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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
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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
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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
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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?
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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”
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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”