Edward J. Khantzian, MD

[[{"type":"media","view_mode":"media_crop","fid":"42468","attributes":{"alt":"Â© robtek/shutterstock.com","class":"media-image media-image-right","id":"media_crop_4392161276738","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4605","media_crop_rotate":"0","media_crop_scale_h":"200","media_crop_scale_w":"109","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â© robtek/shutterstock.com","typeof":"foaf:Image"}}]]I have been working with individuals who have succumbed to and recovered from addictive disorders for the better part of 5 decades. It has been an adventure taking me into the realm of human vulnerability, suffering, and resiliency. The journey has also shown me that addicted individuals have many of the same life experiences we all encounter. In the realm of human psychology, we all face issues of survival and getting along with each other. Our common challenges include regulation of our emotions, self-esteem, relationships, and self-care. Put more simply, to study addiction is to study the psychological challenges we all face. In what follows, I offer some vignettes drawn from clinical experience and daily life that allow us to consider some of the lessons learned from addiction.

My patients who have experienced the benefits of 

 have taught me the 2 most important ingredients for their success: show up and hang in there.

To run the risk of sounding corny or simplistic, the 2-part secret is an effective guide to dealing with many of life’s problems, and recovering addicted individuals learn this well. There has been ongoing controversy over the past several decades whether 12-step programs are the preferable approach for addictive disorders. Some of this debate is legitimate and some of it polarized and unfortunate. As with most effective therapeutic regimens, when adhered to the results are beneficial. In Alcoholics Anonymous (AA) and related programs, there is a saying, “More meetings more sobriety; less meetings less sobriety; no meetings no sobriety.” I offer a recent clinical example.

Nancy, a 57-year-old patient whom I hadn’t seen for several years, suddenly called me late one night. It was evident that besides being intoxicated, Nancy was frantic about her condition and its effect on her work and career. She asked for help “getting some rest” and getting detoxified from her heavy reliance on alcohol. I gave her an appointment for the next morning for an evaluation and referral to an appropriate program for detoxification and rehabilitation.

When I first saw her the following morning, I was struck by her haggard appearance and rambling manner-a far cry from the poised, attractive, and well-spoken person I remembered. Although she had abstained from alcohol for 9 years and had participated in regular AA meetings, after a divorce from an abusive husband she had stopped going to meetings and resumed periodic drinking. Over the past couple of years, her alcohol consumption increased and she was now drinking heavily. Initially she was resistant to my suggestion that she be hospitalized but finally agreed to self-commit for detoxification. She called me that evening, more lucid and articulate, and expressed relief to be there and mentioned that she had attended a good AA meeting.

At our family Thanksgiving dinner 6 months earlier, I had shared the 2-part secret to life with 10 of our grandchildren. I told them that I had learned the secret from my patients and that I was thankful that their parents adhered to this idea and always showed up for their children, hanging in, for example, by driving them to athletic and social events. I said how thankful we were for our grandchildren successfully sticking with their academic and athletic activities. I reminded them that all of this was not without disappointments and setbacks, but that they were succeeding by persistence, again emphasizing our gratitude for that. I was pleased several days later when 2 of my children mentioned how impressed the grandchildren were with my Thanksgiving thoughts.

I believed that Nancy’s comment about “a good AA meeting” in the detox program might be a hopeful sign that she would get back to the basics of showing up and hanging in there. She needed the connection with others to correct her tendency to isolate, which was greatly amplified by her drinking. She needed to share her shame and guilt for her relapse, to benefit from a caring and forgiving environment, and to be supported by people who could help her work through her feelings about losing control and loss of self-esteem.

I may seem preachy, but more hopefully, instructive in reminding my patients (and my grandchildren) that success in life requires paying attention to the basics, starting with showing up and hanging in there.

Look both ways before crossing the street

Self-care, which some individuals who are prone to addiction lack, involves basic habits of health and safety. More specifically, it affects how individuals think, feel, and behave around dangerous and risky situations. The rule of crossing the street is a basic one-but it likely goes back further than that. Think of the toddler in the family room who bumps into a coffee table. Most parents know enough to comfort and soothe the child and caution him or her to be careful. However, some parents hit the table and say, “Bad table!” That’s the wrong message. The toddler needs comfort and guidance, not a message that attributes the mishap to external environmental hazards.

Too often careless and dangerous behavior of addicted individuals is simply 

, stimulus seeking, and risk taking, when in fact we fail to consider how such an individual’s guidance systems (technically I refer to it as an ego function/capacity) for self-care and safety are underdeveloped or absent. Patients with addiction disorders think and feel differently in the face of danger, especially those involved with addiction and related behaviors. But these kinds of behavioral lapses and shortcomings are on a continuum for all of us. You need not have an addiction to suffer this kind of lapse. In what follows, I share maddening instances that involved operating an automobile, some of which test the limits of my self-care and safety:

There’s an alley for cars off the parking lot of my office building that leads in and out of the lot. The way out of the alley is a blind corner with no indication of traffic on the exit out of the lot. When I leave, I proceed with extreme caution because anyone driving out of the exit can’t see me. I continue to be dumbfounded by how little attention is exhibited by drivers zipping out of the lot with no thought to caution. It seems to be a clear setup for an accident. I suppose this seems like a minor hazard compared with the wide range of dangers we all encounter on our highways, but it still unnerves me that leaving my office feels like a daily opportunity for a major mishap. Perhaps I fuss too much, but maybe if we all fussed a little more, the world would be a safer place.

Tailgating also puts me and others in jeopardy. I sometimes glibly share my reactions about this with my patients to make a point about safe behaviors. Namely, I say there are 2 types of tailgaters-the mean ones and the oblivious ones. I emphasize the latter, but both greatly aggravate me (usually expressed not so delicately). I lament that there seems to be so little margin for safety with such driving.

But I leave out my own contribution to lapses in judgment when I angrily make some gesture (non-obscene of course) to tailgaters who place me and my passengers in danger. My wife has to remind me, and I have to remind myself, that it is at least as dangerous to react to tailgaters as it is to tailgate.

Working with patients in recovery, I learned to pay close attention to 

 and thoughts as a reaction to my patients’ stories of the dangers and risks associated with their addictions. I echoed those reactions to my patients so that they could appreciate and understand their lack of alarm that so often left them at risk. But, lapses in worry and thought fall on a continuum. The lessons learned by addicted patients in recovery about safe living should instruct us all about the value of caution and worry. When feelings of anxiety and fear are absent, we are often put in harm’s way; when they are extreme, we are paralyzed. The right dose of worry will guide us more than imperil us.

There are far too many disputes and polarizing arguments about the nature and treatment of addictive disorders. The influence of heredity is among the most notable. Scholars, clinicians, and the public debate its influence. Alcoholism is a prime example. Concordance rates for alcoholism among identical twins are 50/50: if one twin suffers from alcoholism, there is a 50% chance that the other twin will have the same disorder. Beyond twin studies, it is less clear how influential heredity is in the development of alcohol dependence.

A grandmother who had consulted me about her daughter’s alcohol misuse and later, her granddaughter’s addiction, wrote to me recently raising the question about heredity in a poignant email:

Not knowing how family mental issues can affect other generations I am sending you a summary of what I know of the families on both sides.

My mother suffered from depression and anxiety the last 35 years of her life. My brother Ted struggled with depression from his early 20s and used anxiety meds as drugs until he was 55, when he committed suicide. I have been treated for depression since 1976. Stewart [my daughter’s son] has been treated for depression but is not in treatment now. And as you know Sharon [my daughter] has dealt with drugs and depression. Thank God it seems that now it is under control. She still sees Dr F. My other daughter is also being treated for depression.

My husband was treated for depression over the last 12 years of his life. His sister’s son who had been on drugs committed suicide when he was 18. His sister’s daughter who is in her 60s was diagnosed as bipolar many years ago. Meredith’s [my granddaughter] uncle committed suicide several years ago. I do not know if drugs were involved or if he had depression. It is so frightening to see Meredith’s drug use and depression.

It is interesting how a narrative often makes a more compelling case than an empirical study. In the case of the grandmother, heredity jumps out as a possible cause of much suffering, disability, and tragic consequences. But if it is hereditary, it is not clear what is inherited. Is it a specific gene or is it temperament? Or is it a more complex interaction, with one’s childhood environment and aberrant DNA molecules, that renders so many to the fate that the grandmother and her family succumbed to? I learned from Meredith’s father, with whom I also consulted, that Meredith’s mother was abusive and neglectful. In addition, I had a chance to meet with Meredith about decisions for a rehab confinement to overcome a dependency on heroin. She revealed to me a pattern of emotional instability and major difficulties in controlling her behaviors. Her father’s accounts of her erratic behavior, and Meredith’s own description of her behavioral and emotional difficulties, appeared to be more consistent with a borderline personality organization, a condition that more often originates and is rooted in environmental influences and less so in genetics.

The lesson here is that once again, reductive conclusions about human development, whether they are about environmental or biologic factors, often obscure more than they clarify. The grandmother’s tale, most recently focusing on her granddaughter’s behavioral and addiction problems, begs the issue of complexity. The grandmother’s account of the apparent family biological loading, as compelling as it seems, leads to more questions than conclusions about our nature and susceptibility to the range of human troubles that befall us.

Beyond the lessons about persistence, self-care, and the complexities involved in causation offered here by those who suffer and recover from addictive disorders, there is more that can be learned from individuals who endure and mend. But a final message here is to gather in a few of them at a time to assure acceptance and empathy in tolerable and learnable doses. For those who endure these conditions, as well as for ourselves, who to varying degrees are challenged with these vulnerabilities, there is an opportunity to cultivate a kinder understanding of addicted individuals-and to see that we, too, can err or falter from similar human shortcomings.

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. He reports no conflicts of interest concerning the subject matter of this article. 

Articles

A reminder that success in life requires paying attention to the basics, starting with showing up and hanging in there.

Life Lessons Learned From Addictions

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.

[[{"type":"media","view_mode":"media_crop","fid":"33252","attributes":{"alt":"addiction","class":"media-image media-image-right","height":"140","id":"media_crop_6431869658057","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3503","media_crop_rotate":"0","media_crop_scale_h":"160","media_crop_scale_w":"113","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image","width":"99"}}]]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 

, 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:

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.

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.

When addicted persons in recovery speak of the puzzling sense of powerlessness and inability to control their drinking, as Matthew suggests in his e-mail, they also often indicate how the irrationality of it is so painful and bedeviling. As I indicated, the irrational component challenges me as well, on some days more than others, including whether the ideas and theories of addiction psychiatry are sufficient to address and explain what seems so unexplainable and confusing.

I offer a few thoughts here, drawing on my 

 and ideas about addiction, which might shed light on what often can seem irrational and incomprehensible. Although modern neuroscience research has yielded important findings on how substances alter the brain and contribute to addictive patterns of use and misuse, such brain changes and mechanisms alone are insufficient to explain the complexities of dependence on alcohol and addictive drugs. I do not suggest that I have all the answers, but I believe that clinical study and treatment of addiction offer valuable insights into repetitious, self-harm behaviors, as unreasonable as they may seem.

In treatment, my patients consistently reveal their life-long difficulties in dealing with their feelings. They have been plagued by issues of poor sense of self and low self- esteem. Their relationships with others suffer, and they find it difficult to practice self-care. Often they fail to appreciate very real danger-in their surroundings and especially those associated with addiction. I refer to these issues as the human challenge of self-regulation. Persons at risk for 

 are underdeveloped or deficient in some or all of these areas.

In my experience, in the context of experimenting with addictive substances, some people 

 (italics for emphasis) that addictive substances provide short-term relief from the pain, suffering, and dysfunction associated with their problems in regulating their emotions, low self-esteem, and difficulties with interpersonal relationships. These factors then malignantly interact with deficits in self-care to make addictive attachments more likely.

Thinking about addiction as a self-regulation disorder “helps” in part to explain how addictive substances assist in regulating a wide range of challenges. Considering addiction from such a perspective provides some measure of understanding for what seems so unreasonable, irrational, and incomprehensible.

Returning to Matthew and his dilemma: he knows that resorting to alcohol will be devastating, but he nevertheless feels powerless to avoid that prospect. As we so often say in our work as psychiatrists and mental health professionals, people have their reasons for what they believe, say, and do, as unreasonable and irrational as it may seem. Addicted individuals, including my patient Matthew, do not have exclusive claim to this aspect of human existence.

Emerging and Current Issues in the Treatment of Substance Use Disorders

This article was originally posted on 2/9/2015 and has since been updated.

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.

 Khantzian EJ. The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. 

 Khantzian EJ. The self-medication hypothesis of substance use disorders: a reconsideration and recent applications. 

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.

Insights on the Insanity of Addiction

[[{"type":"media","view_mode":"media_crop","fid":"23436","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4626438095575","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1846","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin: 4px; float: right;","title":" ","typeof":"foaf:Image"}}]]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 diminish 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 

. 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 therapy. 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

 has documented robust evidence that supports the efficacy of psychodynamic psychotherapy [See: 

]. 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 

 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 is told that he or she hasn’t bottomed out or “doesn’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 

 of addiction-I have experienced the attack and sting of polemic criticism and outright dismissal of my work and ideas. 

 dismissed the SMH as “dangerously false and misleading.”

 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 5 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 provides will suit them. When individuals reject AA, it should not necessarily be considered denial or resistance, and alternative approaches should be considered.

 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-occurrences with addiction are 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 is 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, when 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 to reflect on their unmindful and risky behaviors and to 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.

This article was originally posted online on 3/18/2014.

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. He is in private practice and specializes in addiction psychiatry.

Shedler J. The efficacy of psychodynamic psychotherapy. 

http://www.apa.org/pubs/journals/releases/amp-65-2-98.pdf

DuPont RL, Gold MS. Comorbidity and “self-medication.” 

Why do so many die as a consequence of addiction? Sadly-and in some cases disastrously-affected individuals are never offered alternative approaches after one option fails. More in this commentary.

Tragic Trends in the Treatment of Addictive Illness

As I approach my 80th year in life, I have come to the conclusion that we avoid a basic aspect of human existence-namely, we are all a little lost and not knowing, and we had better accept this. This is so whether it is the brash young man this morning who challengingly cuts in front of me to turn left when I thought I had the right of way at a 4-way intersection; an academic pundit who presumptuously affirms what addictive illness is or is not about (a matter that I have studied and pondered about for over 5 decades); the interminable standoffs of entrenched politicians unable to come to terms to make our society work better; or the chilling remoteness of the privileged, famous, and wealthy.

Instead of facing this fundamental reality, we posture in ways that counter the feelings of loneliness, uncertainty, and powerlessness that are so basic to our nature. Some strut with attitudes of invincibility, which, for example, can be the lot of high-performing athletes. The intellectually gifted speak with unfettered certainty about whatever is on their minds. Those unfortunate among us have endured childhood trauma, deprivation, and neglect; in adolescence and adulthood, they may adopt uncaring and troubling solutions of violence, the gang, or addiction to express or hide their vulnerability and the inescapable distresses and pain that are so much a part of life.

Maybe it is because I am a first-generation American, born shortly after my parents came to America. Perhaps it was because of and despite the trauma my parents had experienced in the first genocide of the 

 and, later, the great financial hardship when they came to America. They nevertheless remained unassuming, loving, and optimistic. I appreciated the pain and suffering they endured, but I also drew comfort and hope from them for a brighter future and a better world. But there always remained a part of me that was a little unsure and uncertain.

For all I know, the young man who cut me off was simply oblivious to me and in a hurry, but I suspect not. The academic who rigidly sticks to his ideas about the 

 is simply blinded by adhering to a certain perspective. The politicians who squabble are simply motivated by ideological convictions. And who knows what the rich, wealthy, and privileged really consider and experience about their “special” lot in life? In all of this there seems to be so much mean-spiritedness. Whatever attitudes, beliefs, or postures such individuals assume, they likely are so inclined because they draw some comfort or satisfaction from what they do or how they think and behave. But they also pay a price. Feeling secure and so empowered has its advantages but it comes at the cost of setting oneself apart and being less apt to find commonalities and connections with others, a fundamental and necessary aspect of mature human adaption.

, a student and scholar on the wisdom and benefit of 

, draws on the lessons of existential philosophers to instruct that acceptance of human limitations is the beginning of sanity for us as humans and the beginning of sobriety for alcoholics. A main lesson I have learned studying addiction is that we are less pleasure seekers (a myth commonly linked to addictive behavior) and more comfort and contact seekers. In the short term, addictive drugs and behaviors create the illusion of well-being and relatedness. This goes back to the beginning of life. Scholars of infant development have amassed a large body of evidence indicating that the infant is governed not so much by pursuit of pleasure or “oral gratification,” but more by the quest for comfort from and contact with his or her primary caregiver.

The human tendency to posture insensitively, arrogantly, imperially, and all-knowingly precludes us from facing and dealing with the lonely, confusing, and inescapably painful realities of human existence. I commonly remind my patients, especially in group therapy, that the worst fate in life is not to suffer; the worst fate is to suffer alone. It boils down to the challenges of creating in our own lives, and in society in general, multiple contexts, groups, and arrangements-therapeutic and otherwise-that foster meaningful and comforting connections and contacts with each other.

Individuals in recovery have learned this lesson well. Their AA meetings succeed in removing the offending agent (the alcohol) and, more importantly, the fellowship fosters personality growth that transforms them into more mature, caring, and altruistic people. Wouldn’t this suit us all better as individuals and as a society?

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.

We avoid a basic aspect of human existence-namely, we are all a little lost and not knowing, and we had better accept this. In reminding our patients that the worst fate in life is not to suffer-but to suffer alone-we also remind ourselves.

We Are All at Least a Little Lost and Off-Putting: On Transformation

I am a passionate advocate for group therapy. In nearly 5 decades as a psychoanalytically trained psychiatrist, I have found it to be an extraordinarily effective treatment for addictive disorders. It is equally beneficial in treating persons with a range of other disorders and distresses. I periodically jest that I turned in my psychoanalytic couch several years ago for a loveseat to better lend my office to group therapy.

In my experience, a psychodynamically grounded group 

 approach is a remarkably effective tool to address and to modify the difficulties in regulating emotions, self-esteem, relationships, and self-care that repeatedly contribute to the symptoms and characterological problems we treat. Other than specialty journals, I see few papers in mainstream journals that report on the experiences of clinicians or the effectiveness of group treatments. The remarkable case of Glen moved me to offer this “piece of my mind” on the subject matter. 

Glen* is a 42-year-old, successful businessman. On first meeting, he appears nonchalant. Yet, once engaged in conversation he is remarkably engaging and his keen analytical and admittedly critical mind are soon apparent.

The impetus for his seeking psychiatric treatment 8 years ago was the onset of panic attacks that responded to benzodiazepines and an SSRI. Glen had been in ongoing and intermittent supportive psychotherapy since then, but he resisted periodic recommendations for more intensive individual and/or group psychotherapy.

He and his siblings had been beaten as children by their father, while their mother stood by passively. His trauma history is complicated by ambivalence towards his father who sacrificed to provide for his family and assure that Glen and his siblings had a good education.

Glen disclosed that he was disdainful not only of strangers but members of his family as well. He felt little or no emotional connection to his 2 daughters, but enjoyed being with his 6-year-old son. He revealed that a beloved aunt was dying but he would not be troubled in the slightest when she died. Somewhat hesitantly, he suggested that he might even react that way if his wife were to die.

Eventually, Glen agreed to attend group therapy. Convinced that unresolved relationship issues could tragically cause him much unhappiness, he consented to join my group. I felt little headway was being made to understand or modify his puzzling (and I suspected painful) emotional detachment-when I thought a good connection was developing among the members, I asked Glen if he would feel bad if I died. With little hesitation he matter-of-factly said he didn’t think he would. Telling Glen that his panic, anxiety, and tension were related to his need to cut himself off from his feelings produced little effect.

After some time, Glen had a breakthrough. During a session, group members were discussing how a recent member, Peter,* dropped out shortly after joining. The conversation about Peter’s leaving prompted an exchange among group members about their abusive and traumatic experiences at the hands of cruel and neglectful parents. Some members admitted they had not connected with Peter. Glen in particular expressed his dislike.

Animatedly and enthusiastically, and with little warning, he effusively contrasted his reaction to Peter with his own behavior. He said, “I haven’t felt that [detachment] with any of you.” Without pause he added, “I like all of you and I feel I can say anything here and it feels safe.” Then he added, “I feel better and more comfortable when I come to group.”

A week later he offered, “It was not a great ‘ah hah! moment,’ but I had the longest talk with my older daughter this morning, more than I have had with her in a year-she’s a neat kid.” I interjected that perhaps he had wished it had been that way with his father. He quickly responded by saying, “If I thought about that for very long, I would want to kill him.”

 describe the rich affective and interpersonal therapeutic factors in groups that help patients to understand and work out their pain and characteristic ways of being. Their approach is consistent with modified dynamic group therapy (MDGT) for patients with substance use disorders.

In classical psychodynamic group therapies, the techniques are more strictly interpretive about characteristic defenses and transference reactions of the members towards the group leader and each other, or, interactions are interpreted about the group as a whole with an emphasis on group concerns rather than those of the individual. In contrast, MDGT follows the supportive-expressive tradition that emphasizes “fostering trust and connection among the members and the leader, and a high priority is placed on maintaining an atmosphere of safety and comfort in which characteristic and self-defeating ways of seeing oneself [and in the case of Glen, seeing others] are enacted and examined.”

Glen’s reactions from such a perspective can be seen less as involving defenses of repression or suppression but are more in the nature of the “vertical splitting,” whereby disavowed parts of the self are walled off.

 As Glen rather quickly figured out, the friendly, relaxed, and engaging elements of the group functioned to unlock the softer, caring, and more trusting parts of himself, as well as the walled-off rage of childhood trauma. 

The Theory and Practice of Group Psychotherapy.

 Khantzian EJ, Halliday KS, McAuliffe WE. 

Addiction and the Vulnerable Self: Modified Dynamic Group Therapy for Substance Abusers.

 New York and  London: Guilford Press; 1990.


Principles of Psychoanalytic Psychotherapy: A Manual for  Supportive-Expressive Treatment.

Kohut and the Psychology of the Self. London: Routledge; 1996.


Errant Selves: A Casebook of Misbehavior.

For this psychiatrist, group therapy has proved to be an extraordinarily effective treatment for a range of mental disorders. 

Psychodynamic-Oriented Group Therapy: A Pathway to Connection

Until the last half of this century, there were few if any treatments that seemed consistently effective in responding to the clinical needs of individuals who were abusing or dependent upon alcohol. As a result, as is so often the case when professionals are unable to provide adequate solutions for such problems, support or self-help groups emerged (Caplan, 1974). Alcoholics Anonymous (AA) is an extraordinary example of these groups.

AA had its beginnings in 1935 when two alcoholics, Bill W and Dr. Bob S, met and began to work with alcoholics in Akron, Ohio. Together they recruited others who admitted an inability to control their use of alcohol, who supported each others' attempts to abstain, and who spread the word that alcoholism was a disease, which alcoholics could help each other to overcome. Public admission of vulnerability, spirituality, taking inventory of one's life, admitting to personal wrongs, and sharing with and committing to help others became crucial elements in transforming the lives of alcoholics.

In 1974, Gerald Caplan described how such self-help groups (he called them 

) evolve, drawing attention to and providing legitimacy to understanding and remediating such problems. He observed that in doing so, the groups encourage professionals to become more aware of and involved with problems such as alcoholism. Caplan emphasized that self-help proponents and professionals do not need to, nor should they, compete.

In the first two decades of its existence, AA was slow to gain wide recognition or acceptance. Over the last half of this century, however, the program has grown to thousands of AA groups throughout the world, and an estimated 1.5 million to 2 million individuals are involved in AA (Emrick, 1994; Galanter et al., 1998). During this time, there have been an increasing number of medical and psychiatric practitioners and other health care professionals who have been more effectively responding to the medical and psychological problems associated with alcoholism. Early pioneers included William D. Silkworth, M.D. (Bill W's physician); Ruth Fox, M.D., the founder of the American Society of Addiction Medicine; and Stanley Gitlow, M.D., among other prominent physicians.

In conjunction with the successes of AA, the clinicians and investigators who have subsequently become involved have given increasing hope for prospects of treatment and successful recovery. Given the growing acceptance of both approaches, Caplan's original admonition that self-help programs and professionals need not compete has been replaced by a new challenge: how can AA work with and in psychotherapy-and why should it?

An increasing number of clinical investigators and scholars have studied the therapeutic elements of AA. (An extensive review of this literature goes beyond my scope here, but the interested reader is referred to recent reviews that examine these findings [Emrick, 1994; Galanter et al., 1998; Khantzian, 1994, 1995a; Khantzian and Mack, 1989]). There are, however, some investigators who have recently addressed more precisely how AA accesses and modifies alcoholics' vulnerabilities and what some of the psychotherapeutic implications might be for such patients in psychotherapy.

These authors identify crucial elements in AA that establish and maintain abstinence and, perhaps more significantly, draw attention to aspects of AA that are important in producing personality changes and modifying the distress and suffering associated with addictive behaviors. Bean's examination of how AA and psychotherapists can more effectively break through the denial of alcoholics (1975), and Brown's (1985) focus on the central problem of loss of control in alcoholics and the need to maintain their identity as alcoholics have been of singular importance. Bateson (1971) provided a scholarly description of alcoholics' proud and self-sufficient battle with alcohol and the need to relinquish this struggle and engage with others in meaningful contact. Kurtz (1982) focused on alcoholics' need to accept "essential limitation" and AA as a therapy for shame. I recently described how AA challenges alcoholics' problems with engagement and contact (Khantzian, 1995a). These perspectives all emphasize the importance of addressing characteristic (or characterologic) vulnerabilities in the personality organization of alcoholics, and their need for human connection and comfort.

Partly independent of and partly in conjunction with these recent views of AA, contemporary psychodynamic clinicians have focused on deficits in self-regulation and related defenses. These vulnerabilities and defenses involve feelings, self-esteem, relationships and self-care. Knowledge of these allows us to appreciate how and why alcoholics suffer in the ways they do, and what the psychotherapeutic implications might be for such vulnerabilities (Dodes, 1988, 1990; Khantzian, 1981, 1995a, 1995b; Khantzian et al., 1990; Krystal, 1989; Mack, 1981; Wurmser, 1974).

These findings and explanations of alcoholics' vulnerabilities and how and why AA works stimulated me to consider how psychotherapists need to function in evaluating, brokering, monitoring and directing roles to coordinate the clinical needs of patients with substance use disorders (SUDs) (Khantzian, 1988). I described the role of such a clinician as a 

 (Khantzian, 1988, 1985) and emphasized that psychotherapists must not use their alliance only to foster exploration of patients' vulnerabilities, deficits and defenses. I suggested it might be even more important, at least initially, to use the treatment relationship to broker other interventions-especially self-help groups such as AA-to establish abstinence, and to provide the needed support and comfort for alcoholics derived from being with others who suffered and struggled as they did.

The active involvement of the psychotherapist in the brokering and monitoring roles with AA and other needed interventions is important in a number of respects: It further facilitates the therapeutic relationship by maintaining a focus on survival requirement and the need for auxiliary sources of comfort and support; it allows the therapist to monitor how social phobias and/or panic might make AA unlikely as a beneficial prospect; in other instances it might be important in overcoming initial resistances to AA and other support groups; and it could help clinicians determine what combination of self-help and other therapeutic interventions, including or playing down individual psychotherapy, might be most beneficial for which patients.

AA works in psychotherapy because what is evoked in the storytelling and listening traditions in self-help groups naturally complements and resonates with the psychotherapeutic traditions of self-examination, acknowledging distress and coping with it, and fostering personality change. Psychotherapy by design is more interactive and has the added advantage of being more focused and guided. In this respect, clinicians have the special opportunity to pursue the problems of self-regulation, distress, and "character defects" that are revealed or stirred in the storytelling traditions (drunkalogues) of AA. Self-help programs and psychotherapy interact to mutually enrich a better understanding of the special needs and vulnerabilities of individuals in recovery. AA effectively prescribes needed control and direction (e.g., go to meetings; ask for help), and psychotherapy explores and focuses in a sustained way on the suffering and compensatory defenses associated with alcoholic vulnerability. Both stimulate personality change and maturation.

 Bateson G (1971), The cybernetics of "self": A theory of alcoholism. Psychiatry 34(1):1-18.


 Bean MH (1975), Alcoholics Anonymous: AA. Psychiatric Annals 5:3-64.


 Brown S (1985), Treating the Alcoholic: A Developmental Model of Recovery. New York: John Wiley and Sons.


 Caplan G (1974), Support Systems and Community Mental Health. New York: Behavioral Publications.


 Dodes LM (1990), Addiction, helplessness and narcissistic rage. Psychoanal Q 59(3):398-419.


 Dodes LM (1988), The psychology of combining dynamic psychotherapy and Alcoholics Anonymous. Bull Menninger Clin 52(4):283-293.


 Emrick CD (1994), Alcoholics Anonymous and other 12-step groups. In: Textbook of Substance Abuse Treatment, Galanter MC, Kleber HD, eds. Washington D.C.: American Psychiatric Press Inc., pp 351-358.


 Galanter M, Castaneda R, Franco H (1998), Group therapy, Self-Help Groups, and Network Therapy. In: Clinical Textbook of Addictive Disorders, 2nd ed., Frances RJ, Miller SI, eds. New York: Guilford Publications Inc., pp 521-546.


 Khantzian EJ (1995a), The 1994 distinguished lecturer in substance abuse. J Subst Abuse Treat 12(3):157-165.


 Khantzian EJ (1995b), Self-regulation vulnerabilities in substance abusers: treatment implications. In: The Psychology and Treatment of Addictive Behavior, Dowling S, ed. Madison, Conn.: International Universities Press, pp 17-41.


 Khantzian EJ (1994), How AA works and why it's important for clinicians to understand. J Substance Abuse Treat 11(2):77-92.


 Khantzian EJ (1988), The primary care therapist and patient needs in substance abuse treatment. Am J Drug Alcohol Abuse 14(2):159-167.


 Khantzian EJ (1985), Psychotherapeutic intervention with substance abusers-the clinical context. J Subst Abuse Treat 2(2):83-88.


 Khantzian EJ (1981), Some treatment implications of the ego and self-disturbances in alcoholism. In: Dynamic Approaches to Understanding and Treatment of Alcoholism, Bean MH, Zinberg NE, eds. New York: Free Press, pp 163-188.


 Khantzian EJ, Mack JE (1989), AA and contemporary psychodynamic theory. In: Recent Developments in Alcoholism, Vol. VII, Galanter M, ed. New York: Plenum Press, pp 67-89.


 Khantzian EJ, Halliday KS, McAuliffe WE (1990), Addiction and the Vulnerable Self. New York: Guilford Press.


 Krystal H (1989), Integration and Self-Healing: Affect, Trauma and Alexithymia. Hillsdale, N.J.: Analytic Press.


 Kurtz E (1982), Why AA works: The intellectual significance of Alcoholics Anonymous. J Stud Alcohol 43(1):38-80.


 Mack JE (1981), Alcoholism, AA and the governance of the self. In: Dynamic Approaches to the Understanding and Treatment of Alcoholism, Bean MH, Zinberg NE, eds. New York: Free Press, pp 125-162.


 Wurmser L (1974), Psychoanalytic considerations of the etiology of compulsive drug use. J Am Psychoanal Assoc 22(4):820-843.

Until the last half of this century, there were few if any treatments that seemed consistently effective in responding to the clinical needs of individuals who were abusing or dependent upon alcohol. As a result, support or self-help groups emerged. Alcoholics Anonymous is an extraordinary example of these groups.