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Edward J. Khantzian, MDClinical Professor of Psychiatry,

Harvard Medical SchoolCambridge Health Alliance

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Perhaps it took a little time, but it seemed to happen

instantly. He could feel his body relaxing, a stiffness

going out of his shoulders as he sensed the warm

glow seeping through him in all the distant forgotten

corners of his being . . . It was a miracle. There was

no other word. A miracle that was affecting him

mentally, physically, and, as he would soon

learn, spiritually.

Bill W.’s first experience with alcohol as reported to hisbiographer, Robert Thomsen

A half century of study by clinical investigators

The importance of understanding the human psychological

underpinnings for addictive behavior

If you don’t understand it you can’t fix it

To understand and to be understood is a powerful remedy for

the confusion, chaos, and suffering associated with addictions

AA is a special place where such understanding develops

Psychoanalytic influences on the beginnings of AA and the

“Big Book”

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First, what addiction is not:

– Pleasure seeking

– Human self-destructiveness

– Oral dependency

More than anything, addiction is about fundamental problems in self-regulation

Individuals self-medicate the distress and pain associated with self-regulation problems

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As humans we are governed less by instincts and

more by coping skills and capacities acquired from

the caretaking environment. Requirements for

human survival and adaptation place a lifelong

challenge on humans for self-regulation.

Regulating emotions, self-

esteem, relationships, and behavior, especially self

care, are among the main functions upon which

our survival depends5

Involves (based on practice based evidence):

An inability to recognize and regulate feelings

An inability to establish and maintain a coherent,

comfortable sense of self and self-esteem

An inability to establish and maintain adequate,

comforting, and comfortable relationships

An inability to establish and maintain adequate

control / regulation of behavior, especially self-

care6

Drugs enhance or contain feelings

Drugs effect ones sense of self, wellbeing and self-esteem

Drugs effect our ability or inability to careabout or to connect to others

Experimentation with and dependence ondrugs are influenced by ones capacity for self-care

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Feelings are experienced in the extreme: They are absent , vague, and confusing or they are overwhelming and unbearable

Developmental deficits or regression– Affects have a normal (or abnormal) developmental

line Krystal 1988

Affects are inaccessible, vague or confusing– The problem of alexithymia, disaffected, non-feeling

responses Sifneos et al 1977

The problem of anhedonia – do addictive drugs produce pleasure or do they relieve displeasure?

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Inner states of well-being and cohesion are elusive or lacking

Feelings of inadequacy, impoverishment, insecure Kohut 1970, 1977

Feelings of helplessness and rage Dodes 1990

Narcissistic defenses of omnipotence Director

2005

Problems of dissociation Burton 2005

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“If only they could be dependent”

– “We don’t have relationships, we take hostages” anonymous

– The challenge of interdependence

Khantzian & Mack 1989

Creating the capacity for attachment Walant 1995

Addiction as an attachment disorder

Flores 2005

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The primary motivational drives in all mammals

along lines suggested by Bowlby and Fairbairn

are not pleasure seeking or self-destruction (as

some old and modern theories would suggest

EJK italics); rather our drives are object (i.e.

relationship) seeking and comfort seeking.

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Addictively prone individuals think and feel differently around danger and harm

Anxiety, fear, or apprehension are absent or failto guide such individuals in risky situations

There is a failure to draw cause/consequence relationship in the face of risk

Shame and guilt more often comes after the fact than before it

– e.g. “I felt stupid and bad when I did that” [rather] “I will feel stupid and bad if I do that”

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Consists of:

An investment in caring about or valuing oneself – sufficient self-esteem to feel oneself to be worth protecting

The capacity to anticipate dangerous situations and to respond to the cues which anxiety provides

The ability to control impulses and renounce pleasures whose consequences are harmful

Pleasure in mastering inevitable situations of risk, or in which dangers are appropriately measured

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Knowledge about the outside world and oneself sufficient for survival in it

The ability to be sufficiently self-assertive or aggressive enough to protect oneself

Certain skills in relationship, especially the ability to choose others who, ideally, will enhance one’s protection, or at least will not jeopardize one’s existence

Khantzian and Mack 1983, pp. 210-211

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Khantzian EJ, Mack JEM (1994). How AA works and why it is important for clinicians to understand. J. Substance Abuse Treatment; 11:77-92

Khantzian, EJ (1995). Alcoholics Anonymous – Cult or corrective: A case study. J. Substance Abuse Treatment; 12:157-165

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Because addicted individuals are overwhelmed or confused by their feelings, because their self-esteem is shaky, because relationships are elusive or absent, and because their self-care is undeveloped or inadequate, practitioners should be guided by the following essential elements for their work with patients:

This slide and the following one are intended to guide staff, counselors, and facilitators in working

with patients in rehab

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Kindness (just in case this sounds obvious or preachy …)

Comfort

Empathy

Avoid confrontation (unless the devil makes you – but …)

Patience (remember the problems with alexithymia, action, avoidance)

Instruction (e.g., help individuals to learn about emotions and self-care)

Self-awareness (therapist/patient)

Climate of mutual respect (the therapeutic alliance)

Balance – talking/listening

■ AA offers human contact, understanding, and self-expression for individuals who are or have become unaccustomed to availing themselves of these basic human experiences and needs

■ Storytelling is the main vehicle

■ Telling and listening to stories help people to learn and appreciate they are not alone in their suffering and that there is hope

■ It helps people who have been out of touch with or unaware of feelings to attend to and take charge of them

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■ “Alcoholism is a disease of disordered emotions”

■ An AA attendee said, “You switch from pills and booze to people and feelings … it makes you feel better … lot of laughter … the common bond is suffering (Robertson 1989)”

■ Not uncommon to hear, “We didn’t do feelings growing up”

■ Members begin to appreciate how they substituted action or drugs instead of feeling their feelings

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AA as a group experience counters the predisposing and resulting self-absorption and interpersonal isolation associated with alcoholism

The group dynamics of AA compels the appreciation that one is not alone with their problems

12-step programs are a natural vehicle to address the shattered self-esteem and relational issues that predispose to and result from the ravages of a life immersed in alcohol

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The storytelling traditions and the sharing of experiences stimulates self-reflections, especially forcing the realization that one must live life on life’s term rather than one’s own terms

Group psychology, including the group dynamics of AA, counters feelings of shame and guilt and thus fosters meaningful and comforting connection to others

In doing so, the defenses of counter-dependency and self-sufficiency are gently challenged and gradually replaced with genuine care for and about others

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The 12-step traditions implicitly appreciate that what is “solved” with alcohol involves a desire or search for something beyond self for comfort and a better sense of well-being

The problem is the person went to the wrong address (“where do we aim what we thirst for”)

AA is a re-locating experience where the comfort and connection that was discovered with alcohol is replaced with the hope and promise that is provided with the human connections and relationships that the program provides

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The story telling traditions in AA directly and indirectly address the problems of behavioral dysregulation, especially self-care

They do so in that the stories constantly focus on the unthinking and unfeeling behavior involved in persistent drinking and relapse

Although not labeled as such, the stories cause recovering alcoholic individuals to think and talk about their mindless and thoughtless behavior, often with passion and healthy doses of humor

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■ AA works because it not only addresses uncontrolled drinking, but transforms the life of alcoholic individuals emotionally and spiritually

■ The attachment that had been made to substances in place of attachment to people is reversed

■ With abstinence and recovery, self-absorption and preoccupation with alcohol and drugs are replaced by genuine concern for others

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■ AA provides a forum to address the human tendency for self-centerdness and psychological denial

■ Members are reminded that they suffer with a disease, are powerless to control it, and can get better by going to meetings, ask for help, and not using today (my italics for emphasis)

■ When slips occur members are not scolded or banished, but are encouraged to remember that they are vulnerable and to learn from their mistakes

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Beyond the specific elements reviewed here, as

with any beneficial therapeutic program, there is

the essential ingredient of hope that 12-step

programs provide. It is imbedded in the

“promise,” of the program which more often

occurs : “If you don’t drink, things will get better”

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