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  1. Calliope
    Why do so many die as a consequence of addiction? Is it in the inexorable, “progressive” nature of the disease? Or might it be the result of entrenched treatment approaches that repeatedly and increasingly become misaligned with the needs of individuals suffering from addictive disorders? For example, some need, and don’t get:

    • safety, structure, and support
    • medications for symptom reduction and control
    • nurturance and comfort
    • the company and “fellowship” of others
    • storytelling and group sharing to understand their “errant” ways

    The list goes on, and every clinician could add what else might be needed or beneficial to address and provide for those suffering from addictive disorders.

    There continues to be a need for professionals who treat addiction, as well as all health care providers, to continue to fine tune approaches that work best and to avoid approaches that are exclusive or doctrinaire.

    I write this piece to reach an audience of those who suffer with addictive illness, those who witness it as caring friends and family, and to all clinicians who treat it. I do so to counter attitudes of stigma that diminishes empathic concerns for the fate of addicted individuals, and attitudes of therapeutic despair that addictive disorders can engender. And finally, I write it to foster awareness of a problem in the addiction field where parochial attitudes and practice can be harmful for individuals in need of treatment.

    At any given time, we learn of the death of one more celebrity as the media blazons us with such tragic and unwelcome news, a most recent example being the death of Philip Seymour Hoffman. Their achievements and promise, and for some celebrities their notoriety, and the magnitude of such loss, bring us up short. We wonder what addiction is and why it results in deadly consequences. We are left to worry whether it could have been prevented. Celebrity status succeeds in drawing media attention to the scourge of addiction, but we must not forget the countless incidents throughout society, among the rich or poor, gifted or ordinary, and promising or stuck individuals who unheralded and ignominiously suffer the same fate.

    Clearly effective models and approaches for understanding and treating addictive illness exist. These include 12-step programs, relapse prevention, cognitive behavioral approaches, harm reduction therapy, motivational interviewing, medications, and dialectical behavioral treatment. In my clinical experience, modified psychodynamic individual and group treatments are also extremely effective in addressing and resolving the emotional and behavioral problems that drive addictive disorders. Shedler (Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychol. 2010;65:98-109.) has documented robust evidence that supports the efficacy of psychodynamic psychotherapy. Few empirical studies show such approaches work for addicted populations, but Shedler’s findings apply to treatment of addictive disorders, in my experience. Such application needs further empirical study.

    One of the problems in treating addictive disorders is polemics. The debates and controversies go on and date back a half century: Is addiction a disease or a symptom? Do psychiatric disorders cause addiction or is it the other way around? Is it environment or heredity? That debates are rancorous and often bitter is bad enough, but worse, they play out tragically in treatment when adherents of one approach or another rigidly apply a particular model alone to the exclusion of others.

    Sadly—and in some cases disastrously—affected individuals are never offered alternative approaches after one option fails. Too often in my own practice, a patient is referred for consultation by a psychotherapist who has adopted a symptom approach alone, trying to get to root causes of drug and alcohol abuse without considering first the need to get the addictive behavior under control; or on the other hand, the patient who has tried and failed 12-step work for decades only to be told they haven’t bottomed out or “don’t want” sobriety.

    Having authored ideas and perspectives of my own that have received fairly wide recognition (positive and negative)—such as the self-medication hypothesis of addiction (SMH), addiction as a self-regulation disorder, and the psychodynamics of addiction—I have experienced the attack and sting of polemic criticism and outright dismissal of my work and ideas. One example I came upon dismissed the SMH as “dangerously false and misleading.” (DuPont RL, Gold MS. Comorbidity and “self-medication.” J Addict Dis. 2007;26 Suppl 1:13-23.) In another case, a doctoral candidate informed me that her Institutional Review Board (IRB) warned her that she should not refer to self-medication in studying a population of chronically relapsing heroin addicts because the IRB felt it was risky and could precipitate relapse.

    Of course I am not alone in feeling the bite of criticism from colleagues. It comes with the territory. However, when it comes to addiction, the issues involved too often hinge on life and death. Rigid adherence by practitioners can jeopardize the course of one’s addictive illness including fatal consequences.

    To treat effectively is to avoid the pitfall of approaches that derive from polemic and exclusive adherence to a particular treatment model. Instead, there is a need to combine and flexibly integrate elements of what we know works, whether it be 12-step treatment, individual or group psychotherapy, SMART recovery, medication-assisted treatments, and so on, in permutations and combinations acceptable to and compatible with our patients’ needs. And finally, in response to the five bullets about shortcomings in treatment I outlined at the beginning, I would offer some final reflections:

    • The structure, connections, and support provided by 12-step programs are natural correctives for the risk and shambles entailed with addictions, and despite its unacceptability to some, clinicians should encourage patients to expose themselves to the Alcoholics Anonymous (AA) traditions to discover whether the advantages and benefits the program provide will suit them. When individuals reject AA, it should not necessarily be considered denial or resistance and alternative approaches should be considered

    • Many patients need medication management for addiction and co-occurring psychiatric disorders which fuels the need to self-medicate symptoms associated with these conditions (it is worth remembering that the highest co-occurrence with addiction is in patients PTSD and bipolar disorder, conditions in which despair, rage, and agitation beg for amelioration and relief). Medication-assisted therapies, such as methadone and buprenorphine, should clearly be considered, especially when a range of psychosocial treatments are not working

    • Kindness, empathy, understanding, and patience—these are powerful elements that should be basic to whatever psychotherapeutic approach are adopted, including facilitated 12-step programs; they are powerful antidotes to the discomfort, shame, and guilt heavily woven into the fabric of addictive problems. Confrontation should be avoided, but in extreme cases when necessary, where self-harm and danger are imminent, it must be done in a way that preserves self-esteem

    • Although AA is not considered psychotherapy, it truly is therapeutic in the sense that the fellowship and connections it provides work powerfully to reverse loneliness and isolation, factors that so commonly predispose to and result from addiction

    • Group therapies, including 12-step groups, provide interactive and validating experiences. Storytelling and sharing help members reflect on their unmindful and risky behaviors and pursue more thoughtful and measured ways to correct attitudes and actions associated with addictive behaviors​

    Having focused in this piece on some dangerous attitudes and practices that threaten treatment outcomes and can actually endanger patients, it is worth mentioning that addictive disorders are far from a hopeless condition. Many patients get better. Addictions so often represent misguided attempts to deal with life challenges that involve troubled feeling, self-esteem, relationships, and self-care. They have opted for chemical solutions in place of human relational ones when they have felt unable to deal with these challenges. Effective treatments create pathways to help find such solutions. In my experience, patients who have found these solutions are some of the most admirable and mature individuals with whom I have worked.

    By Edward J. Khantzian, MD

    Psychiatric Times
    March 18, 2014

    Dr Khantzian is Clinical Professor of Psychiatry, 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.


  1. It'sOn
    Great article! Thanks for posting. It full of lots of important points and thoughts for consideration and I look forward to reading it again.
  2. Poppi
    This entire article nearly made me cry: knowing that there was an addiction specialist and professional out there--much less one with such renown--that understands the desperate need for the acceptance of the validity of multiple kinds of treatment ideologies.

    People can easily accept that there are many ways to successfully lose weight--why not to quit drug addiction?

    The points I highlighted above really stood out to me, not only because I fit the addict described (e.g., am bipolar and have PTSD, don't want to go to AA/NA meetings and having the stigma of "not wanting" recovery because of my rejection of the 12-step dogma, and for other reasons) but because his points here are so poignant in their description of the reality of why addicts often start--and hopelessly continue--using drugs against their better judgment.

    I'd like to write more, but I kind myself a little emotional about this issue. Thank you Calliope for posting this--and I encourage every struggling addict on this site to read this as well. We should all be so lucky to be accepted in the manner in which Dr. Khantzian so clearly demonstrates.
  3. Calliope
    I too found this piece heartening, and hope not only that it reaches addicts who will be helped by knowing there are clinicians like him out there but also that his aim to "foster awareness of a problem in the addiction field where parochial attitudes and practice can be harmful for individuals in need of treatment" might be realized at least somewhat.

    Given Dr. Khantzian's academic position at Harvard I figured he must have published more. He has, and I have uploaded a more expansive recent article on this topic. (Khantzian, Edward J. Reflections on treating addictive disorders: a psychodynamic perspective. The American journal on addictions / American Academy of Psychiatrists in Alcoholism and Addictions, 2012, Vol.21(3), pp.274-9; discussion 279.) Including some of it here seems a useful addition to this thread. First, a portion of the commentary by Kathleen T. Brady, MD, PhD Acting co-Editor, The American Journal on Addictions:

    Dr. Khantzian calls our attention back to a very fundamental and critical area in addictions that is underappreciated and understudied, yet is something we deal with in every therapeutic encounter. Understanding the psychodynamic forces that underlie addictive behaviours and the feeling states of patients with addictions is critical to developing the therapeutic relationship that can provide the context for a healing experience.

    Dr. Khantzian reminds us that the view of addiction as “pleasure-seeking” is a widely held misperception that contributes to the view that addictions should be managed in the criminal justice sector rather than be viewed as a disease or disorder. Anyone who treats individuals who suffer from addictive disorders recognizes that substance use is associated with shame, pain, chaos, and confusion for the addict. The notion that addictions are a manifestation of suicidal intent is another misguided perception that is discussed. Most people with addictions have dreams and aspirations for their future and look forward to the day when they have sustained abstinence and stability in their lives. Viewing these individuals as suicidal can lead to misaligned therapeutic endeavors. As Dr. Khantzian points out, one of the most important principals in the therapeutic context is that patients need to feel heard and understood. Imposing a predetermined interpretation of an individual’s motives as either pleasure-seeking or suicidality rather than listening to their story and trying to understand their perspective is a recipe for a failed therapeutic relationship.​

    And from Dr. Khantzian's article itself:

    A psychodynamic perspective suggests that addiction is fundamentally a disorder of self-regulation. More precisely, individuals with addictions suffer because they cannot or do not regulate their emotions, self-esteem, relationships, and their behavior. As humans we are governed less by instincts and more by coping skills and capacities acquired from the caretaking environment. Requirements for human survival and adaptation place a lifelong challenge on humans for self-regulation. Regulating emotions, self-esteem, relationships, and self-care are among the main functions upon which our survival depends. In my experience, individuals self-medicate the distress and pain associated with their self-regulation difficulties.​
    So one might ask if addiction is a self-regulation problem, how do addictive drugs “help” with self-regulation?
    • Drugs enhance or contain feelings.
    • Drugs affect one’s sense of self, well-being, and self-esteem.
    • Drugs affect our ability or inability to care about or to connect to others.
    • Experimentation with and dependence on drugs are influenced by one’s capacity for self-care.
    Notice that the word help is in quotes. Based on my experience, addiction is an attempt at self-correction that fails. It is the real and illusory nature of addictive drugs and behaviors. Short-term addictive drugs might work; they can provide a temporary fix for what the person suffers with. That is what is “reinforcing” about addictions. Long-term, addictive drugs fail. They do so because they become an end in themselves. They erode any existing human capacities to cope, and preclude possibilities to develop solutions to the challenges of regulating emotions, self-esteem, relationships, and self-care.​

    Because addicted individuals are overwhelmed or confused by their feelings, because their self-esteem is shaky, because relationships are elusive or absent, and because their self-care is undeveloped or inadequate, I have concluded practitioners should be guided by the following essential elements for their work with patients:
    • Kindness
    • Comfort
    • Empathy
    • Avoid confrontation
    • Patience
    • Instruction
    • Self-awareness
    • Climate of mutual respect
    • Balance—talking/listening​
    Although many of the listed elements seem self-evident and basic, it is worth commenting upon how and why they are important. I begin with kindness because it is so important yet, because of certain traditions and tendencies, it often wanes or is absent in the treatment relationship. First of all, most of us are influenced more than we like to think by the early psychodynamic paradigm that fostered reserve and impassivity thus making kindness in treating clinicians less likely apparent. Second, whether we like to admit it or not, addicted patients foster disbelief or distrust in clinicians (and worse still if we are unaware of the mistrust) thus making it less likely to be kindly disposed to our patients.

    Appreciating the pain and suffering that is at the root of addictive disorders, we need to remember all the things our addicted patients are uncomfortable about and how not understood they feel. In this respect the role of empathy is critical in countering such distress. I say, “avoid confrontation . . . but if the devil makes you,” because addictive disorders are maddening to self and others, including treating clinicians. Our patients make us madly angry and crazy given how insane and irrational addictive behaviour can seem or be. I believe this in part is what fosters counterproductive and harmful confrontations, more likely angry than not, in clinicians if they are not careful. But “if the devil makes you,” because on certain occasions firm proscribing interventions are necessary to insure safety, confrontations have to be done in such a way that preserve self-esteem and are supportive. We need to keep in mind how out of touch our patients can be with regard to their thoughts and feelings. Thoughtfulness and emotions fail to serve addictively prone patients in assuring self-preservation, and instructive approaches are necessary and consistent with psychodynamic approaches. And finally, regarding the final three bullets, in my estimation self-awareness in the patient and clinician, and the balance between talking and listening, are central for a climate of mutual respect, all key to establishing and maintaining a positive therapeutic alliance.​
  4. Poppi
    Calliope, you made my day! I got up this morning and immediately went on D-F to see what's been happening in the two hours I've missed activity LOL :) And, lo and behold! To my great surprise and delight, you have done it again--you took the time to research Dr. Khantzian's other works (which I can imagine are many, if he is responsible for popularizing the treatment model of the self-medicated hypothesis of addiction, and because Harvard is a research one university, so he's got to publish or perish to stay in his prestigious position). I am grateful to have the opportunity to read more of his work, so thanks again Calliope, you've really outdone yourself!

    Considering the article, I feel much the same sense of relief and interest as I did for the first, and found myself thinking about the ever-changing field of psychology--that red-headed bastard child of the soft sciences--and how Dr. K's contention is based on the self-actualization and -fulfillment of needed care which admittedly is something of a new concept.

    With the emergence of Dialectical Behavior Therapy c.1993, Linehan's groundbreaking assertion that certain therapy-seeking populations notoriously difficult to treat (potential suicides, Borderline Personality Disorder, etc.) could be effectively treated by teaching emotion regulation, mindfulness, and interpersonal relationship skills, her work became the cornerstone of behavior-centered therapy and was later successfully adapted in chemical addiction arenas (which is where I discovered it).

    I think Dr. K's work is similar in that he proposes radical kindness and compassion for addicted sufferers, and again, I find that such a rare stance and a welcome reprieve from the distancing viewpoints of the clinicians and counselors (save one in my experience) that is so prevalent in treatment today.

    I mention the single counselor who taught me something beyond the formulaic fill-in-the-blank personal "reflection" exercises when I came to her in a crisis because--of all things--another addict had accused me of splitting hairs with semantics (can you imagine? Me?! No way! :) ). Tempers had been flaring all day, as they typically do when you are caged with a bunch of lunatics, but instead of the usual talk-it-out nonsense, she advised me to do something I'd never attempted with anyone before: she said I ought to approach him with kindness and care, and I'd find a more receptive audience for when I needed to express my hurt or ask for a change in his behavior.

    It's really silly that I never developed this skill that the old adage of catching more bees with honey than vinegar referred to, but this simple suggestion of being kind over being righteous changed my perspective in a major way; and if I may be just slightly prideful, I approach almost every single post I write here in that exact manner, and I have come to find that my advice is better received than other posters who have the same message but lack the care and humility to finesse the situation so all parties are respected.

    I hope I didn't toot my own horn too much with that, and I realize my practice of radical honesty concerning addiction might be unusual--and perhaps unwanted at times--but I believe that if I care for the addict, he can learn to care for himself, and that is ultimately the core foundation on which Dr. K's therapeutic model rests.

    If you'd ever like to promote more of his research here, perhaps you (or I, as I would be honored to accomplish this) could write a Wiki about this wonderful man who has done such a service to the suffering addicted population? He certainly merits mention as a powerful advocate for change, but also a well-established clinician who is responsible for many currently popular addiction ideologies. Let me know what you think!
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