 12-step programs provide. It is imbedded in the “promise,” of the program which more often occurs : “If you don’t drink, things will get better” 26
Editor's Notes
- Presentation grows out of my training as a physician, psychiatrist, and psychoanalyst. Main data grows out of my clinical experience - “practice based evidence”Experience extends over nearly 5 decades of trying to understand what motivates addictive behavior and what works in dealing with addictive disorders.My approach is a psychodynamic oneA psychodynamic approach, more simply put, gets at the human psychological underpinnings of addictive behaviorWe need such a perspective given the stigma, negative stereotyping, and horrible judgment placed on individuals with addictive disorder, not the least of which addicted individuals place on themselvesMore than anything in this talk, I would like to stress that suffering is at the heart of addictive disorders and that this consideration should remain central in considering the treatment needs of individuals with addictive disorders
- For most of us who are social drinkers we likely do so because the alcohol does something for us. The lesson here is it does something much more for others, as Bill Wilson experienced. I call it “the discovery” referring to the drug-of-choice experience As powerfully seductive as addictive drugs are, it cannot be emphasized enough, they are not universally appealing or captivating. This is so whether it is opiates, stimulants, or depressants. Many, many individuals experiment or are exposed to these drugs, but far, far fewer become addictedBeyond neurobiological and heredity factors, a psychodynamic approach attempts to get at what are the human psychological underpinnings that makes addictive drugs, including alcohol, so much more compelling for some than others.Such a perspective should not and need not compete with the other perspectives
- The treatment relationships in individual counseling and group experience offers a humane, comforting, and containing antidote to the dehumanizing, discomforting, and disorganizing consequences and experience of addictive disordersBe sure to acknowledge the psychiatric and psychoanalytic influences on the development of AA (i.e. the influence of Drs. William Silkworth, Harry Tiebout, etc.)Silkworth - “allergy;” and how alcoholics found a sense of ease and comfort with the effects of alcohol, and degrees of psychiatric instability associated with alcoholismTiebout appreciated the egoism of alcoholic i and how AA effectively challenged their resistance and denialAnd clearly Bill W was well aware of how his parents divorce profoundly affected his self-esteem, referring to his feelings of “inferiority.” From my perspective the 12-step program is an extremely sophisticated group psychology that helps contain and stop unbridled drinking at the same time it works to transform People and stimulate personality change, growth, and maturity.
- Ancient and recent formulations that invoke pleasure seeking and self-destructive motives to explain addictive behavior still loom large.- take the language of modern-day neuroscientists who speak of and seek the “reward” and “pleasure” pathways in the brain to explain the reinforcing properties of addictive substances; or the cynical view that addiction is suicide on the installment plan- I would challenge anyone in this audience to give me examples of individuals who became and remained addicted to drugs or alcohol because of the pleasurable aspects of their use - more than anything, addictive behavior is driven by human suffering and misery, only to perpetuate that suffering and misery
- The good news and the bad news about the human condition-the bad news is that we are not hard wired to adjust to our inner and external environment-the good news is that we are not hard wired to adjust to our inner and external environment That is, we are challenged to learn how to figure out who we are, what goes on inside us, how we feel about ourselves, and how to get along with the human and non-human environment that surrounds us -this makes for possibilities of satisfaction and joy or the alternatives of dissatisfaction and misery
- Put another way, you could say alcoholism is:A disease of disordered emotionsA disease of disordered self-esteemA disease of disordered relationshipsA disease of disordered self-care
- Notice well that the word help is in quotesThe real and nature of addictive drugs and behaviors illusory - short term addictive drugs really work – they fix short term what the person suffers with – that is what is “reinforcing” about addictions- long term addictive drugs fail. They do so because they become an end in themselves, erode on any existing human capacities, and preclude on possibilities to develop solutions to the challenges of regulating emotions, self-esteem, relationships, and self-care
- Comment on Henry Krystal’s seminal clarifications that feeling have a normal developmental line – from feelings being undifferentiated, somatized, and not verbalized to … -that is, we go from our experiencing feelings as being unclear, localized in our bodies, and without words, and if all goes well, to be able to distinguish feeling ,experience them emotionally, and giving words to our feelingsInsert my speculation – when we so often refer to the “high” or “pleasure” associated with addictions what we are really referring to is how such agents and behaviors relieve states of the lows of depression or states of displeasure, anhedonia, and suffering which are out of awareness
- That is, it is a worse fate than just not feeling good about yourself or doubting yourself. The problem get to issues of core problems of identity, lacking vitality, and feeling helpless and lost about ones sense of self or well-beingBravado and postures of self-sufficiency (I like to refer to it as strutting) detract self and others from appreciating the underlying feelings of inadequacy and emptinessDon’t assume the person sitting in front of you professing who and what they feel they can handle is necessarily the case
- Early psychodynamic characterizations of addicted individuals, especially alcoholic individuals, were ones of “oral, clinging, and dependent” characters. Such characterizations detract from where the too often the problem for addictively prone individuals is one of being counter-dependent an not needing othersDenying the need for others (likely an inescapable human condition) it should not be surprising that addictive behaviors and substances could seem like magical elixirs to offset inner feelings of emptiness and low self-regardKaren Walant (an esteemed colleague) reminds us in her wonderful book, Creating the Capacity for Attachment, how devoid of vitality and alienated addicted individuals can feelAlong similar lines, Philip Flores indicates [click to next slide] that addictions at their roots are an attachment disorder
- Lessons learned from the empirical study of infant and childhood development Pleasure is momentary and not unimportant but human connection and the comfort we derive from each other is more sustaining and lasting We are much more comfort and connection seeking than we are pleasure seeking
- Recall counter-transference/intersubjective problems with self-care deficits witnessed [early and continuing up to the present] – especially epitomized with IV heroin addicts crossing the needle barrierThe following two slides is how JEM and I summarized the essentials of Self-care in 1989
- Distinguish an “outside view” vs an “inside view”. Many inspiring views of individuals who have experienced the magic and benefit of 12-step experiences in recovery. My outside view derives from my exposure to 12-step programs directly and indirectly – mostly the latter where I have had the chance to witness clinically the benefit and transformations in my patients who have benefitted from the AA experience
- “lonely and despairing people discover and appreciate they are not alone or unique in their suffering and that there is hope”The support and acceptance that the stories evoke act as powerful corrections for the problems and deficits in being aware of, accepting, and expressing their feelings
- The AA approach works in subtle and “magical” ways to help alcoholic individuals begin to deal with their emotions in more mature and flexible waysParticipants speak of “learning what life is about”Listening to stories help some to experience and identify for the first timeThe program helps some to express their emotions and for some it helps to better bear painful emotions
- Notwithstanding the convictions of an active alcoholic’s best thinking that they can solve their problems their way, AA helps to appreciate that the problems of human psychological suffering are not best faced or solved alone.As participants are constantly reminded, “Identify, don’t compare” - a way of challenging what is referred to as “ terminal uniqueness” in the programThe gentle instructions and admonishments are more often offered light-heartedly and with healthy doses of humorNewcomers are met with a simple greeting of “hello” and welcome, a modest and powerful first step to counter and ameliorate the shame and guilt the newcomer struggles with
- Henry Tiebout referred to some of these aspects of alcoholism as the “egoism of the disease”
- e.g. “Your best thinking got you here”Or, “we're here because we are not all thereOr, my friend who has a smiley post-it on his bathroom mirror to face every morning with the caption, “Have a good day, unless you have other plans”