THE GUILFORD SUBSTANCE ABUSE SERIES

HOWARD T. BLANE and THOMAS R. KOSTEN, Editors"

Recent Volumes
Psychotherapy and Substance Abuse: A Practitioner's Handbook
ARNOLD M. WASHTON, Editor
Introduction to Addictive Behaviors. DENNIS L. THOMBS
Treating Alcohol Problems: Marital and Family Interventions
TIMOTHY J. O'FARRELL, Editor
Clinical Work with Substance-Abusing Clients
SHULAMITH LALA ASHENBERG STRAUSSNER, Editor
Clt:an Start: An Outpatient Program for Initiating Cocaine Recovery
WILLIAM E. McAULIFFE and JEFFREY ALBERT
Clinician's Guide to Cocaine Addiction:
Theory, Research, and Treatment
THOMAS R. KOSTEN and HERBERT D. KLEBER, Editors
Alcohol Tolerance and Social Drinking: Learning the Consequences
MURIEL VOGEL-SPROTT
Removing the Roadblocks: Group Psychotherapy
with Substance Abusers and Family Members
MARSHA V ANNICELLI
Group Psychotherapy with Adult Children of Alcoholics:
Treatment Techniques and Countertransference Considerations
MARSHA V ANNICELU
Children of Alcoholics: Critical Perspectives
MICHAEL WINDLE and JOHN S. SEARLES, Editors
Preventing AIDS in Drug Users and Their Sexual Partners
JAMES L. SORENSON, LAURIE A. WERMUTH, DAVID R. GIBSON,
KYUNG-HEE CHOI, JOSEPH R .. GUYDISH, and STEVEN L. BATKI
Alcohol in Human Violence. KAI PERNANEN
Clinical Textbook of Addictive::: Disorders
RICHARD J. FRANCES and SHELDON I. MILLER, Editors
Drinking and Driving: Advances in Research and Prevention
R. JEAN WILSON and ROBERT E. MANN, Editors
Addiction and the Vulnerable Self:
Modified Dynamic Group Therapy for Substance Abusers
EDWARD J. KHANTZIAN, KURT S. HALLIDAY,
and WILLIAM E. McAULIFFE
Alcohol and the Family: Research and Clinical Perspectives
R. LORRAINE COLLINS, KENNETH E. LEONARD
PSYCHOTHERAPY
AND SUBSTANCE ABUSE
A Practitioner's Handbook
Edited by
ARNOLD M. WASHTON
THE GUILFORD PRESS
New York London
I60
BASIC ISSUES AND PERSPECTIVES
Trimpey,]. (1!i94a). The shortcomings of RET in addictions. Journal of Ration-
al Recovery, 6(6),7-12.
Trimpey,). (1994b). "Treatment" is dead. Journal of Rational Recovery &(6)
1-2. ' ,
Willis, C. S. (1992). A preliminary look at Rational as an alternative
. to Alcoholics Anonymous. Paper presented at AABT annual convention
Boston, MA. '
Young, H. (1989). Practicing RET with Bible-belt Christians. In W. Dryden (Ed.),
Howar.d Young; Rational therapist (pp. 77-96). loughton, Essex, England:
Gale Centre. 8
Addiction as a "Self-Medication"
Disorder: Application of Ego
Psychology to the Treatment
of Substance Abuse
SUSAN LYDEN MURPHY
EDWARD J. KHANTZIAN
INTRODUCTION
Substance abuse and dependence are tied intimately to an individual's
attempt to cope with his/her internal and external environments. Viewed
from a contemporary psychoanalytical perspective, suhstance dependence
can best be understood by examining how such a person's ego organiZij,,,.
riQl\.and sense of self serve or fail thdndividuat's'attempts tocope,'and
how. the .specific effects of various substances facilitate or impede such
Mack, & Schatzberg, 1974; Wurmser, 1974; Blatt,
Rounsaville, Eyre, & Wilber, 1984; Treece & Khantzian, 1986).
The psychodynamic study and treatment of substance-abusing in-
dividuals has yielded findings that indicate that a range of,self-regulation.
are involved in addictive disorders. These
and disturbances are accessible, understandable, and
modifiable through psychodynamic treatment methods (Khantzian, Hal-
liday, & McAuliffe, 1990). Findings based on psychOdynamic approaches
are supported in the main by empirical diagnostic findings that document
161
162 BASIC ISSUES AND PERSPECTIVES
coexisting psychiatric disorders, including a range of personality disord-
ers (Khantzian & Treece, 1985; Rounsaville, 1990).
Clinical findings suggest that addiction results when individuals dis-
cover that the drugs they experiment with can relie:ye or control the pain- .,
','<"; -1
derive from defiCitsin.:egogpa<;@,.h the
dbjeclcdations. In other words, .it is.,the .. vulnecabk",
is the central problem in addiction. . . .. ,.
The psychodynamic perspective is valuable because it provides a
basis to explain some of the subjective and experiential aspects of the
meaning and function of substances in a person's life. It also explains
SOme of the qualities and functions that characterize substance abusers
and provides a basis for understanding that individuals, through their
substance abuse, are trying to work out and solve human problems in
coping.
A psychodynamic perspective does not and should not compete with
findings that derive from biology, social SCience, and systems theory.
These latter perspectives complement those derived from a psychodynam-
ic one. Ultimately, the challenge remains to understand and think about
addictive disorders in integrative terms. It may be helpful at this point
to present some of the alternative theories that account for substance
abuse. Each of the perspectives of geneticS, social science) psychodiag-
nostics, and family and systems theory has an advantage in describing
certain features and etiologial determinants of substance abuse.
For ease of presentation, this review of competing theories will use
Lettieri, Sayers, and Wallerstein's (1980) framework, which identifies four
areas of theoretical focus: whether the theory focuses'on one's relation-
ship to nature, to others, to society, or to the self.
Theories that focus on one's relationship to nature include those that
propose a genetic marker or predisposition to alcoholism or other sub-
stance abuse in certain iridividuals and those that posit a primary role
for chemical receptors in the brain.
Although these theories, including those of Schuckit (1985), note the
importance of environmental factors in the initiation of substance use,
the point here is that biology truly is destiny. Substance abuse, in these
theories, does not denote psychological problems but simply the exis-
tence of a biological system programmed to respond in a certain way to
chemical agents. Indeed, these researchers suggest that the
@gY'assoCiated"with-"substance abuse is a consequence, not ,a'cause, ,of
tlhronic sllbstan@use, and that much of this psychopathology disappears
with successful treatment.
Theories that focus on onc's relationship to others are most often
seen within the context of family. and The substance
abuser -isseenas.the ':symptombearer" fOLa system that is
able to maintain a precarious state of equilibrium only by assigning the
responsibility for all family problems to a designated member. Here the
Addiction as a "Self-Medication" Disorder
163
addictive behavior of the patient serves afunctionforthefamHy, which
has an investment in maintaining the system.
These theories, which are often used to explain concepts such as
codependence, assume the existence of concordant psycho:logical disord-
ers within the family system, including the member whose role is that
of identified patient.
Theories that focus onf!lq'detyAnciude those that attempt to explain
the addictive process in terms 'ofdrug subcultures. Here, substance abuse
and addiction secure a role for those individuals who are otherwise
alienated from or disenfranchised by SOCiety.
This phenomenon is often referred to as substance abuse as a career,
The drug provides more than a means of getting high; it provides a rea-
son to get up in the morning and to embark on those activities that will
provide the money needed to maintain a habit and a way of filling time
in a productive fashion that would otherwise be denied to those individu-
als who cannot get or keep a normal job. In this context, substance use
is also seen as pr.ov-iding the user with a community of like-minded in'-
.dividuals who acknowledge and accept the user's place in the substance-
using culture.
Societal theories also help to explain the use of alcohol and the place
of the neighborhood bar in 9ur culture. Individuals who might other-
wise have difficulty forming and maintaining affectional bonds have a
ready-made environment in which they can find both comfort and- status.
The question of preexisting psychological disorders that might predi-
spose people to substance abuse is an important philosophical question
for the societal theorists. If people cannot find and keep a satisfying po-
sition in their culture, is it the individual who is disordered or the socie-
ty? In general, however, the incomplete socialization assumed in these
examples is seen as signifying characterological impairment or ,deficit.
There are also competing theories of self, or psychodynamic theories,
Which have been put forward to explain substance abuse. Early psycho-
dynamic formulations were based on drive. thepry, which placed an em-
phasis on pleasurable and aggreSSive drives and the unconscious meanings
of substance use, as well as models that emphasize the' 'sensation-seeking"
nature of those individuals who are predisposed to abuse substances. In
these models, the instinctive and pleasurable aspects of substance use ex-
plain the compelling nature of addiction (Carrol & Zuckerman, 1977;
Zuckerman & Neeb, 1979).
Other models stress the self-destructive aspects of substance use, or
what Menninger referred to as "chronic suicide." These psychodynam-
ic models presuppose the existence of qnc09sciQ4s wishes and self-
destructive trends and see substance abuse as a _qeurotic_compromise for-
mation betw,een ,conflicting drives and needs, a that allows
the person to stay alive. while acting on the need to harm the self.
More recertt psychoanalytical formulations have placed greater em-
164 BASIC ISSUES AND PERSPECTIVES
phasis on problems in adaptation, ego and self disturbances, and related
psychopathology as etiological factors in substance dependence (Krystal
& Raskin, 1970; Murphy, Rounsaville, Eyre, & Kleber, 1983; Bell & Khant-
zian, 1991).
A variety of substance use patterns and degrees of dependence may
be identified in which everyday problems of living are involved. However,
we believe that becoming and remaining addicted to substances is in most
instances associated with a range of psychological vulnerabilities and relat-
ed characterological disturbances. Taken from the psychoanalytical per-
spective, the meaning, causes, and consequences of substance use can
be understood Dest by considering how the personality
ticularly ego.psychologicaband self structures, of an
-with subjective_statesofdistress,-environmental influences,
effects'. Such an approach can explain both more benign, self-limited
degrees of substance involvement and the more malignant patterns of mis-
use and dependence.
THE SELF-MEDICATION HYPOTHESIS
Khantzian's self-medication hypothesis holds that substance-dependent
individuals are predisposed to use and to bec()me dependent on substances
primarily as a result of ego impairments and disturbances in their sense
of self, involving difficulties with drive and affect defense, self-care, de-
pendency, and need satisfaction. The theoretical work that follows fo-
cuses on these imp'lrlf!!l:fflfs-all'd'distlli"tiances in the ego and the sense
orsl':lr.'""
The use of sUQstances as an adaptive device was explored in Khant-
zian's early work (Khantzian etal., 1974; Khantzian, 1974, 1975), which
focused on the relationship of heroin use to a range of human problems,
including pain, -stress, and dysphoria. In attempting to adapt to one's emo-
tions and one's the action of the substance and immersion
in the drug subculture could be used to mute, extinguish, and avoid a
range of feelings and emotions. Rather than settling for more ordinary
defensive, neurotic, characterological, or other adaptive mechanisms as
a way of dealing with di"stress, substance users adopt an extraordinary
solution by using a powerful drug (Khantzian et aI., 1974). Dysphoric
feelings, when experienced by individuals whose ego stability is already
subject to dysfunction and impairment as a result of developmental ar-
rest or regression, are a disorganizing influence on these individ.uals' ego
functions. Thus, it appeared that the use of substances by such individu-
als was in the service of drive and affect defense.
In recent years, considerable attention has been focused on self psy-
chology. In contrast to ego psychology, in which the emphasis is on dis-
turbance in structure and function in coping with drives and emotions,
Addiction as a "Self-Medication" Disorder
165
self (or narcissistic) psychology relates more to troubled attitudes and ex-
periences about the self and others. Kohut (1971) and Kernberg (1975)
explored how disruptions and disturbances in a person's eady develop-
ment, particularly around nurturance and dependency needs, lead to self-
pathology in adult life. Both investigators consider and
dependence manifestations of such disorders, although neither Kernberg
nor Kohut has systematically explored this relationship. A number of in-
vestigators have attempted to relate this recent understanding of narcis-
sistic processes and disturbances to substance dependence. Reports by
Weider and Kaplan (1969), Krystal and Raskin (1970), and Wurmser
(1974) stressed narcissistic vulnerabilities and decompensation as
predisposing factors. Wurmser, in particular, noted that substances are
used to counteract the distress.nd dysphoria associated, with decompen-
he emphasized the importance of painful af-
fects involving hurt".rage, .shame,- and loneliness'. More recently,. Dodes
(1990) pointed out the role of helplessness and reactive narcissistic rage
as important factors that precipitate, relapse to the use of substances.
Both the ego psychological and self structures of an individual con-
tribute to the individual'S personality organization, and as part of the per-
sonality, structures interact with painful affects, environmental
influences, and substance
ADDICTION AS A SELF-REGULATION DISORDER
Clinical work with substance abusers suggests that four areas of self-
regulation problems, namely, affect life, self-esteem, relationships, and
self-care, predisposed these individuals to become dependent on and to
relapse to substances of abuse. -
Self-Other Deficits and Satisfaction of Needs
A feeling of self-worth derives from the comforting, valuing, and valued
aspects of early parenting relationships. When these relationships have
optimal, individuals can comfort and soothe themselves or reach
out and depend on others for comfort and validation. When develop-
mental deficits and impairments occur in relation to such needs, we see
extreme and contradictory patterns around needs and wants, qualities
not uncommon in substance abusers (Khantzian, 1990).
These narcissistic disturbances lead to problems in accepting depen-
dency needs and in actively pursuing goals and satisfactions. Such
problems often attach themselves to and painfully play themselves out
in family life, personal relationships, and career issues. They also manifest
themselves in certain attitudes incorporated into one's personality or-
ganization, such as excessive self-sufficiency, disavowal of needs, bravado,
166 BASIC ISSUES AND PERSPECTIVES
and counterdependence, all of which make human contact more difficult
and substance abuse more likely. These defenses and the related charac-
ter traits are employed in containing a range of longings and aspirations,
but particularly those related to nurturanceandcdependency.needs. It is
because of the massive repression of these needs that such individuals
fe"hcutoff, hollow, andempty:It is the inability of these individuals to
acknowledge and pursue actively their needs to.be. admired; and to
and be loved, that leaves them vulnerable to substance use (Khantzian,
1990).
Self-Care
Self-care as an ego function is complex. It is probably the result of a num-
'ber of component Junctions and defenses such as signal anxiety, reality
testing, judgment, control, and synthesis. When this function is impaired,
defenses such as denial, justification, and projection are used. We are all
subject to our instincts, drives, and impulses, and if they are expressed
indiscriminately, we are subject to hazard and danger. Most of us check
ourselves and automatically exercise caution, or we are appropriately
worried and fearful of the prospects of danger or hazardous involvements.
Such checking or cautionary responses are all integral part of our ego
mechanisms of defensc., However, it is exactly in this regard that sub-
stance abusers are deficient in their ego capacities for self-care (Khantzi-
an, 1991).
Problems with self-care develop out of a failure to adequately inter-
nalize self-protective survival functions which are established in early
phases of development. Self-care problems such as accidents and prevent-
able medical, legal, and financial difficulties are evident in histories predat-
ing substance abuse, where we see a persistent inability to worry about,
anticipate, or consider the consequences of action or inaction (Weiss,
Mirin, Michael, & Schugub, 1986; Khantzian, 1991).
These self-care deficits are also evident in the disregard for danger
seen in the supstance use itself. Characterological features of this vulner-
ability are evident in the substance abuser's counterphobia, hyperactivi-
ty, impulsivity, aggressiveness, and denial of danger (Brehm & Khantzian,
1992). In our opinion, it is the combination of deficits in self-care and
affect defense that malignantly combine to make substance use and de-
pendence likely and persistent.
Affect Regulation and Affect Defense
Problems with affect defense are at the heart of substance dependence
problems. We see in these patients significant developmental failures in
which substances have been adopted to protect against overwhelming,
confusing, or painful affect as a consequence of structural impairments.
Addit.:tion as a "Se(f-Medication" Disorder 167
In"other substances are used-to ward-off or calm intense affects
OFtO relieve dysphoric states (Milkman & Frosch, 1973).
Individuals differentially medicate themselves with various classes
of substances to compensate for and to counter intense and threatening
affects associated with the defects and distortions in affect defense. The
"hoice of substances used generally. correlates with the affect defended
against, Opiates are most often deployed against rage and aggression,
whereas stimulants are used either to counter states of depletion, aner-
gia, and depressive affect, which often is atypical or subclinical in na-
ture, or to augment hypomanic states. Depressants, including alcohol,
are used to ameliorate states of emptiness and isolation due to rigid, over-
drawn, and counterdependent defenses. Khantzian (1975) referred to this
process as self-selection, in which a person discovers that the short-term
effect of a certain substance results in improved functioning or a sense
of well-being by augmenting shaky or impaired defenses or by. produc-
ing a release of feelings from rigid and constraining defenses.
However, the literature on infant research and affect development
suggests that much of the substance abuser's experience of affects is pain-
ful, not only because feelings are intense and overwhelming but because
feelings are often absent, confusing, and without words.
This quality has been ref .... red to by such terms as alexitbymla, dis-
affected, affect deficit, bypopboria,and nonfeeling responses and ap-
pears to be a key reason why such patients often appear superficially to
be free of distress (Wurmser, 1974; Krystal, 1982; McDougall, 1984).
The use of substances as an affect defense thus also points to what
Krystal describes as affect regression, a global and undifferentiated ex-
perience of emotions that can only be poorly verbalized and are there-
fore partly converted to somatic sensations.
The Control of Addictive Suffering
Although substance abusers attempt to relieve their suffering through the
use of drugs and alcohol, it appears that their main, goal is the control"
ratherthan the eradkation, oftheir feelings.
These individuals suffer with their feelings because they often do not
recognize, understand, or control them, but when they take substances,
they can produce a condition which, over time, they are able to recog-
nize, understand, and control.
Even when the effects and aftereffects are unpleasant and painful,
these people have managed to substitute a dysphoria that they have in-
vented and controlled in place of a dysphoria that is elusive and that they
do not control. This is a use of the defense of turning the passive into
the active, a resort to external action in order to deny inner helplessness.
Having failed to develop adequate internal mechanisms for coping with
internal drives and the addiction-prone iildiv.idual is constantly
168 BASIC ISSUES AND PERSPECTIVES
involved with a range of behaviors and activities, including substance use,
in the external world to serve the needs for a sense of well-being, sec uri-
ty,and pleasure. Shaky or rigid defenses and low self-esteem cause the
addiction-prone individual to tucn more exclusively to the external en-
vironment for the satisfaction of needs and wants. Wurmser has referred
to this predisposition as an addictive search and has expanded eloquent-
lyon how such predispositions are part of the necessary and sufficient
causes that lead to addiction. It is the constant search and hunger for satis-
factions from one's environment, interacting with the more incidental
and adventitious influences such as exposure to drugs, drug availabiljty,
and peer-group pressure, that determine the initiation and continuation
of substance use.
Physical and Psychological Dependence
and Progression
Addiction-prone individuals' ego and self disturbances predispose them
to dependence on substances, given the general and specific appeal of
thest:: substances. There is a natural tendency in such individuals to use
heavier and heavier amounts, resulting in physiowgiJ:al
However, it appears that there is also a psychological basis to depend
increaSingly on substances. Substance use and dependence predispose in-
dividuals to progression in their usage gatterns, with a tendency to
preclude the development of more ordinary human solutions to life's
problems. In repeatedly resorting to a substance to obtain a desired ef-
fect, the individual becomes less arid less 'apt to come upon other
responses and solutions in coping with internal life and the external
world. It is in this respect that an addiction takes on a life of its own.
There is an ever-increasing tendency for regression and withdrawal,
which is compounded by society's inclination to consider such behavior
as deviant and unacceptable. Regressed and withdrawn individuals dis-
cover that, in the abse-nce of other adaptive mechanisms, the distressing
aspects of their condition can be relieved only by either increasing the
use of this preferred 'substance or switching to other substances to over-
come the painful and disabling side effects of the original drug of de-
pendence.
J The addict's relationship with and dependence on a substance are
(
' the result of failure to find more ordinary solutions to the human problems
;' of coping with emotional distress and seeking satisfaction for one's needs
and wants. Substances have been substituted as an extraordinary solu-
tion for a range of problems, but particularly as a means to cope with
major ego and self disturbances. However, these solutions are at best short
term and tenuous, and the long-term dependence on substances has seri-
ous, maladaptive aspects and consequences. As a result, substance abusers
may be very ambivalent about their substances. Often, consequences such
At!diction as a "Sef/-Medication" Disorder 169
as legal, medical, and interpersonal crises that result from long-term sub-
stance use break down the rationalizations and denial that have support-
ed their continuing substance use and dependence. At these times,
alternative solutions and satisfactions become possible and realizable and
may-for the first time with some people, and once again for some
others-make possible the replacement of substance use with human in-
volvements such as relationships, benign compulSive activities, religious
immersion, and becoming the treater rather than the treated. This may
occur or without treatment interventions or relationships.
CLINICAL VIGNETTES
In this chapter, we have reviewed some of the psychological vulnerabili-
ties that govern a reliance on and relapse to the use of substances of de-
pendence. We have focused primarily on painful and dysphoric affect
states and related vulnerabilities in self-regulation involving self-other rela-
tionships and self-care that predispose to substance use and that make
reliance on substances likely and compelling. In this section, we present
some brief clinical Vignettes to highlight how certain individuals use the
psychoactive properties of addictive drugs to modulate painful affects;
to manage with a deficient, restricted; or inadequate sense of self; and
to overcome interpersonal difficu'Ities.
Vignette 1: Alcohol and the Bipolar Self
The two women described here, Marge and Ann, shared a tendency to
be quite verbal and articulate. Although different in other respects, both
women discovered that alcohol served them well, temporarily, to over-
come subtle and painful problems with relating to people and express-
ing their emotions.
Marge was a hypomanic 48'year-old woman who despite her verbal
facility was surprisingly restricted in expressing her emotions. During an
interview in which she was struggling to describe: her problems with ex-
pressing herself and where her use of alcohol fit in to thiS, she said, "I
get on the phone and I want to drink and drink and drink. I want to be
able to feel sad-and to get happy." In the following psychotherapy hour,
she related how she had a wonderful joke to tell and that she drank three
glasses of wine in order to be able"to call people and share it." In con-
trast, during her interviews with her therapist she spoke rapidly and cir-
cumstantially in a manner that was defensive, irritable, and distancing.
Ann, a 42-year-old professor of art history who was active and effu-
sive, described how she used alcohol to overcome her characteristic ways
of responding to. hurt and disappOintment, especially in important rela-
tionships. She described how in her relationship with her boyfriend she
I70
BASIC ISSUES AND PERSPECTIVES
responded to distress with a "deep, icy calm." She spontaneously relat-
ed how. she had discovered that at these times, and in similar instances
when she felt cold and cut off, alcohol "always warmed" her.
Technical and lay accounts of alcohol effects often stress its appeal
as an antidepressant. In fact, alcohol is a poor antidepressant. The two
cases here, however, do bring out its shortterrn Hbeneficial" action. In
Marge's case, alcohol augmented both her experience and expression of
sadness and happiness. In Ann's case, the alcohol helped to soften the
characteristic and rigid defenses of isolation and withdrawal, which left
her feeling cold, empty and cut off.
Vignette 2: Cocaine and the Restricted,
Depressive Self
Jeff was an appealing and articulate 47-year-old college dean of students
with a long history of alcoholic drinking which progressed to a heavy
dependence on cocaine.
Jeff described how, since his high school years, "alcohol had allowed
me to get outside myself and put aside my reserved character." Without
alcohol, he said he was "retiring and quiet-[but when] drinking, I was
more expressive and better company."
In his mid-30s Jeft.discovered.cocaine. He said, "It allowed me to
be a lot of things I had been in the past. My energy returned, I had a sense
of humor and felt like a worthy companion again." Jeff had been feeling
anergiC and had bt:en avoiding social situations before this discovery. As
is often the case, Jeff's increasing use of cocaine prompted an escalating
use of alcohol, culminating in an admission to a detoxification and re-
habilitation program which allowed him to remain abstinent for 5 years.
About 1 year before being seen by one of us (EJK), the patient sought
out psychiatric treatment in the context of marital difficulties in which
he was again becoming increaSingly isolated and uncommunicative. Not
insignificantly, treatment with Prozac (fluoxetine hydrochloride) had dra-
matically reversed his symptoms to the point where, as he said, "words
out, unfiltered-I look forward to going home to nIY wife-
and I can laugh again."
In this case, alcohol had originally served Jeff as a disinhibiting
agent:'tater, he discovered that cocaine acted as a to
his depreSSive anergia, low self-esteem, and tendency to avold meaning-
ful or enjoyable social contact. His description of the more recent ther-
apeutic and corrective action of Prozac provides compelling testimony
of how individuals such as Jeff both knowingly and unknowingly attempt
to self-medicate a painful sense of restriction through the use of addic-
tive drugs.
Addiction as a "Self-Medicatiun" Disorder III
Vignette 3: Opiates, Anger, and Self-Hatred
Lorraine was a 39-year-old psychiatrist who sought consultation for de-
pendence on Darvon (propoxyphene napsylate), a synthetic opioid-type
analgesic. She had become dependent on the drug in the context of a
stormy, painful psychotherapy. The drug was originally prescribed for
a painful colitis condition, but her use of the drug escalated when she
discovered that it could also attenuate the intense emotions being stirred
up in psychotherapy.
She reported in the consultation that "the opiates calm me down-
they make me feel peaceful. The drug quiets down my self-hatred and
anger that I have from time to time. I become more optimistic-I use it
to cope. "
Lorraine's description of the antirage, antianger, and
ing influence of opiates is consistent with our experience in interview-
ing over 250 opioid-dependent individuals from many different
backgrounds, including professionals, street addicts, and patients like Lor-
raine, who have become iatrogenically dependent on narcotics. In our
experience, the drug's major action, and thus its appeal, is that it has a
powerful antiaggression and antirage action which ameliorates the
organizing subjective distress associated with such intense affect, as well
as the fear of counteraggression engendered by these emotions.
SPECIFIC GUIDELINES FOR CLINICAL APPLICATION
We are hopeful that the vignettes given here conveyed some of the specific
painful feeling states that make various classes of drugs appealing and
addictive. We also hope that these vignettes made evident our belief that
it is suffering, not pleasure seeking or self-destruction, Ihat is at the root
qfaddictive disorders. Individuals who suffer with addictions do so be-
cause they are unable to regulate their emotions, their behaviOrs, and their
self-other relationships. Treatments that are successful are those that ef-
fectively help individuals identify, understand, and modify their self-
regulation vulnerabilities and deficits.
Effective evaluation and treatment of substance abusers must take
place within the context of a gradually evolving treatment alliance. Such
a gradual approach allows individuals first to perform the necessary
ing up of their self-regulation vulnerabilities, including difficulties in es-
tablishing conditions of safety, trust, and mutuality, before attempting
to uncover and examine the self-defeating personality characteristics that
obscure and belie their suffering.
The outcome of such treatment is that many of those patients who
172 BASIC ISSUES AND PERSPECTIVES
were unable to sustain abstinence from substance abuse because of un-
derlying psychological factors escape the suffering that originally caused
them to attempt self-mt;dication and become able to maintain abstinence
and sobriety.
EVIDENCE OF EFFECTIVENESS
AND COST CONSIDERATIONS
Studies testing the efficacy and cost-effectiveness of treatments based on
a psychodynamic understanding of suhstance abusers are few in num-
ber. Some of the most important empirical work has been done through
the University of PennsylvanialVeterans Administration Medical Center
with patients enrolled in their methadone maintenance ptograms. Woody,
McLellan, Luborsky, and O'Brien (1986) were able to demonstrate that
patients with moderate to severe depression treated with supportive-
expressive psychotherapy responded more favorably and improved more
in terms of symptom reduction and overall functioning than did patients
treated with methadone and drug counseling alone. In our own work
at Cambridge Hospital and the Harvard Cocaine Recovery Project, we
have preliminary evidence that a modified dynamic group approach that
targets deficits in affect management, self-esteem, relationships, and self-
care helps to retain membership in groups and to achieve the benefits
of symptom reduction and improved fUllctioning for a majority of the
patients who were in the project (Khantzian et aI., 1990). More recently,
a report by Walsh et al. (1991), in which the benefit and cost of inpatient
treatment for alcoholics was compared both to 12-Step programs and to
a choice of programs, provided eviden;e that more intensive, inpatient
psychosocial treatments cost-effdctive and beneficial when meas-
ured in terms of postdischarge criteria such as number of days of alcohol
use and time lost from work as a result of drinking. A more extensive
review of the literature would, unfortunately, go beyond the scope of
this chapter.
CONCLUSION
Neither pleasure seeking nor self-destructive motives explain the com-
pelling nature of addictive disorders, which represent an extraordinary
solution to human suffering. Instead, 'it is vulnerability in or damage to
the psychological structures controlling affect defense, self-care, depen-
dency, and need satisfaction that lead people to use and to become de-
pendent on substances to regulate themselves.
. Although suffering is an inevitable and unavoidable aspect of life,
It appears that substance abusers have disabling problems with affect
recognition, affect tolerance, and qualities of self-other relations that
Addiction as a "Self-Medication" Disorder
173
produce a special relationship with suffering which these patients seek
to relieve while perpetuating it.
These individuals have discovered that the psychoactive properties
of addictive substances can temporarily regulate, by relieving or controll-
ing, painful and confusing feelings, including emotions that they feel about
themselves and others. Thus, these'substances may be used to relieve pain-
ful emotional states such as depression, rage, or anxiety; or drug effects
may be employed to counter states of emptiness, anhedonia, or the ina-
bility to access or give words to their feelings.
What Wurmser (1974) describes as deficits in affect defense, and
Krystal and Raskin (1970) refer to as the defective stimulus barrier of ad-
dicts, are vulnerabilities described in psychoanalytical terms that impli-
cate early trauma and developmental disturbances. The accompanying
problem of being unable to regulate their self-care blinds addicts to the
costly, precarious, and even lethal hazards entailed in their attempts to
correct their self-regulation difficulties. What originally was discovered
to be a self-corrective measure more often turns out, if unbridled and
untreated, to be self-destructive (Khantzian, 1975).
Before his suicide, the poet John Berryman suffered himself with sub-
stance abuse. Describing his emotional turmoil and his attempts to es-
cape from it, Berryman wrote: "Now there is further a difficulty with
the light I I am obliged to perform in complete darkness I operations of
great delicacy I on my self."
This is, in essence, what the perspective of ego and self psychologi-
cal approaches to substance abuse holds, that those who suffer with un-
bearable structural deficits are attempting to operate, in the dark, on their
damaged selves.
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