Psychotherapy for addictive disorders

Commentary: Elders, Others and Addiction: Do They Care
and Want to Understand

Edward J. Khantzian, MD

I decided to write the following piece after I lectured to a
group of senior citizen. It turned out to be a remarkably
gratifying experience for the audience and for myself. In part I
think it was successful because I touched on a nerve of the
attendees, one that is of concern to so many these days, given
the tragic scourge of addiction that has cut such a wide swath
throughout our society. I covered a lot, namely the scope and
reasons for the epidemic, the psychodynamics of addiction,
and the challenges we face politically, socially, and the price
tag to address the needed remedies. Admittedly my audience of
lay people was at least upper-middle class and well educated,
but I still worried if my perspective and some of the clinical
issues I raised would miss the mark because they would not be
aligned with their interests, concerns and priorities. It turned
out they were deeply engaged, including a keen interest in the
extent and nature of addiction problems and what it would
entail to !x them. Although it was likely not a person there was
not on Medicare, their questions and comments revealed,
beyond their lot in life, that their concerns about addiction
issues touched most of them, either personally, their families
or friends.

I was recently asked to speak to a group of seniors. I was
much surprised by the turnout of 250 citizens. The group
sponsoring the lecture is committed to life-long learning for
seniors andmy lecturewas one of a series to address “hot-button
issues.” I had planned to speak aboutmy experience, spanning 5
decades, of working with individuals who had succumbed to
addictive disorders focusing on the theme of “why some
individuals aremore vulnerable than others.”But the day before
and the day of my presentation I began to panic about my
audience and what the scope of my presentation should be.

This talk is generally well received, especially given the
mounting concerns about the scourge of addiction throughout
our society, and usually consists of clinicians, counselors and
educators. My audience this day was different—the seniors.
So I panicked a bit—wouldmy audience be responsive to or be
interested in my psychodynamic and psychiatric perspective
on vulnerability to addiction? Beyond the usual issues I cover
in this talk, I realized for it to be meaningful for this audience I
had to at least make reference to social, cultural, and biological

contexts of addiction, and not least of all was the epidemic of
addiction and the role of opiate drugs. Also, I wondered
whether I should avoid or tone down technical issues about
addiction and the psychodynamics of addictive vulnerability
to which I usually refer. To put it less tactfully, should I
“dumb-down” my talk? About this last concern—no need to
worry, I diluted little from my usual presentation and they
were with me all the way.

So I started by referring to some of my own daunting
concerns about the magnitude of the addictions scourge, to
which I quickly sensed my audience resonated. I cited a recent
New York Times article indicating that more than a thousand
young people were dying in our country eachweek from opiate
overdoses. In passing I mentioned that the President just that
week had declared we had a “public health emergency” with
the epidemic. I mischievously made an aside that if he had
called it the National crisis that it was, public funds and
Federal support would follow as a remedy. Most of the
audience caught the irony and chuckled. Next I wanted to
make reference to the context of the social, psychological and
addictive issues that are involved with the development of this
disorder. I continued with the following prefacing remarks:

! Human unhappiness and sadness is an inescapable part of
life. Some of us handle it better that others

! We were living in a time in our country where there was
more unhappiness and misery as evidenced by divisive
rancor played out in our political discourse with each other

! I contrasted the sense of feeling “less-than” in under
privileged sectors of our society, versus the enormous stress
and strain that the more privileged experience, especially
among the young to compete and excel

! That there were counter-productive polarized contentious
concepts approaches to what addiction was and what to do
about it, albeit the contention not as bad as it used to be

! That one of the best kept secrets in medicine was that
addiction was treatable. Namely there were options that
worked, such as self-help (eg, AA and NA), talking
treatments (eg, individual and/or group treatments), and
when combined with each other and with medication
assisted treatments (MATs—methadone, buprenorphine,
naltrexone, etc.) were extremely bene!cial and often life
savingReceived January 7, 2018; accepted March 3, 2018.

The American Journal on Addictions, 27: 161–162, 2018
Copyright © 2018 American Academy of Addiction Psychiatry
ISSN: 1055-0496 print / 1521-0391 online
DOI: 10.1111/ajad.12706

161

! I reminded my audience that suffering was not the worst
fate; suffering alone was the worse fate, and that the
combination of these treatments was an extraordinary
antidote to the isolation, stigma, suffering and chaos,
associated with addiction

! I made reference to the down-side of all the illuminating
breakthroughs by the neurosciences how addictive drugs
affected the brain over the past 3–4 decades; but too often
they minimized, overshadowed or detracted from a better
understanding and appreciation of the human psychological
vulnerabilities that pre-dispose to addiction.

! And !nally, by way of background I reviewed how the
changes in the way which drugs are dispensed andmarketed
can affect and produce unanticipated problems and tragic
consequences. For example, taking the acetaminophen out
or Percocet1, and taking aspirin out of Percodan1, each of
which contain only 5mgms of oxycodone allowed dispens-
ing of large amounts of oxycodone. The original reason for
the removal of the acetaminophen and the aspirin was that
excessive amount of either could be toxic, the former
wrecking the liver and the latter wrecking the gut.
Unfortunately the removals allowed huge doses (eg, 100–
500mgms) of the opiate making addiction more likely.
I then shifted to the main focus of my talk, namely why

some of us are more vulnerable than others to become
addicted. I stressed the fact that despite the purported
seductive and captivating nature of addictive substances,
millions of individual consume and use these drugs, but only
10% or less become addicted. This is the case whether it is
prescribed by a physician, or whether it is in the case of
adolescent experimentation and use. That is, these drugs are
not universally appealing. I stressed the life challenges of
regulating our emotions, self-esteem, relationships and self-
care, and how the properties of addictive drugs interact with
the discomfort and suffering so many of us experience with
these self-regulation challenges. Namely susceptible individ-
uals, affected by troubled and traumatic life experiences dating
back to childhood, and/or individuals with co-occurring
psychiatric conditions, discover that addictive drugs short
term relieve, change, or make more bearable the unending
suffering associated with their self-regulation dif!culties.

I then went on to explain that in my 5 decades of treating and
studyingaddictivedisorders Ihadbecomeconvinced that suffering
is at the root of addictive disorders, and not old and new ideas and
theories of addiction that emphasize pleasure seeking or self-
destructive motives. I spoke of the idea or theory of self-
medication, a hypothesis of addiction that I originated and
published in 1985. I de!ned the theory of self-medication, namely
that addictive drugs (i) short term relieve psychological suffering;
and (ii) that there is a considerable degree of preference, or

self-selection in an individual’s drug of choice. I described the
action of each class of drug, namely the effects of opiates,
depressants (especially alcohol), and stimulants respectively, and
how each class of drugs interact with and or ameliorate particular
distressful states of feelings and suffering. I stressed that certain
people have enduring painful states of subjective distress, not
necessarily psychiatric disorders, but that some do suffer with
psychiatric conditions (I listed and described a number of the
conditions) which are exceedingly distressful, wherein particular
painful feelings predominate. Short-term these conditions are
relieved by one class or another of these addictive drugs.

In my concluding remarks, I reemphasized that more than
anything addiction has to do with suffering. It has little to do
with pleasure seeking, and addiction is not motivated by self-
destructive motives. States of persistent psychological suffer-
ing, distress, or co-occurring psychiatric disorders make it
more likely that a person might be prone to develop a
dependence on addictive drugs, and that the idea or theory of
self-medication is a valuable, humanistic way to understand
and treat addictive disorders. In addition, it is an important
model to counter the stigma and prejudices associated with
addictive behavior. The idea of self-medication helps to
understand and accept, rather that to condemn and reject,
individuals with these disorders. And understanding that
addiction is rooted in suffering can and does effectively guide
our group, individual, and medication assisted treatments of
addictive disorders.

I guess my talk was a great success. More than usual, so
many in the audience connected with my talk and ideas, as was
evident with the astute questions they asked, their attentive-
ness and the surprising number of seniors who effusively
thanked me for my talk as they were leaving.

I realized from their reactions I should extend my talk or
“conversation” to my colleagues and the broader community.

There are so many critical issues that need to be addressed
and are in need of change to better deal with the staggering
challenges in our society of addictive disorders. We should
stop unproductive arguments with each other about the nature
of addiction and how to treat it. We should be better
communicating with each other about different approaches
and strategies for intervention and treatments, and combining
and integrating empirically proven programs that work. We
need more certi!ed well trained addiction counselors,
clinicians and practitioners to address, diagnose, and treat
addictive disorders

And !nally we need the political will and public support to
assure adequate funding to address the social, psychiatric and
psychodynamic conditions that co-occur with and are
intimately associated with addictive disorders.

162 April 2018

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