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The American Journal of Psychiatry, VOL. 157, No. 11

Book Forum: ADDICTIONS | November 01, 2000

Treating Addiction as a Human Process

MARK S. GOLD, M.D.

Am J Psychiatry 2000;157:1892-1894. 10.1176/appi.ajp.157.11.1892

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By Edward J. Khantzian, M.D. Northvale, N.J., Jason Aronson, 1999, 712 pp., $70.00.

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Edward Khantzian has been a consistent voice for the role of psychiatry and psychiatrists in the evaluation and long-term treatment of addicts. This new book brings together a substantial portion of his previous work in one volume. Except for three chapters, the book is a compilation of his collected works, previously published as journal articles or book chapters, organized in chronological sequence. Khantzian intends this book for students, clinicians, and patients interested in the psychology and treatment of addictions.

Khantzian has been a vocal advocate for the inner world of addicts, and in this book he offers his extensive experience as a clinical psychiatrist who has spent his career developing insights into psychodynamic understanding of the addict. By bringing more psychiatry to the addict, Khantzian has been a champion for parity and treatment access and has supported patient advocacy efforts to reduce stigma and shame. At the same time, he has proposed that societal contempt and condemnation internalized by the addict provoke feelings of shame and despair, providing fuel for a vicious cycle of drug use to counter the feelings. This is a mainstay of his theory.

Khantzian does not minimize neurochemical, genetic, and other biological findings and theories but tries to apply them to his psychodynamic model. Khantzian has extended Freudian theory, which views drug use as a displaced addiction to masturbation. Freud may have been describing himself and his relationship to his pipe and tobacco while also predicting that drugs of abuse are taken because they hijack the brain systems that are normally quiet and reserved for reinforcement of primary drives, like sex. Khantzian is always asking, Why do people take drugs? One answer he provides is, Because they have to. Addicts suffer from subclinical or DSM-IV deficits and diseases that they learn to self-medicate with a preferred drug. The self-medication hypothesis leads to Khantzian’s overall view of addicts as people with considerable lack of self-care and self-governance who destroy themselves as a consequence of not knowing how to regulate or care for themselves. Thus, addiction is not pleasure seeking but remedial action to relieve suffering.

It was surprising to find out in the foreword by Jerome Levin that for many years Khantzian was engaged in a "three-front war" with more traditional psychoanalysts, with those in the recovering community who see him as rejecting the disease model, and with "the more radical behavioral and neurochemical theorists and practitioners who have attacked him for incarnating a redundant and illusionary emphasis on inner life" (p. xvii). Hyperbole aside, Khantzian has been widely respected and admired for his clinical work and experience. Furthermore, his lectures and papers on self-medication have stimulated the intended controversy as well as considerable thought and research. Khantzian writes, "I do not assume to have all the answers here, only some special ones, answers that are often not enough considered in an era of biological psychiatry and empiricism" (p. 5). Rather than prospective studies or systematic research, Khantzian’s writings have used cases and clinical experience based on the principle that every human problem has a reason and represents an attempt to solve a problem.

In his earliest work, Khantzian explored the treatment implications of self-medication and combining psychotherapeutic and psychopharmacological treatments for alcoholics. He advocated the targeting and treating of depression and anxiety, which he judged to be important to the development of alcohol dependency. Khantzian has changed his theory from the concept that all alcoholics uniformly suffer from pathological ego and self-formations to the idea that alcoholics have a degree of abnormality and difficulty in self-regulation. This evolution came from treating patients who had benefited from therapy in 12-step programs and showed great flexibility, strength, and resiliency.

I enjoyed chapter 15 the most; it is a new contribution written specifically for this book. The notion of self-medication is one of the most intuitively appealing theories in the field of addictions. The more closely a drug matches what is missing in the person or more effectively treats a disease, the more powerful and reinforcing. This hypothesis is consistent with biological theories of addiction liability as well as the theory of drug use as reinforcement or pleasure. A person with an alcoholic biological parent finds that alcohol is the key to an internal lock, that it is more like heroin than alcohol. Khantzian reiterates that drugs of abuse relieve psychological suffering and that a person’s preference for a particular drug involves some sort of psychopharmacological choice or specificity. Patients experiment with various classes of drugs and discover that one is better because it ameliorates, heightens, or relieves affect states that are problematic or painful. With his patients, Khantzian explores suffering, character, and self-medication and develops treatment based on the patient’s inner-life characteristic defenses. Through the therapeutic alliance, patients develop an understanding of how their suffering, defenses, avoidances, and separation relate to their drug use.

I would like to look at Khantzian’s contention that depression, dysphoria, or a similar state might cause alcohol dependence. The 13.7% lifetime prevalence of alcohol abuse and dependence in the ECA survey is the highest of the 44 adult disorders surveyed (1). Alcoholism and depression are commonly seen in the same patients at the same time (2). Major depression is the most common comorbid psychiatric diagnosis in alcoholics (3). The ECA found lifetime comorbidity rates of 30%–50% for the diagnoses of alcoholism and major depression (4).

Depression and alcoholism can present as two separate diseases, and neither protects the person against the other. Family, twin, and adoption studies indicate that there is substantial inheritability in the etiology of alcoholism (5). Depressive illnesses also run in families and appear to have an important biological basis. Affective disorders and alcohol dependence may share a common risk factor or factors that may be familial. Therefore, the presence of one disorder may indicate a greater risk for the other (6).

Alcoholism may cause relapse in depressed patients and contributes to the course of the depressive illness. Successfully treated depression may recur with alcoholism. Psychiatric symptoms in patients who abuse alcohol may be temporally or medically related to acute intoxication, active disease, withdrawal, detoxification, and recovery (7). Alcohol can cause temporary affective symptoms even in subjects with no history of clinically relevant depression (8). Alcohol use produces the same subjective symptoms and objective signs required for the DSM-IV diagnosis of a major depression. Measuring depression with the Hamilton Depression Rating Scale, Brown and Schuckit (9) reported that 42% of inpatient male alcoholics scored 20 or greater and that only 6% maintained those scores after 4 weeks of abstinence and treatment. Dorus et al. (10) reported that 32% of alcoholics had met criteria for major depression on admission but that they had a 50% reduction in depressive symptoms after 3 weeks of abstinence. Brown and Schuckit (9) divided a group of depressed alcoholics on the basis of primary (symptom cluster that appeared first) and secondary (later appearing symptom cluster) qualifiers for the two diagnoses. These researchers found that after 3 weeks of abstinence, the group with primary alcoholism and secondary depression showed a 49% reduction in depressive symptoms. The group with primary depression and secondary alcoholism showed only a 14% reduction. Clearly, there exists a subset of depressed alcoholics who, if treated early with antidepressants, would falsely appear to have responded to the pharmacological therapy.

No studies have shown that depressive disorders actually cause alcoholism. Schuckit (11) suggested that patients display inconsistent drinking patterns and may actually consume less alcohol early in the course of a depression. Continued drinking in the face of alcohol-induced depression is a result of addiction to alcohol (11, 12).

Depression can be considered a part of the natural course of addiction. Miller and Janicak (13) posited that depression associated with early recovery is protective and healing. A grief reaction after a loss is considered normal and expected. Depression is an integral part of the process of recovery from addiction. The addict can suffer losses of alcohol, drugs, or relationships. The benefit of treating the depression must be weighed against the risk of aborting a natural healing process (13). The textbook of Alcoholics Anonymous (14), first published in 1939, contains a description of a prominent American businessman who received treatment from several American psychiatrists and even traveled to Europe, where he was treated by Carl Jung. His alcoholism continued to progress until he began a 12-step recovery program. When patients who have well-developed rationalization and denial skills are allowed or encouraged to believe that their problems are the result of something other than their addiction, the disease continues to progress and treatment of their depressive symptoms is rarely successful (15).

Khantzian understands but cannot explain why many individuals experience discomfort, pain, and confusion but do not use drugs or use them and do not become addicted. He also understands that self-treatment with drugs causes more distress than it relieves. According to Khantzian, an individual prone to aggression might find that alcohol produces a state of marked dysphoria and dyscontrol but that opiates are experienced as soothing and containing (p. 249).

In chapter 25, "Alcoholics Anonymous—Cult or Corrective?" (Khantzian’s Distinguished Lecture at Cornell, North Shore), he gives us a pearl in the form of a clinical practice secret:

I tell my patients that the two-part secret is 1) to keep showing up and 2) to hang in there.…When I have shared the secret in clinical contexts, it has been met with acceptance, tinged with amusement and curiosity, by most of my patients.…What I am getting at here is the fundamental fact that most human problems are not best encountered or solved alone.…One of the more extraordinary examples of this realization is the benefit that so many participants of AA have derived from their group.…Twelve-step programs do this not by enslaving or engulfing the self with substituted forms of mind control and subordination of self, as occurs in cults; rather, such programs succeed by creating conditions of interdependence, safety and comfort, which provide the potential for human maturation and the transformation of self. (p. 432)

I also particularly benefited from chapter 28, "Group Treatment of Unwilling Patients," and plan to share chapters 29 and 30, "The Substance-Dependent Physician" and "Understanding and Managing Addicted Physicians," with our impaired physician program director. Hidden inside these chapters is Khantzian’s initial approach to treatment and basic addiction treatment principles:

• Good basic care begins with a careful history. We teach our Fellows that addiction, as a clinical problem, has two central features. The first is the loss of control over the use of addicting substances characterized by continued use despite adverse consequences of that use (the unmanageability of substance use and therefore of life itself). The second central feature of addiction is the denial of the use of alcohol and/or other intoxicating drugs and the denial of the consequences of that use (dishonesty).

• Early hospital confinement and achievement of abstinence are essential.

• Impaired physician committees should be used for advocacy and monitoring of progress. We teach our Fellows that unless treatment of the comorbid illness is essentially the same, diagnosis comes before treatment. Depression remains difficult to diagnose in early alcohol recovery, but treatment of depression with antidepressant medications reduces relapse (2).

• AA and Narcotics Anonymous (NA) are invaluable. In our program we go a step farther by generally reevaluating patients for psychiatric medications only after they are both successfully detoxified and alcohol-free and involved in a 12-step program for at least 21 days.

• Adjunctive psychotherapeutic and psychopharmacologic interventions should be given when indicated. We teach our Fellows that helping addicted patients overcome their character defects is part of the process of becoming and staying clean and sober. We also agree with Khantzian that detoxification is not generally treatment and has been overemphasized. For decades the treatment of addiction focused on detoxification, with the "drying out" usually taking place in a residential or hospital setting. Today the major emphasis of treatment by primary practitioners and many psychiatrists is still the treatment of abstinence. Cigarette smokers are treated with the patch or nicotine replacement. Alcoholics are treated with chlordiazepoxide or now with the newer loading doses of benzodiazepines. Opiate-dependent patients are treated with methadone or clonidine. However, detoxification-only approaches often result in unnecessarily high rates of relapse.

Khantzian points out that "several investigators (Gold, Miller, Schuckit, Vaillant) have argued that most of the anxiety and depression associated with substance use is the consequence of chronic use and clears over time with abstinence" (p. 255) and that "contemporary investigators [8, 12] have popularized and emphasized the hereditary, cultural, and biophysiologic underpinnings of addictive disorders" (p. 9). However, he notes,

These polemics are counterproductive and reflect linear and reductionistic reasoning. Findings from genetic, neuropsychological, longitudinal, and diagnostic studies are cited to suggest that the effects of chronic and heavy drug/alcohol use produce the psychopathology associated with substance dependence. These arguments are bolstered by observations of alcoholics and addicts who respond favorably to AA/NA and experience marked amelioration of their psychological suffering when they abstain from alcohol and drugs. Reviewing the findings of the various perspectives reveals that the cause-consequence debate is not so easily resolved. A clinical and psychodynamic perspective provides a basis to understand, integrate, and reconcile some of the findings that at times are contradictions but more often can be seen as complementary and resolvable. (p. 366).

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