Self-Medication: Not as Simple as It Sounds
We use the word all the time to "explain" addiction. But the concept of self-medication is based on deep, complex theories that have yielded deep, effective approaches to addiction treatment. Here's how it works.
Addiction is often referred to as self-medication. The idea seems simple enough, but the psychological processes driving an addicted patient’s need to self-medicate are extremely complex. By understanding these internal dynamics, we hope to improve therapy outcomes.
Harvard Medical School psychiatrists Edward Khantzian and Mark Albanese formulated the self-medication hypothesis (SMH) over the past 40 years, beginning with Khantzian’s work with heroin-addicted patients, often in conjunction with methadone treatment. Today, this population would also include many patients addicted to opioid pain medications. Over 12 million people reported using these painkillers for nonmedical purposes in 2010. These people account for a significant number of patients who enter my consulting room. Marcus, in the following case study, was one such patient. His story of self-medication—the psychological needs it fulfilled for him and the therapeutic work we did to enable him to meet those needs himself—illustrates a clinical application of the theories that the rest of this article explores.
Marcus was a young adult with an opioid dependence. When he began treatment, he and his wife were separated and living apart. Marcus had been the victim of sexual trauma at a young age. He began using substances as a pre-teen and had been addicted to opioid pills for much of his adult life. He had significant symptoms of a self-disorder including dissociation, explosive anger, difficulties regulating self-esteem and sexual acting out. He also acted out with me by defaulting on his fee and making excessive “urgent” telephone calls to me between sessions.
As Marcus and I developed an understanding of his behavior, it became clear that he harbored angry feelings toward me because, as he saw it, I was “one up” on him. He believed that I was unilaterally deciding the “rules” of therapy and that, due to his commitment to the work, he should have more influence over them. What felt to me like his excessive demands began to take shape as a deep yearning in Marcus to be heard and known as an effective agent in the therapy and in his life. We focused on the patient/therapist dynamics around these demands, on Marcus’s associated anger and need to be mirrored and idealized in order to gain self-worth.
Early in treatment, Marcus would express his anger in his behavior—by not paying his fee in a timely manner, leaving garbage in the waiting room, not flushing the toilet in the waiting room bathroom and devaluing my therapeutic interventions. He also had regular explosive outbursts towards his wife and co-workers. I responded to his expressions of anger by acknowledging his internal experience but holding him accountable so that I did not feel disrespected: when he left garbage in the waiting room, I made it clear that his feeling angry was acceptable but that he still had to clean up after himself. We discussed how his anger, which I had validated, was connected to his inappropriate behavior.
We also used mindfulness-based approaches to treatment, which helped Marcus with self-regulation. During one session, Marcus asked if he could lead a mindfulness exercise. I agreed, surrendering to his emerging sense of empowerment by taking on the role of the receiver. He went on to lead several more mindfulness exercises, at times creating his own scripts, which were very insightful and effective. This process served to mirror Marcus's grandiosity without disrupting the “rules” of therapy. As this phase of the treatment continued, he began to express his needs more appropriately—verbalizing his feelings rather than acting them out. He also began to have more successful interpersonal relationships and more success at work, resulting in a pay raise. He was able to abstain from using opioids for several months during treatment.
Addiction and relapse are a response to narcissistic rage. Addictive substances function as mirroring and idealization for the patient, who is unable to do this himself.
The self-medication hypothesis began as an alternative to traditional psychoanalytic theories that emphasized the addicted patient’s strivings toward self-destruction or euphoria. Instead, the SMH suggests that addicted people are medicating their immense psychological pain with specific classes of substances for different types of pain. The sources of these painful states are related to difficulties with self-regulation and self-esteem, adaptive behavior and accommodation to reality. These personality deficits coalesce into what Khantzian refers to as the addictive vulnerability.
A key aspect of the addictive vulnerability is a lack of emotional regulation. These patients are not able to know, tolerate or express their feelings. Addicted people also tend to lack adequate regulation of self-esteem and interpersonal relationships and to be unable to anticipate dangerous situations and the consequences of their behavior. Psychological trauma is associated with addictive vulnerability.
The SMH suggests that the specific action of each class of substances appeals to specific kinds of psychological distress. In general, opioid-addicted patients are attempting to cope with intense rage and aggression by seeking opioids’ calming and soothing effects; stimulant users are either medicating depression or trying to maintain a manic lifestyle with the drugs’ energizing effects; and patients addicted to alcohol and benzodiazepines are seeking the tranquilizing effects of these substances in an attempt to relieve anxiety (often related to interpersonal relations). There is often “progression” from one class of substances to another based on internal need.
Khantzian’s concept of the addictive vulnerability—and its deficits in self-regulation—is partly based on psychoanalyst Heinz Kohut’s “psychology of the self.” Kohut traced these deficits back to a lack of sustaining self-object experiences early in life. Self-objects are relationships that provide the self with sustenance and enable the development and maintenance of the self’s cohesion, stability and sense of value. This occurs through adequate experiences of mirroring, idealizing and twinship. When these fundamental psychological needs are not met, the emerging self experiences a narcissistic wound that predisposes the personality to intense rage and anxiety caused by a fear of the annihilation of the self. Addiction is an attempt to relieve this rage and anxiety.
Regarding treatment, Kohut emphasized that these patients place special demands on the therapist because of the intensity and complexity of their transference, consisting as it does of mirroring, idealizing and twinship. The therapist’s empathy and attunement with the patient’s needs are important for consolidating the patient’s self and enabling the development of healthy narcissism with its positive self-regard and ambition.
Perfect empathy and attunement are, of course, unsustainable, and there are inevitable ruptures and repairs in the patient/therapist relationship. When not overly traumatic for the patient, these serve as “optimal frustrations” and as the basis for productive treatment. As the patient repeatedly experiences these ruptures without the destruction of the relationship, he is gradually exposed to the unreality of his narcissistic demands. Through a process called transmuting internalizations, the patient takes in the therapist’s capacity to mirror and idealize the self and develops more adequate self-regulation and a sense of internal vigor. Following successful treatment, the patient will have a greater capacity for mature self-object relationships, in which empathy is maintained, as compared to the immature relationships of self-disordered individuals, in which others are treated as extensions of the self and not as independent entities.
Based on Khantzian and Albanese’s SMH and Kohut’s psychology of the self, Jerome D. Levin, a psychologist and the director of the New School's Alcoholism and Substance Abuse Counselor Training Program, developed an integrated approach to treatment, suggesting that addiction, and specifically addictive relapse, is a response to narcissistic rage, and that addictive substances and behaviors function as mirroring and idealization for the patient. The use of these substances or behaviors fulfills the psychological needs that the patient cannot meet: the capacity to self-soothe, to regulate anxiety, to be alone and to develop positive self-esteem and a stable identity. Through transmuting internalizations, the patient can develop these psychological capacities and, it is hoped, no longer depend on the substances or behaviors.
But what are Levin's technical recommendations for working with addicted patients? He emphasizes that it is important to act flexibly and do what works, including using supportive “techniques” such as cognitive and behavioral strategies. Other therapists have developed a mindfulness-based approach to relapse prevention that enables the patient to observe his addictive urges without judgment and then differentiate internal experiences from behavior.
As the vignette about Marcus shows, I have found mindfulness-based approaches to be useful adjuncts to psychodynamic work based on the SMH and the psychology of the self. The therapist’s management of a mirroring transference helps the patient modulate his or her a state of anger without the use of opioids. By connecting the opioid dependence to Marcus's anger and aggression, I found an inroad to understanding his attempt to cope with distressing emotional states related to early trauma. But successful treatment of addicted patients like Marcus requires unusual flexibility from the therapist. Although work with addicted patients is difficult, chances for recovery can be increased by understanding the intricate dynamics behind the patient’s need to self-medicate.
Jason M. Stewart, PsyD, is a clinical and sport psychologist in Garden City, New York. He focuses on working with men on issues related to work, sports and addictive/compulsive behavior. He is also the editor of the upcoming Acceptance, Mindfulness and the Psychodynamic Evolution (New Harbinger Publications). He can be reached at DrJasonStewart@gmail.com.