Understanding Addiction as Self Medication: Finding Hope Behind the Pain

by Edward J. Khantzian, Mark J. Albanese

Addictive behaviors beg for an informed explanation to guide patients, families, students, and clinicians through the maddening and often incomprehensible nature of the addictions. Too often addiction is perceived to be merely a moral weakness or purely a brain disease, ignoring the deep personal pain that can permeate the lives of the addicted. But taking an honest look at the underlying emotional or mental issues can more clearly illuminate not only the causes of the addiction, but also the cure. Doctors Edward J. Khantzian and Mark J. Albanese, leading researchers in the field of addiction, see addictions primarily as a kind of self medication―a self medication that can temporarily soothe anxiety or pain, but that ultimately wreaks havoc on the lives and health of both the addicted and their loved ones.

With practical advice, compelling case studies, and nuanced theory drawn from their years in clinical practice, Doctors Khantzian and Albanese look at the core reasons behind many addictions and provide a pathway to hope. Understanding Addiction as Self Medication looks at a range of addictions, including alcohol and substance abuse, and clearly explains how to understand other addictive behaviors through the lens of the Self Medication Hypothesis. This book provides a much-needed guide to both understanding addictions and working towards healing.

Genres: Psychology, Addiction

192 pages, Hardcover

First published September 18, 2008

Reviews

[Shannyn Martin]

The following thought occured to me at work today as I was mulling over the arguments presented in this book: emotional pain is a natural part of being human, and as humans we tend to naturally seek ways to relieve our suffering. Logically, the more that a person suffers, the more willing they might be to go to extremes to relieve their pain. That's the crux of the "self medication hypothesis" of addiction, and it may sound like a simple idea (I myself have mentally nominated Dr. Edward Khantzian for several Captain Obvious awards throughout my reading) but, the more I read, the more complex layers I discover that underlie such a seemingly simple explanation. This book presents a few crucial ones, which I will list below:

1.) In an early chapter, the authors reference a preexisting psychological concept that I had to Google to figure out how to pronounce: alexithymia. It's New Greek, the authors explain, that breaks down to "a" (referring to the absence of feeling), "lex" (referring to words) and "thymia" (referring to feelings), thus translating to "no words for feelings." They argue that "major damaging or neglectful experiences either growing up or later in life" tend to damage a person's "capacity to experience and know one's feelings... In other words there is a problem or disorder in knowing, naming and feeling feelings... The SMH emphasizes that addictive drugs and behaviors relieve this dysphoria associated with painful and confusing feelings..."

The authors expand on this idea in a later chapter, first referencing a case study involving a "media celebrity" named "John" who, after kicking his heroin habit, now had a more successful career, a stable romantic relationship and restored relationships with his parents. Nevertheless, he was considering getting high again and remarked to his therapist that "You know, doc. I might get high or I might not, but I know that in the morning I will feel shitty, but at least I will know what I feel and why I feel it."  The authors then go on to reference the work of Dr. Henry Krystal (I keep wanting to call him Dr. Billy Crystal in my mental notes), apparently a psychological trauma expert, who specialized in development psychology and posited that "at the outset of psychological development, feelings are experienced bodily only, are undifferentiated ( i.e., feelings such as anxiety and depression are indistinguishable from one another), and are without words. As the child grows and develops into adulthood, feelings are experienced subjectively, emotions become differentiated such that a person can distinguish anxiety from depression, and words are attached to feelings." To make a long story short, he argues that emotional trauma often disrupts this development process, which might explain why adult addicts and alcoholics have such a plethora of dysregulated emotional patterns. 

The authors go on to note: "Working with substance-dependent patients, Dr. Krystal has observed that often they cannot tell or distinguish whether they are sad, tired, hungry or sick. Little wonder that alcoholics in recovery use and benefit from the acronym HALT, referring to hungry, angry, lonely, and tired..."

The authors end the chapter with the following supposition that, frankly, blew my effing mind: perhaps an addict or alcoholic like "John" who experiences their emotions as confusing, ambiguous and painful can be drawn to both the relief substances temporarily supply *and* the pain of substance use, because that pain becomes an identifiable explanation for the more ambiguous pain they have felt all along as a result of their trauma, which they may or may not remember. Relapse perhaps becomes some tempting because "at the same time that addicts relieve distressing states with drug effects, they also convert the more vague and confusing aspects of their feeling life from a passive experience into an active one. Substance abusers actively replace preexisting passively experienced admixtures of pain, dysphoria, and emptiness with admixtures of analgesia, relief, dysphoria, and distress produced by the drug and its aftereffects... When individuals use drugs, they change qualities and quantities of feelings, and more importantly, they succeed in substituting uncontrolled suffering with controlled suffering, replacing a dysphoria that they do not understand with a drug-induced dysphoria that they do understand."

2.) A major component of Khantzian's self medication hypothesis is the observation that people very often, usually through a process of trial and error or "self selection," gravitate towards a specific "drug of choice" whose effects regulate the particular emotional or psychological dysregulation they struggle with. The soothing and calming effects of opiates, for instance, are especially appealing to people who struggle with rage or aggression. I didn't know this but, according the the authors, "empirical evidence suggests that opiate users are three times more likely to have a history of child abuse" or other early childhood trauma that created deep-seated feelings of anger or aggression that the individual "had not established the defensive and adaptive psychological mechanisms that would allow them to regulate" such feelings. Cocaine users are a bit more complicated, they argue, in that they are subdivided into "low energy" users and "high energy" users. The low energy users apparently rely on cocaine's stimulants to counteract their sluggishness and, more importantly, to counteract anhedonia (the inability to feel pleasure) and other depression related symptoms, while high energy users may use the drug to sustain periods of mania or, paradoxically, stimulants can actually calm these types, if I am understanding correctly (this section was a bit confusing). Finally we get to the part about me, the substance abuser who prefers alcohol and sedatives, and I have to say the authors are pretty spot on (although there's a good chance I'd say the same thing if I read my horoscope in the paper). These substances, they argue, appeal mostly to "individuals who maintain rigid, constricting defenses" and who, research finds, "inhibit and over-contain their experience of emotions," who have "a greater tendency to over-control their anger and refrain from acknowledging emotions" and thus rely on the effects of central nervous system depressants to "[reduce] anxiety and [produce] feelings of relaxation" and to "[soften] their psychological defenses" and facilitate more comfort with intimacy and with expressing emotions... This would easily explain why I become viscerally uncomfortable when someone hugs me or gives me a heart-felt compliment, despite my actually desire for such contact. 

There is some nuance to consider with this aspect of the hypothesis though. The authors write: "A person might use a substance other than their drug of choice because, for example, it is available and adequately effective. Some may have more than one substance of choice. Likewise, two or more emotions may co-occur. And the nature of the dysregulated effect may change over time, so that the substance of choice could be expected to change." 

3.) The authors subscribe to what I understand to now be the mainstream "bio-psycho-social" concept of addiction (as opposed to viewing addiction purely as a brain disease or a moral failing), acknowledging that genetics or biological factors may indeed play a role alongside psychological and sociological factors. I found this to be a really interesting example of this complexity: researchers from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) found that "girls who suffered childhood sexual abuse were more likely to develop an alcohol disorder if they had a low-activity variant of a gene responsible for an enzyme involved in regulating the body's response to stress.," which suggests the "disease" can not so easily be explained by addiction neuroscience (which, btw, is literally still in its infancy). The authors mention a then popular HBO documentary that particularly ground their gears: like so many such documentaries, this one presented addiction as a "brain disease" that corrupted "pleasure pathways" while astoundingly failing to notice that the "case examples of the of the individuals interviewed for" their own goddamned documentary "including their descriptions of actions and feelings involved in the course of becoming addicted, made compellingly clear how distressing personal events and unhappiness had been involved when they first became addicted and when they relapsed, as well as how addictions have perpetuated the distress in their lives.

...

I probably have more thoughts on this book that I need to unpack, but suffice it to say I HIGHLY recommend it to anyone seeking a serious understanding of the very complex (but also in other ways very simple) issue of what we call addiction. 

[Stephanie]

very interesting read.