Life Lessons Learned From Addictions

October 19, 2015
Edward J. Khantzian, MD
Volume 32, Issue 10

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

[[{"type":"media","view_mode":"media_crop","fid":"42468","attributes":{"alt":"© 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":"© 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.

The 2-part secret to life

My patients who have experienced the benefits of recovery 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.

CASE VIGNETTE

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 attributed to impulsivity, 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 my feelings 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.

Disputes and debates about heredity

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:

Dr Khantzian,

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.

Thank you for your help.

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.

Some final musings

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.

Disclosures:

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.