“Addictions from an Attachment Perspective”—A Review (part III)

Share this Blog post

Welcome back from my interlude late last week. This is part III of my multi-part blog series wherein I review the 2014 edited volume entitled Addictions from an Attachment Perspective—Do Broken Bonds and Early Trauma Lead to Addictive Behaviours? We’ll start off looking at Chapter III—The Self-Medication Hypothesis and Attachment Theory: Pathways for Understanding and Ameliorating Addictive Suffering— by Edward Khantzian. Here we go.

Khantzian echoes Richard Gill’s introductory comments when he suggests that we not view persons displaying addictive behaviors as being “pleasure seekers” or “self-destructive characters,” but rather we should view them as “individuals who are in pain and seek and need contact and comfort.” Translation: people displaying addictive behaviors are indicating in their own way that they need attachment relationships with “alive and living objects” (see part II), but, for whatever reason, are not able to engage in such relationships. Because it causes individuals pain to not be able to engage in appropriate attachment relationships, Khantziam puts forward the idea that these individuals engage in self-medication. Again, these persons are not self-medicating to gain pleasure; they are self-medicating to relieve pain. I guess you could call addictive behavior an “analgesic” or pain-relieving process. Here’s how Khantzian describes what he is calling the Self-Medication Hypothesis (SMH):

The Self-Medication Hypothesis (SMH) derives from persistent clinical observation and inquiry about how individuals who depend on addictive substances do so because they have had the powerful discovery that what they suffer with is relieved temporarily by addictive substances.

I would suggest that the SMH also applies when addiction is not to a substance but to a process such as addiction to pornography or gambling. “A fundamental premise of the SMH,” writes Khantzian, “is that addiction behaviour is grounded in the human penchant (especially in the infant, but persisting into adulthood) for seeking comfort and contact, not pleasure.” Many of the authors writing (speaking) in Addictions for an Attachment Perspective engage in this type of reframing: reframing addiction not as pleasure-seeking or some sort of chemical or process “joyride,” but as repeated attempts to gain temporary relief from pain and suffering, the pain and suffering that comes from not being able to have comfort and contact with others.

Using the Self-Medicating Theory as a background, Khantzian tells us that addictive drugs “become compelling” for the addict for two main reasons:

  1. They relieve human psychological suffering
  2. There is a considerable degree of specificity in a person’s drug-of-choice

Khantzian then describes in some detail the “specificity” nature of opiates, central nervous system depressants (which include alcohol), and stimulants. I invite the reader to avail themselves of this information if it is of interest. Again, I would suggest that “specificity” extends to addictive processes such as addiction to gambling, sex, or pornography. Khantzian draws on his many years of clinical and research experience when he correlates “the elusiveness and absence of feelings” in addicts and the “repetitious, compulsive nature of addictive behaviour.” Informed by this apparently robust correlation, Khantzian frames therapeutic change as moving the person from “relief of suffering” to “control of the suffering.” As mentioned in part II, this shift from relief to control often comprises a “tortuous journey.” Why? Well, Khantzian provides some insight when he states: “Major trauma and neglect greatly heighten and worsen the self-regulation deficits that are so commonly and persistently associated with addictive disorders.” In essence, Khantzian frames addictive behavior as displaying an inability to self-regulate emotion. Khantzian gives us this “bottom line”: “Addicted individuals suffer because they cannot regulate their emotions, self-other relationships, and self-care. They self-medicate the pain and suffering associated with these self-regulation difficulties.” Using opiate and alcohol use as examples, here’s Khantzian summary of the above process:

When feelings are threatening, or overwhelming, opiates can become captivating in their ability to powerfully contain intense, disorganizing, and dysphoric affects, especially rage and associated agitation. Similarly, but not as effectively, high doses of depressants such as alcohol can contain such intense affect.

So, rather than framing addictions as pleasure-seeking, we should strive to frame addictions as repeated attempts to gain such things as containment, organization, and harmony of affective states. Recall that in my review of the book Origins of Attachment, I focus in on Beatrice Beebe and Frank Lachmann’s observations concerning dissociation. In part III of my Origins review, I write the following:

Beebe and Lachmann tell us that a propensity toward “dissociation may have its origins in early difficulties in integrating experience in the context of failure of maternal recognition, and intense stress that remains unrepaired.” Beebe and Lachmann suggest that the brain dissociates as a protection against too much stress resulting from an inability to make sense of incoming data streams, such as nonverbal, imagistic, acoustic, visceral, or temporal. Dissociation then is a form of calming the self (and the biological organism holding the self) once the self is no longer able to make sense of incoming data streams.

Ergo, addiction could be looked at as attempts to make sense of incoming data streams, such as nonverbal, imagistic, acoustic, visceral, or temporal. I would, however, add that integration brought about through an addictive process takes place within certain areas of the brain, say, the mid brain and its focus on objects (as I have blogged about in earlier posts). Louis Cozolino—a neurobiologist of some note— told us during a talk up in Santa Fe that the amygdala—the mid brain’s main fear center—is able to determine its own context divorced from the context often provided by upper brain regions, say, the prefrontal cortex. According to Cozolino, fear centers will often provide their own contexts when brain systems as a whole have experienced trauma or neglect. To move context from the mid brain fear centers to the upper brain regions is no easy feat. In the same way parents act as a prefrontal cortex for their kids, offering up context, reflection, and perspective, therapists too can act as a prefrontal cortex, which happens to be home to the Executive Function skills such as changing and updating cognitive models (i.e., Bowlby’s Inner Working Models), mental time travel (e.g., fluidly moving between past, present, and future), empathy, perspective taking, focusing attention, etc. Addiction, then, could be looked at as expressing a desire for the “higher” contexts of the upper brain. Sadly, addiction tends to imprison us within the fear stories emanating from mid brain centers such as the amygdala. All of this brings up Jungian implications, for instance, why an addict may become attached to so-called “dark side” archetypes. As Khantzian puts it, “Feelings of poor self cohesion and fragmentation are relieved by the calming action of opiates or sedatives.…”

Khantzian now delivers a case example to illustrate his Self-Medicating Hypothesis. I invite the reader to avail themselves of this case example. Khantzian does allow that at times he felt that the subject of his case example extended “to others what he wished had been extended to him during his traumatically damaging and depriving childhood.” Thus the adult hyper-caregiver unconsciously wishes he or she had been cared for as a child. The adult who focuses his or her love on a number of different people unconsciously wishes he or she had been the focus of attention.

Khantzian finishes up by bringing his observations back to a Bowlbian attachment frame. Khantzian states:

When early attachments have been compromised, disrupted, traumatic, and neglectful, the human tendency is one of relational retreat and isolation and to attach to the inanimate dependencies of addictive substances and behaviours.

Using the work of B. Reading as a background, Khantzian continues thus:

[I]ndividuals who might be addictively prone adopt the inanimate attachment to drugs to substitute for their inconsistent and insecure attachment issues that date back to their childhood.

Khantzian offers up a short vignette to illustrate the above point. With respect to therapeutic change, Khantzian writes, “Psychoanalytic approaches of passivity, therapeutic detachment, and strictly interpretive techniques, are not best suited for individuals with addictive disorders if they are suited at all, and more likely such approaches perpetuate the confusion, shame, sense of alienation, and disconnection with which patients with an addiction suffer.” I will add from my own clinical experience using behavioral techniques with troubled teens (many of whom had serious problems forming appropriate attachment relationships) that such techniques likewise can “perpetuate the confusion, shame, sense of alienation, and disconnection with which patients with an addiction suffer” (quoting Khantzian again). As a side note, during a treatment team meeting I mentioned the attachment difficulties that the kids I was working with displayed. The clinical director simply (and candidly) said that attachment difficulties cannot be addressed within a behavioral treatment setting. I often wonder how many of the kids I worked with (now adults) never ultimately received the treatment they so richly deserved. Yes Virginia, certain modalities can cause harm if used for the wrong problem at the wrong time. Thank you Edward Khantzian for making this important point.

In the next part we’ll look at Arlene Vetere’s Chapter Four—Alcohol Misuse, Attachment Dilemmas, and Triangles of Interaction: A Systemic Approach to Practice. See you then.