On Kindness and Treating Addiction

On Kindness and Treating Addiction

By Edward J. Khantzian 09/01/16

One of the seminal figures in the theory and practice of addiction treatment reflects on the therapeutic value of kindness.

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On Kindness and Treating Addiction
It doesn't take much.

Much of the focus in the current dialog around addiction treatment is either theoretical (abstinence vs harm reduction) or focused on technique (motivational interviewing, cognitive behavioral, etc). So it can be easy to forget that addiction psychotherapy is, first and foremost, psychotherapy. A confounding variable in the psychotherapy of addiction is a punitive aspect that clients with addictive disorders often experience from others, as well as themselves, and sometimes from therapists. Dr. Edward Khantzian, a longstanding thought leader in the field of addiction, reminds us how powerful the stance of kindness can be in working with these individuals…Richard Juman, PsyD

Reading a manuscript recently about addiction stimulated me to think again about how I stressed in a 2012 paper (1) that among a number of elements that were crucial in treating addicted individuals, I put “kindness” at the top of the list. When I wrote the article, I immediately thought how naïve and simplistic that assertion might seem given the complexities of what needs understanding and remediation in addictively vulnerable persons. Among a number of other necessary therapeutic elements, I listed comfort, empathy, patience, avoiding confrontations, instruction, etc. At the time, I offered some good explanations why I though kindness was so important and not to be minimized. The two reasons I stressed were (a) traditions of impassivity and therapeutic neutrality with many psychotherapeutic modalities which are not readily relinquished, and (b) how our tendency to distrust our patient’s veracity render us to be less than benevolent in our attitude.

Beyond the reasons I explained at that time, I found myself rather impatiently reacting to an insufficient concern about kindness in our work. I found myself reacting “Is there any other way to be!” In addition to a pervasive, unyielding concern for my patients not feeling understood, shame ridden, lost, and stigmatized, I found myself further wanting to explore and explain why kindness is so unremittingly important in meeting our patients’ needs. I first looked up some definitions, which I condense as follows: Webster’s offers "quality or state of being gentle and considerate." Oxford adds, "friendly and generous." And the online Psychology Dictionary refers to "benevolent and helpful action." These definitions get to the heart of so much of the ungentle, unfriendly, un-benevolent attitudes that others heap upon the addicted—and the addicted heap upon themselves. From a psychodynamic perspective, I would add that in clinical care, kindness also involves sensitive, empathic attunement to affect.

In my work studying and treating addicted individuals over the past 5 decades, I have placed a major emphasis on how dysregulated addicted persons are with regard to their feelings, sense of self/self-esteem, relationships, and behavior, especially self-care. Exploring affects (feelings) and empathic attunement to the critical areas of psychological life in which they play out are vitally important in accessing and modifying these areas of dysregulation:

-Affects cut across all aspects of self-regulation in the development of addiction

-Affects are the organizing basis for self-experience (Stolorow et al 1995)

-Affects are the foundation for a sense of well-being (Kohut 1970)

-Affects are the currency for human connection and attachment (Bowlby 1973)

-Affects are the primary ingredient for guiding behavior, especially self-care (Khantzian and Mack 1983)

Navigating through the domains that we all face in regulating our lives is challenging enough. For those struggling with the developmental deficits of not knowing feelings, having insufficient self-love, troubled relationships, and poor self-care, the addictively prone are tragically ill-equipped to meet the human challenges of coping with their inner psychological life or external reality. Is it little wonder then, that those individuals so burdened resort to the inanimate solutions of addictive substances and activities?

Although the word “kindness” does not explicitly come up in the following vignette about Faith, it is clear how important a part it played in her gaining a better hold on how old and recent wounds so much governed her reliance on alcohol to fix her troubled sense of self and to alleviate her anxiety and depression:

The Case of Anxious and Melancholic Faith

Faith’s out-of-control drinking and a devastating depression were precipitated when she was terminated from a highly placed executive position in a major health care corporation. A hypercritical, intimidating senior officer was instrumental in her removal from her position. Much of her success and ambition was driven and compensatory. She was raised by an immigrant mother who was insufficiently supportive and, like her boss, hypercritical of Faith, but this was further compounded by mother taking to her bedroom for years at a time by her own immobilizing depression. For most of her growing up years, she says home was an unhappy place given mother’s depression, father's drinking, and her parents’ constant fighting.

She was referred by her psychopharmacologist for individual and group psychotherapy to deal with her heavy drinking. Although she did not adopt abstinence, almost immediately she was successful in significantly cutting back the frequency and amount of her drinking. In her own words, she said she was “self-medicating” her anxiety (in low to moderate doses), and when the anxiety and depression mounted to unbearable levels, she would drink to obliterating levels (e.g. the entire bottle of wine) and go to bed.

From the start of treatment, Faith quickly formed a positive attachment to her therapist and was openly expressive of her appreciation for the comfort and reassurance she was experiencing from the work with the therapist in her individual and group therapy. In a recent individual visit, even as she was wondering aloud why she was continuing to use alcohol, adding that she was no longer self-medicating, she spontaneously indicated that the antidepressant was relieving her sadness and despair. But she quickly added that her energy levels remained low and the alcohol energized her. She volunteered that she definitely felt better and that she was okay with the controlled drinking, but was aware that it was a “slippery slope” and realized she could get back to” numbing” herself with alcohol. The therapist wondered with her if she might think about what she might be numbing. She thought about how she used to get her “adrenaline lift” from the kudos and recognition she obtained from her position, but then offered that she derived little comfort or satisfaction currently from her reading group, arts and crafts, or prettying up her home. She ended the session wondering about what else might give her a “lift or pleasure.”

The progression from Faith’s unthinking compulsive drinking to ameliorate her immense suffering, to a relatively rapid development of a capacity to think and worry about her troubled state of being and her use of alcohol, was impressive. Her demeanor, especially early in treatment, was a melancholic and anxious one. In contrast, it was notable to witness the comfort, support, and clarification she drew from her individual and group therapy, as well as the opportunity to share her distress and gratitude in her treatment—interactions that were not likely or available in her family of origins. As much as her therapist was active in appreciating, validating, and supporting her gifts and decency, it was also evident that she was drawing on her individual and group contacts to begin to feel better about and within herself. With the help of her therapist, she was fruitfully considering alternative ways to find comfort and self-acceptance beyond the external praise and admiration she derived from her work performance and career. Literally, the therapeutic process activated her where she could begin to shift from deriving satisfaction from external accomplishments and admiration, to one where she was more and more appreciating that her comfort and better sense of self had to come from within. As they say in recovery, “it’s an inside job.” Put in terms of attachment theory, she was reversing the attachment to the inanimate (i.e. the alcohol) to the human ones afforded by her individual and group therapy. And of course, as she got better, she was also reconnecting to her loving husband and her three daughters from whom she had withdrawn as her alcohol use was progressively denying her these vital attachments.

It seems to me that kindness goes hand-in-hand with careful and empathic attunement to affect experience in helping clinicians and patients to gain inroads on the self-regulation deficits that predispose them to their addictive solutions. I would contend that a persistent attitude of kindness is one of the most important ingredients in establishing and maintaining a positive and trusting relationship. Such a relationship is the foundation and the most important ingredient for therapeutically accessing and modifying the problems that our patients face. It enables the task of dealing with the deficiencies involving affects, self-esteem, relationships, and self-care that are the most bedeviling challenges that addicted individuals face and need help to overcome.

References

(1) Khantzian, E. J. (2012). Reflections on treating addictive disorders: A psychodynamic perspective. The American Journal on Addictions, 21: 274–279.

Dr. Khantzian is Professor of Psychiatry, part time, at 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 in private practice and specializes in addiction psychiatry. Full Bio.

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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.

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