Second Thoughts About Addiction

By Edward J. Khantzian 07/09/15

A seminal figure in understanding and treating substance misuse reflects on his legacy.


​Edward Khantzian, MD is one of the most significant figures in the history of addiction treatment, having put forward, in 1974, the “self-medication​ hypothesis" of addiction​, which asserted that substance use is best construed as effort to relieve an inner psychological struggle or discomfort​. It also maintains that the choice of substance that comes to be relied on is therefore extremely relevant to developing treatment strategies. The self-medication model has had an enormous impact on our understanding of the etiology and treatment of addiction. Now, over 40 years later, and in a period in which a “disturbed brain mechanism” of addiction is perhaps dominant, Dr. Khantzian reflects on our current view of addiction, and his own.—Richard Juman.

It has been awhile since I treated intravenous, opiate-using patients. But there was a time when they were the group with whom I worked predominantly and where I began to develop my ideas about what makes dependency on addictive substances so powerful and compelling. My background is that of a psychiatrist who subsequently trained as a psychoanalyst, so understandably I came to the study and treatment of addictive disorders with a keen interest in bringing that background to my work with addicted individuals. Some of my methodology-minded colleagues tell me it is tricky to attribute causality between different conditions, but others reassure me that psychodynamic, psychoanalytic clinicians such as myself are the “meaning-makers” and are permitted to draw connections between feelings, thinking, and behaviors, in this case those involving addictive behaviors. It is that background and frame of mind that I bring to my thoughts and reflections about the human frailties, suffering, and tragedy entailed in addictive disorders. 

I was once again greeted today by another newspaper headline referring to the mounting opiate epidemic in our surrounds, in this case, highlighting the problem of the growing number of opiate newborns coming into the world from opiate-dependent mothers. It immediately started me thinking of the cruel and self-absorbing nature of addictive illness wherein the only thing that seems to matter is the addicted individual's need to place their compulsion and need to support their addictions ahead of all else. In the case of the addicted mother referred to in the article, I found my visceral reactions running ahead of my usual clinical understanding and, like so many of us, feeling—how can a mother be so unmindful and uncaring of their newborn and infant child?

My stirrings triggered some misgivings that maybe I have missed the boat pursuing human psychological vulnerabilities and that the neuroscientists are on the correct path in studying how addictive drugs change the way the brain works, such that an addicted mother comes so much under the sway of the disturbed brain mechanism that doom her to become hopelessly dependent on the drug, thus rendering her so dreadfully destructive to her baby and herself.

First of all, I had to remind myself, as I have to remind my patients, my colleagues, and my students, that with addictive illness it is imperative to not confuse causes of addiction with its consequences. After working with addictive illness now approaching five decades, I remain convinced that human emotional suffering and pain is at the root of addictive disorders. This is the case whether it is the suffering that predisposes to and precipitates addiction, or whether it be the incredible pain, suffering, and self-disregard that invariably results from the addiction. 

Recently, in a book that my colleague Dr. Mark Albanese and I authored on our understanding of the human psychological suffering that predisposes to addictions, we decided that to be complete we needed a chapter on “contexts” in which addictions occur. We emphasized that addictive drugs, despite their purported powerful seductive properties, are not universally appealing, and that only a small percentage of those that try these drugs become addicted. We raise the question,“Why is this so?” Clearly conditions of poverty, deprivation, violence, and social upheaval foster addictions, but wealth, privilege, and celebrity status do not protect against it. And in neither case are individuals born to misery or privilege exempted from human suffering, especially when exposed to deprivation, neglect, and abuse in the myriad forms that it takes. I offer here an example of a patient who came from an emotionally deprived background who had unfortunately discovered alcohol as a short-term elixir for his interminable distress.  

“Jack”: Down and Out.

Jack’s case brings out the context of life-long feelings of distressful emotions, poor self-esteem and related problems with relationships that powerfully connected him to his reliance on alcohol to deal with the troubling internal and external surrounds in which he found himself.  

A man in his late forties, and a devoted father to one daughter, Jack was a melancholic and anxious man, so much so with regard to the latter that he was subject to recurrent and unabating panic. He had been self-medicating his panic and the anticipatory anxiety with alcohol for many years. One of the consequences of his heavy drinking was that it had become progressive and now suffered with an alcohol dependency disorder that required no less than a half-dozen detoxifications over the past three years. There were other complications of his alcoholism as well. He lost his job as a parts manager in a large appliance outlet, a position at which he was very knowledgeable and effective. In addition to alcohol interfering with employment prospects, a major downturn in the economy made the possibility of alternative work even more dim. Around the same time, his wife asked him to leave and filed for divorce. More recently, he lost his license to drive because of driving under the influence.

Jack says he was always a loner. He did little dating as a young adult, mainly as a result of shyness. Even now, he finds it awkward and difficult to convey to his wife how and what he feels. When with male peers as a young man, he used alcohol to express himself, but added that he had been anxious all his life, saying, “Alcohol was my way of dealing with it.”

In a recent visit with his psychiatrist, just after release from his most recent detoxification, he reviewed with the psychiatrist his unrelenting penchant to revert to alcohol. In a seemingly naïve manner, his psychiatrist asked him if alcohol still did it for him (i.e., relieve his anxiety). The following is a near verbatim encapsulation of what followed.

“Maybe for the first hour … it leads to a sense of elation … like a wave as if there is nothing wrong or bad; it takes me away from things that feel bad or unmanageable ... I feel free to talk to someone.” He clarified that the sense of well-being lasts for about an hour, then quickly added the “obsession becomes a compulsion … a mental urge” and that the first drink was the only good one.

The case of the mother with the newborn infant brings out another context—oppressive surrounds. In the newspaper article, reference was made to the mother with her newborn returning to small living quarters for her and her baby—consisting of two bedrooms occupied by nine other individuals, which makes one wonder about all the distress and dysfunction such living quarters would produce. Recent studies have shown, for example, that moving individuals into better housing results in being happier and better mental health. Surprise, surprise.

I offer here, from my perspective, some thoughts about why and how opiates and other drugs become so compelling. Early in my career starting a treatment program for intravenous using, opiate-dependent patients, I had the opportunity to interview, evaluate, and study the many patients coming to our program, a significant number of them being mothers of newborns and young children. Early on, I learned to ask each patient what the heroin did for them when they first used the drug (i.e., avoiding the issues of the drug relieving symptoms of withdrawal from the drug).  

Aside from much else that I learned about addiction from these patients, what I was struck by was how they predominantly emphasized how they felt “normal … calm … [and] comfortable” when they first tried these drugs. I also observed, as they became stable on methadone, that they were less agitated, angry, and violent in their manner, in their interactions with me, and in group contexts. A more recent example revealed the same calming and containing action of opiates. A popular musician described the effect of opiates when he said, “It was like putting on a warm blanket” indicating that his threatening and disorganized feelings of anger and rage went away and he could be soft with his wife.

Exploring with patients their backgrounds (as most clinicians working with addictive disorder discover) I have been impressed by the pervasiveness of traumatic violence, abuse, and/or neglect they experienced in their growing up environments, findings that more recent empirical studies repeatedly document and confirm. In many cases the predisposing issues are more subtle examples in which discomfort and distress originate in contexts of failure in empathy and early attachment problems. 

For Carl, a patient I have been seeing in individual and group therapy, high doses of alcohol drowned out long-standing vague feelings of dysphoria and poor sense of self. He dated these feelings back to childhood and especially his adolescence when he began to turn to alcohol for relief. He placed his distress at that time in the context of parents, though well-intentioned, failing to notice or respond to his loneliness and isolation. 

Over the years I learned that such experiences and background produce at least a two-fold problem, namely (a) the development of vague and confusing emotions alternating with intense feelings, and (b) the inability to tolerate their feelings. Individuals so affected substitute chemical addictive solutions in place of human ones. I do not know how much of this applies to the mother of the newborn in the newspaper article, but I wouldn’t be surprised if some of these factors held true for her as well. 

Coming forward to the present and the clinicians, students, and investigators with whom I now work, I keep asking them if my early and subsequent impressions and understanding about vulnerability to addictions remains useful, or whether it has become a model or paradigm of understanding that is out-of-date and not relevant? Maybe the neurobiological psychiatrists are the ones on the right track, and ideas about psychological vulnerability to addiction are outdated. Invariably, however, my contemporary colleagues and students assure me they discover in their work with addicted individuals that they and their patients, like myself, are guided by such an understanding to accept and adopt treatments that help them to make inroads on the suffering that underlies their addictions and to recover.  

After nearly five decades of studying and treating addictive disorders, I am convinced that we need multiple approaches—clinical, neurobiological, societal, and cultural ones—to deal with, address, and resolve the complexities and suffering entailed with addictive disorders.

Dr Khantzian is Professor of Psychiatry, part time, Harvard Medical School at the Cambridge Health Alliance, and President and Chairman, Board of Directors, Physician Health Services of the Massachusetts Medical Society in Waltham, Mass. He is the  author, with Dr. Mark Albanese, of  Understanding Addiction as Self Medication: Finding Hope Behind the Pain 2008.

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Edward J. Khantzian is Professor of Psychiatry, part time, Harvard Medical School in Boston, and President and Chairman, Board of Directors, Physician Health Services of the Massachusetts Medical Society in Waltham, Mass. He is the author, with Dr. Mark Albanese, of Understanding Addiction as Self Medication: Finding Hope Behind the Pain, 2008. He is in private practice and specializes in addiction psychiatry. You can find him on Linkedin.