So much has been said and written about addiction, much of it so wisely put by individuals in and out of recovery. One popular adage is “the definition of insanity is doing the same thing over and over again and expecting a different outcome.” In clinical terms, one of the most distinguishing diagnostic features of addictive disorders is that those affected continually and repeatedly revert to their addictive behaviors, despite the devastating negative and adverse consequences.
In my own career and investigative studies as an addiction specialist spanning many decades, I have emphasized that a primary factor that contributes to repeated abuse is that addictive substances temporarily relieve emotional pain and suffering that otherwise feel unmanageable or intolerable. That is, those who endure such distress self-medicate, and they wittingly or unwittingly provide support for the self-medication hypothesis (SMH) of addictive disorders, a theory that has received much endorsement and at least an equal amount of criticism and rejection.1,2
On occasion, I somewhat satirically comment that I believe in the SMH more on some days than others. Although I continue to believe that it is a powerful paradigm to explain addictive disorders, today was one of those times when I found myself thinking it does not satisfy the complexities (or perhaps the subtleties) involved in the bedeviling, repetitious, self-harming behaviors associated with addictions. An e-mail from a former patient with whom I had parted ways because I relocated my office to another community, stimulated my thoughts about the irrationality of addiction and doubt and curiosity about the SMH aspect of addiction.
Matthew is a 55-year-old gifted author and college professor of English studies. After struggling for many years as a heavy drinker, he sought out professional help with only modest progress in obtaining control over his drinking. He finally established abstinence and a protracted period of sobriety (5 years) before he started treatment with me. He then immersed himself in AA meetings where he felt supported and found a caring sponsor to work with him.
For reasons not entirely clear but at least to some extent related to recent stressors (some related to chronic musculoskeletal pain), he resorted to periodically drinking large amounts of alcohol. The following e-mail typified that pattern, in this case indicating that his current drinking was in part celebratory:
Dear Dr K,
I finally felt okay physically last week, when my class began. I had a great week, so much so that I wanted to celebrate/prolong and drank a bottle and a half of wine Friday night. Saturday was a total loss, but I managed to get out and buy one bottle of wine, which I consumed. Feel okay now and am ready for 4 straight days of classes.
Not worried about drinking during the class, but certainly when it ends. The whole thing is very strange. I guess my life was turned upside down by the pain in recent months, not able to go to early morning meeting, etc. But something has to give . . . haven’t quite figured it out. Don’t feel committed to sobriety.
Thanks so much for your text. Would love to come see you, but obviously I need to find someone in the area, sooner than later.
I responded to his e-mail as follows:
Get back to basics. That should include someone to work with you on the insanity of addiction. You know what to do as well as anyone else, and that is to get a safety net of others who care about and love you. YOU CAN’T DO THIS ALONE.
I would also add that I am not entirely surprised about your notion that when you complete your course, you will be more apt to drink. Perhaps success creates the illusion that you can control the uncontrollable and be immune to the consequences of drinking.
And should you continue to delay in finding someone, come see me in the interval for a sanity check.
I was reminded that persons addicted to substances find countless reasons to drink and drug—to grieve, to celebrate, to heighten feelings, to reduce or drown feelings, to get a job done, to drink when a job is done, and so on. Obviously, the reasons to self-medicate are myriad and the motives, seemingly contradictory.
My response to Matt was guided in part by my unyielding, evolving curiosity and interest in what it is that governs and drives the needs and issues that perpetuate addictions. So notwithstanding the criticisms of self-medication motives, the repetitious nature of the “insanity of addiction” does not necessarily contradict. Rather, it begs the question whether addictive behaviors accomplish or fix anything for those who repeatedly resort to it.
To Matt’s credit, he followed up with several e-mails and a phone call to indicate that he was more aggressively seeking out an addiction counselor locally to obtain support and to regain control of the drinking.
Dr 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 in private practice and specializes in addiction psychiatry.
1. Khantzian EJ. The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. Am J Psychiatry. 1985;142:1259-1264.
2. Khantzian EJ. The self-medication hypothesis of substance use disorders: a reconsideration and recent applications. Harvard Rev Psychiatry. 1997; 4:231-244.