2000 AAAP ANNUAL MEETING KEYNOTE ADDRESS
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Treating Addiction as a Human Process: A Plea for a Measure of Marginality
Edward J. Khantzian, M.D., Tewksbury Hospital, Tewksbury, MA and Clinical Professor of Psychiatry, Harvard Medical School
It is important to think about the nature of addictive vulnerability and why our patients feel they must resort to taking drugs. The first part of this presentation is taken from the title of my book Treating Addiction as a Human Process. Then a plea will be made for a measure of marginality, a special way of thinking. In this era of the brain and biological psychiatry, it is incumbent upon us to bring together the different worlds in which we operate.
In counting the patients I have evaluated or treated over time it adds up to between 1000-2000. I still come from the time-honored tradition of the case method of study. What I know about this subject I have mostly learned from my patients, literally one patient at a time. My perspective is one of a psychoanalytically trained psychiatrist with a parsimonious model. The clinical psychodynamic perspective is a special one. The relationship with patients is primary and within that treatment context we have an extraordinary opportunity to understand addictive vulnerability and relapse.
In this relationship with the patient are the potentially identifiable elements of addictive vulnerability. It encompasses what goes on as you sit with your patient, the subtleties of how they move and express or don’t express themselves, and the emotional reactions they invoke in you. This is learning from the patient. To help understand this, I have proposed a triad: the person, the pain, and the drug and how these three factors interact.
The following is a case vignette: Will is an articulate professional man who had difficulty accepting his addiction. He was quite isolated, tense, anxious, angry, off-putting when first confronted with his alcoholism. He evolved into one of the most loving and lovable of men when in recovery. Will provided the following vivid vignette to explain the sources of his self-regulation difficulties and how alcohol became a magical elixir to counter his inner distress and constricting defenses: My childhood was a period of isolation and loneliness. There was restriction, suppression, repression, oppression and depression. I distinctly recall my first drink at 17 years-old and how all of that changed. I recall the frosted highball glass, the two ice cubes, unscrewing the red top of the Beefeaters’ Gin bottle, the cracking of the ice cubes when liquor splashed over them, the strong odor of juniper berries. I recall the tightening of my throat when the foreign solution burned going down and then I recall the unfettering of my emotional chains that followed. I began to feel free—free to feel. I felt happy; even giddy—unashamed, unpretentious and uninhibited. I felt that I finally was a member of the human race, "one of the guys," an equal. Although it would appear he was describing the disinhibiting effects of alcohol or alcohol as a superego solvent, actually he was describing alcohol as a better ego solvent. This is not an unusual experience. It is a description of how a man is built, how he’s constricted, how that constriction causes him to suffer, and about this powerful discovery of what the drug does for him.
The following is a quote from the epilogue of my book given to me by a patient years ago This quote from Rainer Maria Rilke captures something special about what we are dealing with involving addictive vulnerability and the human psychological factors that go into it. "How should we be able to forget those ancient myths about dragons that at the last minute turn into princesses who are only waiting to see us once beautiful and brave… perhaps everything terrible is in its deepest being something helpless that wants help from us."
Jung’s famous quote "Spiritum Contra Spiritus" captured the fact that there was something special in those turning to substances. The vulnerability involved in addiction says that there is something in the use of the substance that has to do with our penchant to seek comfort, connection and wholeness in the core of ourselves. In his new book on addictive vulnerability, Jerry Levin interprets Jung’s quote as appreciating that in the use of substances there is a spiritual quest. I like the way he puts it: the quest is admirable but the path is deplorable.
A modern day term that has become popular is that the reward centers get hijacked in the brain by substances of abuse. I think it is just as likely the "emotional brain" that gets hijacked. However, we shouldn’t get the idea that these drugs are universally appealing and addicting. The following is my evolving perspective of what is central to addictive vulnerability. I have adopted an overarching paradigm of substance abuse as a self-regulation disorder. This has led me to think about the nature of personality organization involved in these problems as follows:
1) Substance Abuse as an Attempt to Cope. This is an adaptive perspective. When Mark Gold reviewed my book in the December, 2000 American Journal of Psychiatry he said that "every human problem has its reasons and represents an attempt to solve a problem." It does something for the patient to have his symptoms and it goes beyond simply the biological substrata of a disorder. Substance use is a specific adaptation, an attempt to compensate for what didn’t develop in a person to allow them to cope with life’s troubles. Use of drugs and alcohol address developmental deficits such as emotional and behavioral disregulation, and are failed attempts at self-correction. This adaptive perspective places great importance on the treatment relationship. I engage my patients in the discussion of "what do drugs do for you" rather than what they do to you. This has led to a revealing discovery for me and increased my learning.
2) Substance Use as Self-Medication. Drugs relieve human suffering. Psychopharmacologic specificity is important to the patient, e.g., cocaine’s action is different than opiates’. Dose also makes a difference. Drugs are not universally appealing, but there are specific drugs of choice to help patients feel and function better. People have tried to prove or disprove the self-medication hypothesis. I published a review of this literature in Harvard Review of Psychiatry (1997). Looking at the primary/secondary arguments, the results come out about 50-50. Half of the studies indicate that substance use disorders (SUDs) follow on the use of substances and the other half that SUDs follow the development of a psychiatric condition. Patients self-medicate the pain, which might or might not be associated with the psychopathology that meets the DSM-IV criteria. This brings us back to the person, the pain and the drug and how they interact. There are arguments that cannot be answered by the self-medication hypothesis, e.g., substances often lead to suffering and not all who suffer become dependent on substances. Therefore, a more overarching paradigm is needed to explain this.
3) Substance Abuse is a Self-Regulation Disorder. This paradigm accounts for some of the inconsistencies in the self-medication hypothesis. There are self-regulation factors in addictive vulnerability. One such factor is disordered self-esteem which contributes to dependence and affects how we relate to others and how isolated we feel. Another factor is disordered relationships, which also contributes to dependence. Two essential factors that malignantly combine in what is disordered about people are disordered emotions and disordered self-care. They make it more likely for a person to become dependent on drugs.
4) Substance Abuse and the Disordered Person. Disordered emotions make a person prone to action, activity, circumstantiality, stimulus seeking, and risk taking. In my experience, patients do not have an unconscious desire to destroy themselves. Rather they don’t anticipate danger and have an underdeveloped capacity to care for themselves. They are vulnerable and their defensive style includes counterphobia, bravado, aggressive posturing, defensive self-reliance, and "non chalance".
In conclusion, the challenge is that treating the substance abusing patient requires us to deal with a person that suffers. The challenge for the clinician is to target the suffering in the person and not only the brain synapses or symptoms alone. Such a perspective has implications for all interventions whether they are psychological, social or biological.
Finally, I want to refer to the "Marginal Man" by Everett Stonequist (1937). His concept of "marginality" meant living between different worlds, rather than the contemporary meaning of being peripheralized. In order to better serve our patients, we all need to dwell more between the margins within which we usually operate, to cultivate models that are truly integrative and inclusive rather than fragmented and competing. We must listen to what the other person is saying and see how alternative ways of thinking often complement our perspective. We need to try to integrate rather than polarize our thinking. I make a plea for marginality. As we try to understand our patient’s needs, we truly need to think about the bio-psycho-social perspective and how they are related in the patients we treat.
2000 AAAP Annual Meeting Proceedings Copyright 2001 AAAP