Edward J Khantzian

• MD
• Harvard Medical School

An understanding of addiction to drugs and alcohol and their treatment is reviewed from a modern-day psychodynamic perspective drawing on ego/self-psychology and object relations and attachment theory. The author places emphasis on addictions as a self-regulation disorder. Deficits in regulating emotions, self-esteem, relationship, and self-care in...

The author reviews recent developments in psychoanalytic and psychodynamic theory and practice and their applications to understanding and treating addicted individuals. Emphasis is placed on experience near, more interactive, and empathic approaches stressing structural, self-psychology, object relations, and attachment theory in contrast to early...

In contrast to early psychoanalytic theory, which stressed pleasurable/aggressive drives and the symbolic meaning of drugs to explain their appeal, a modern psychodynamic perspective of substance-use disorders (SUDs) places greater emphasis on intolerable painful or confusing affects that make addictive drugs compelling. A psychotherapeutic relatio...

Background Stimulant medications have shown promise as a treatment for cocaine dependence (CD) for several decades, yet these treatments have not been widely studied and substantial barriers to clinical implementation remain. The “Self-Medication Hypothesis,” posits that an individual's choice to use a particular substance is to some degree based o...

The literature on relapse to addictive behavior tends to emphasize external triggers, albeit this literature does consider emotional factors. In this paper we review insights garnered from the literature on individual psychodynamic psychotherapy with addicted individuals that help to understand factors that predispose to and maintain addictive beha...

Contemporary psychodynamic therapists, as contrasted with early ones, are more active and interactive, less dependent on interpretations, and more focused on affects, self-regulation, and interpersonal relations, with a premium placed on the therapeutic alliance. Evidence supports the utility and effectiveness of the psychodynamic paradigm. Two cas...

The psychological factors that predispose an individual to substance abuse are the same factors involved in relapse, a major threat to recovery from a reliance on substances. Modified Dynamic Group Therapy (MDGT) is a group therapeutic approach that is sufficiently supportive and structured to provide the safety and comfort that such patients requi...

This dialogue between two clinicians who have each specialized in the treatment and psychodynamic research of addiction over many years considers the continuing relevance of psychodynamic views and the importance of a broadly self-medication and relational stance. We discuss the psychotherapy of addiction and those qualities required by the worker,...

According to E. J. Khantzian's (2003) self-medication hypothesis (SMH), a psychoanalytically informed theory of substance addiction that considers emotional and psychological dimensions, substance addiction functions as a compensatory means to modulate affects and self-soothe from the distressful psychological states. To manage emotional pain, dysp...

An evolving perspective (1970-1980)Group therapy as a corrective (1980-2000)How do groups work?Conclusion

The harm reduction paradigm has been proposed as a beneficial therapeutic alternative for substance dependent individuals who cannot or do not readily achieve abstinence. A brief discussions is presented on how this alternative has fostered another unproductive polarized controversy in the addiction field. The author presents a group vignette in wh...

The author discusses papers by Director and Burton, placing their work in a context of contemporary psychoanalytic models for understanding addictive behavior. Whereas early psychoanalytic models stressed drive theory and a topographic model of the mind, the contemporary models discussed here emphasize themes of dissociation—integration, helplessne...

This report describes the MICA (Mentally Ill Chemically Abusing) Program at the Tewksbury Hospital campus in Tewksbury, Massachusetts. Several campus facilities collaborate in the MICA Program. Through Expert Case Conferences, principles of integrated psychosocial treatment with dual diagnosis patients are demonstrated. An expert clinician focuses...

The self-medication hypothesis (SMH) is derived from clinical work with patients who have substance use disorders (SUDs). There are two core aspects of the SMH, namely that substances of abuse relieve human psychological suffering in susceptible individuals and that there is a considerable degree of psychopharmacologic specificity in an individual'...

This article addresses how and why groups help people with addictive disorders feel better and change. It advances the position that problems in self-regulation and the psychological suffering that ensues are at the root of addictive disorders. Group work is especially effective in addressing these problems, providing a means of relief, and examini...

Substance abuse is a common comorbid illness in patients with mood disorders. Little has been written about the pharmacologic treatment of patients with affective lability and co-occurring substance abuse, however. The following report will describe clinical experience using divalproex sodium in substance-abusing patients with mood disorder. Twenty...

Background: Substance abuse is a common comorbid illness in patients with mood disorders. Little has been written about the pharmacologic treatment of patients with affective lability and co-occurring substance abuse, however. The following report will describe clinical experience using divalproex sodium in substance-abusing patients with mood diso...

This is a remarkable book in its scope, conviction, and perspective. The author, Dr Robert L. Dupont, has been a prominent figure and voice for the prevention and treatment of substance use disorders for the past quarter of a century. He is not dispassionate about his subject matter. This is evident not only in the amount of material that he covers...

The self-medication hypothesis of addictive disorders derives primarily from clinical observations of patients with substance use disorders. Individuals discover that the specific actions or effects of each class of drugs relieve or change a range of painful affect states. Self-medication factors occur in a context of self-regulation vulnerabilitie...

Alcoholism is associated with tremendous suffering, psychological denial, and physical and emotional debilitation. Much of the suffering that plagues alcoholics is rooted in core problems with self-regulation involving self-governance, feeling life (affects), and self-care. Alcoholics Anonymous is effective because it is a sophisticated group psych...

A review of the substance abuse literature in the 1980s focuses on deficits in self-regulating capacities, in self-care functions, and in other vulnerabilities of the self, such as an inappropriate use of defenses and problems in intimacy. Various models which attempt to explain these behaviors are described, as well as techniques of dynamic psycho...

This new book by John E. Gedo, erudite and provocative, is characteristic of his four decades of effort as a psychoanalyst. In it, he addresses two fundamentally important problems in psychoanalytic theory and practice, namely, linking or connecting the clinical observations of psychoanalytic practitioners to a scientific understanding of the mind,...

A review of the substance abuse literature in the 1980s focuses on deficits in self-regulating capacities, in self-care functions, and in other vulnerabilities of the self, such as an inappropriate use of defenses and problems in intimacy. Various models which attempt to explain these behaviors are described, as well as techniques of dynamic psycho...

The effectiveness of psychotherapy in the treatment of substance abuse continues to be debated among theorists and practitioners. This paper proposes that psychotherapy can play an important role in the treatment of the addictions. However, it is critical that this psychotherapy is geared toward the special needs of substance abusers. Using researc...

Contemporary psychodynamic perspectives on addiction, along with the disease model and Alcoholics Anonymous (AA), consider control the core issue of problems with addiction. Contemporary psychodynamic treatment also complements the 12-step treatment approach. Both AA and the psychodynamic perspective are attuned to the paradoxical nature of control...

Individuals prone to substance dependence suffer because they cannot regulate their emotions, self-esteem, and relationships. Furthermore, they suffer with deficits in self-care in which they fail to anticipate harm and danger, including those associated with substance use. Deficiencies in regulating emotions and self-care malignantly combine to ma...

The renewed public, governmental, and professional interest in addictive disorders should serve to encourage the interest of psychiatrists in this important and rapidly changing field. It is the view of the Group for the Advancement of Psychiatry (GAP) Committee on Alcoholism and the Addictions that all psychiatrists should possess expertise in the...

Addicts and alcoholics suffer vulnerabilities and deficits in self-regulation. A principal manifestation of their self-regulation disturbances is evident in the way they attempt to self-medicate painful affect states and related psychiatric problems. Individuals select a particular drug based on its ability to relieve or augment emotions unique to...

AA’s success rests on its ability to establish and maintain abstinence. This basic and essential accomplishment has tended to detract from the fact that AA is successful in good part because it is a sophisticated psychosocial form of treatment that addresses human psychological vulnerabilities that alcoholics and others share related to problems of...

The author advocates that a clinician play the role of a primary care therapist (PCT) for substance abusers to assure that appropriate treatment interventions are provided to meet patient needs. In treating substance abusers, the PCT must be concerned about patients' needs for control, containment, contact, and comfort, especially initially, but al...

Psychotherapy with substance-dependent physicians presents special problems. Accurate assessment and effective response is rendered difficult due to underrepresentation or denial by the patient and countertransference impediments to recognition and limit setting by the therapist. Case examples illustrate problems, pitfalls, and therapeutic strategi...

This book is well suited for serious students of the mind who seek a perspective on the intellectual ferment going on in contemporary psychoanalysis. At the same time, it provides a scholarly and clear presentation of the history of ideas and scientific method in psychological thought in particular and in medicine in general. John Gedo's book about...

The article which follows this introduction was originally published as a Special (Cover) Article in the American Journal of Psychiatry in the November, 1985 issue, the same month in which the First International Drug Symposium, sponsored by The Bahamas Ministry of Health and The Embassy of the United States of America, was convened to discuss the...

In this article we have brought to bear on the complex problem of substance dependency the psychodynamic perspective: a model that views the problem from the inner experience and psychological structure of the individual drug user. Chronic drug dependence has been associated with a range of personality styles and psychopathologic conditions but mos...

This article has no abstract; the first 100 words appear below. Specialists in addiction and general clinicians debate hotly the relation between psychopathology and substance abuse. Positions tend to polarize, with one camp supporting the "disease concept" and holding that alcoholism causes psychopathology, and the other, more traditional, camp at...

Quant a la pertinence du role de la psychiatrie et de la psychanalyse dans le traitement de l'alcoolisme, le septicisme persiste. La perspective psychodynamique devrait permettre la levee des dernieres reticences

In contrast to early psychodynamic formulations of addictions which stressed pleasure seeking or self-destruction, a modern psychodynamic perspective places greater emphasis on understanding addicts' disturbances in regulating their internal emotional life and adjustment to external reality. Effective treatment rests on providing interventions and...

We diagnosed and classified a diverse sample of 133 narcotic addicts using DSM-III criteria. Seventy-seven percent of the sample met criteria for one or more diagnoses on axis I, and 65% met criteria for a personality disorder on axis II. In total, 93% met the criteria for one or more psychiatric disorders other than substance abuse. Although heter...

Recent clinical observations and psychiatric diagnostic findings of drug-dependent individuals suggest that they are predisposed to addiction because they suffer with painful affect states and related psychiatric disorders. The drugs that addicts select are not chosen randomly. Their drug of choice is the result of an interaction between the psycho...

OUR CALL as physicians to the profession of medicine involves complex motives. It is probably safe to say, however, that for most of us, making people healthier, taking care of patients, or repairing them plays some part. As we attend to the injuries and dysfunctions of our patients, we also attend to our own. The healing traditions constantly chal...

Drug/alcohol dependent individuals need to discover and understand how they have adopted extraordinary drug solutions for a range of problems. I believe human relationships can best provide this opportunity through either a professional psychotherapeutic relationship or peer group experiences such as group therapy and self-help groups such as AA or...

Explores evidence from the psychoanalytic and psychiatric literature and from clinical experience that supports the likelihood that people who become dependent on drugs have a psychological predisposition to do so. The nature of this predisposition is discussed, and evidence that this also holds true for cocaine dependence is presented. It is sugge...

The authors report on three cases of cocaine dependence treated with methylphenidate. All patients treated showed marked to dramatic improvement with regard to toxic/abstinence signs and symptoms, craving behavior and other behavioral disturbances associated with heavy and chronic cocaine abuse. The authors explore the possibility that cocaine depe...

A patient with an extreme case of cocaine dependence improved remarkably with methylphenidate treatment. Her extreme, exclusive reliance on stimulants suggests that certain stimulant and cocaine addicts might be medicating themselves for prediposing or resultant affective and behavioral disturbances.

The literature reporting on aspects of ego functioning and psychopathology among narcotics and polydrug dependent individuals is reviewed. Data are presented which indicate impairment in ego functioning and evidence of considerable psychopathology in three groups of drug-dependent individuals entering an inpatient detoxification/treatment unit. The...

Evidence is reviewed for considering an ego-impairment/psychopathologic basis for understanding alcoholism. Despite conflicting reports, there is also evidence that psychotherapeutic and psychopharmacologic treatment may be effective. The author describes his management and treatment of alcohol problems based on an appreciation of the alcoholic's e...

A variety of old an new substances and drugs with powerful psychotropic effects have come into common use during the past decade. Patterns of involvement include experimental, occasional, regular controlled, and regular uncontrolled use, with physical and psychologic dependence and toxic reactions as the frequent result of abuse patterns. This incr...

The aim of this paper is to explore some of the important interrelationships of drug use/dependency and impulse problems. Over the past fifteen years mental health professionals and citizens alike have been inundated by accounts in the mass media and in the scientific literature that link drug use/dependency with criminality, violence, brutality, a...

This paper will focus on group psychotherapeutic work with narcotic addicts in an outpatient program using methadone maintenance and other support services. The authors demonstrate some of the problems and challenges of working with such a group of patients. They delineate how the program structure and therapeutic strategies evolved in response to...