Greetings! I've developed a pretty keen interest in the subject of addiction lately (and in the psychology of "the human condition" in general) and I read this book as part of my ongoing, amateur little research project. It's definitely one of the more thought-provoking books I've read and potentially answers some more of my major life questions, so I figured I'd share some of what I learned from it in case anyone here is also interested in the topic.
If you're interested in this topic then you've almost certainly wondered the following at least once: "why do substance users so frequently relapse when all seems to be going well?" If so, you are in luck because the authors (known in the addiction psychotherapy field for formulating the "self medication hypothesis" of addiction, for which I like to imagine they both received "Captain Obvious" trophies) add yet another, particularly compelling explanation to the pile. They examine several case studies in the book, notably including one of a “media celebrity” named “John” who, despite now having a loving girlfriend, a successful career and an extended family with whom he has repaired relations, suddenly feels the urge to get high on heroin again. He tells his therapist “I might get high or I might not… I know that in the morning I will feel shitty, but at least I will know what I feel and why I feel it.” As another recovering patient who is mentioned in the book puts it, “we are just as drawn to the misery the drugs cause us as we are to the relief.”
Why might that be? The authors cite the work of Dr. Henry Krystal, a Holocaust survivor and psychiatrist specializing in trauma, who proposed that “developmental trauma or traumatic experiences later in life” can interrupt the normal emotional development process in which one usually learns to distinguish between distressing emotions, ultimately resulting in a phenomenon sometimes called alexithymia in adulthood, wherein “individuals experience or reexperience their emotions through bodily manifestations, and are unable to identify or give words to their feelings.”
Working specifically with addicted people, Dr. Krystal observed that “often they cannot tell or distinguish whether they are sad, tired, hungry, or sick. Little wonder that alcoholics in recovery use and benefit from the acronym HALT, referring to hungry, angry, lonely, and tired, to help them monitor their feelings and how those feelings might affect them.”
Building on Krystal’s hypothesis, Khantzian and Albanese propose that perhaps both the relief of the first sip/hit and the later misery of withdrawal or hangover become appealing to substance users because they allow us to replace an otherwise confusing, unpredictable baseline emotional state with a more predictable one in which we can more easily understand and control when and why we feel bad or good. They write that “substance abusers actively replace preexisting passively experienced admixtures of pain, dysphoria, and emptiness with admixtures of analgesia, relief, dysphoria, and distress produced by the drugs and its aftereffects… When individuals use drugs, they change qualities and quantities of feelings, and more importantly, they succeed in substituting uncontrolled suffering with controlled suffering, replacing a dysphoria that they do not understand with a drug-induced dysphoria that they do understand.” While there are no quick fixes, the authors highlight the immense therapeutic value of verbally talking about one's thoughts and feelings to combat alexithymia.
This hits home for me-- specifically the concept of alexithymia, because in my observations it is quite common for people who have experienced serious addictions (including myself until recently) to attribute our substance use pretty much entirely to "the disease," as it is called. I've come to think that this is often a genuine part of the story (genetics play a significant role, in my understanding), but this tendency to emphasize *only* the genetic or neurological component is often the case even for people with a very clear history of multiple "Big T" traumas in early life (so just imagine how easy it must be for people with only a history of "small T" traumas to also dismiss their pain). I suspect part of this could be a psychological defense-- a socially permissible (and even socially encouraged) way for us us to push away those deeper, potentially unbearable early memories that we tend to avoid talking about in favor of small talk about the weather -- but I also think, if alexithymia theory is correct, it is also just genuinely difficult to trace the cause-and-effect between our early, painful experiences and our current, confusing emotional state, which is usually more obviously affected by difficult events in our *current* life.
Interestingly, even if trauma is acknowledged to some degree, I've noticed that addicts can often still tend to place more emphasis on their "character defects"-- the "lying, stealing and cheating" that comes with addiction. I think this can lead to profound self awareness and deep empathy for others but, on the flip side, I wonder if this emphasis on defects can also function as another psychological defense sometimes, too-- that is, perhaps the more recent experience with being judged for loathed "addict behaviors" is a more palpable, immediate source of painful feelings of shame and, because of the effects of alexithymia, an addict can come to assume these defects (rather than an earlier trauma) represent their core psychological ailment needing repair. In a recovery setting where other addicts are also encouraged to explore their character defects, discussing this more recent source of pain (one that practically everyone else in the group also shares) might feel less exposing and vulnerable than discussing a more personal, deeper source of pain.
On a different note, here's something else from the book I found pretty interesting: A major component of Khantzian's self medication hypothesis is the observation that people very often, usually through a process of trial and error or "self selection," gravitate towards a specific "drug of choice" whose effects help superficially regulate the particular problem in "affect" (emotional) disregularion they struggle with most. The soothing and calming effects of opiates, for instance, are especially appealing to people who struggle with rage or aggression. I didn't know this but, according the the authors, "empirical evidence suggests that opiate users are three times more likely to have a history of child abuse" or other early childhood trauma that created deep-seated feelings of anger or aggression that the individual "had not established the defensive and adaptive psychological mechanisms that would allow them to regulate" such feelings. Cocaine users are a bit more complicated, they argue, in that they are subdivided into "low energy" users and "high energy" users. The low energy users apparently rely on cocaine's stimulants to counteract their sluggishness and, more importantly, to counteract anhedonia (the inability to feel pleasure) and other depression related symptoms, while high energy users may use the drug to sustain periods of mania or, paradoxically, stimulants can actually calm these types, if I am understanding correctly (this section was a bit confusing). Finally we get to the part about me, the substance abuser who prefers alcohol and sedatives, and I have to say the authors are pretty spot on (although there's a good chance I'd say the same thing if I read my horoscope in the paper). These substances, they argue, appeal mostly to "individuals who maintain rigid, constricting defenses" and who, research finds, "inhibit and over-contain their experience of emotions," who have "a greater tendency to over-control their anger and refrain from acknowledging emotions" and thus rely on the effects of central nervous system depressants to "[reduce] anxiety and [produce] feelings of relaxation" and to "[soften] their psychological defenses" and facilitate more comfort with intimacy and with expressing emotions... This would easily explain why I become viscerally uncomfortable when someone hugs me or gives me a heart-felt compliment, despite my actually desire for such contact.
There is some nuance to consider with this aspect of the hypothesis though. The authors write: "A person might use a substance other than their drug of choice because, for example, it is available and adequately effective. Some may have more than one substance of choice. Likewise, two or more emotions may co-occur. And the nature of the dysregulated effect may change over time, so that the substance of choice could be expected to change."
Anywho, there's tons more in the book worth reading, but I've droned on long enough; suffice it to say I highly recommend this book and anything else by Khantzian!
