What Addiction Is Trying to Regulate

There is something difficult to understand about a person returning to what is making their life worse. They may see the damage as clearly as anyone else. They can describe what is happening to their health, their relationships, their money, and still go back.

At some point, the explanation begins to feel inadequate. If they know, why does knowing change so little? We listen to another promise and wonder whether they mean it. Perhaps they do. That possibility can be harder to understand than a lie, because it leaves us with someone who seems sincere and still does the thing they said they would stop.

I think we sometimes expect understanding to do work it cannot do on its own. Recognising the damage does not necessarily give someone the ability to manage what happens when they try to stop.

That is the question Edward Khantzian’s self-medication hypothesis brings into focus. Drawing on clinical work with substance-use disorders, he proposed that addictive use can offer temporary relief from difficulties in regulating emotion, caring for oneself, relating to others and maintaining self-esteem (Khantzian, 1990, 1997).

The damage may be obvious while the relief remains largely private. We see what happens after someone uses; we may know much less about what happens inside them before they do.

1. Regulating overwhelming emotions

We speak about anxiety, anger and shame as though naming an emotion tells us what it is like to experience it. But the same word can describe something one person finds unpleasant and another finds almost impossible to bear.

The difference may involve how intensely a feeling arrives, whether the person can think while experiencing it, or whether they trust it will pass. Even knowing what one feels is not always straightforward. There may simply be agitation, pressure or a need for something to change immediately.

For someone else, the difficulty may be an absence of feeling: emptiness, deadness, a sense of being present in their life without feeling particularly connected to it.

Khantzian suggested that substances can become attractive partly because of the particular way their effects alter these states (Khantzian, 1997). They may quiet agitation, create energy, soften inhibition or provide distance from something that otherwise feels inescapable.

Seen this way, the familiar explanation that someone uses because it makes them feel good begins to seem incomplete. Relief can be powerful without resembling happiness. It may amount to a few hours in which a person no longer feels trapped in a feeling they cannot manage.

This does not make the substance safe. It helps explain why a warning about the future may fail to address the immediate problem. The person giving the warning is thinking about a life being damaged; the person using may be trying to get through the evening.

Both are responding to something real, but they are not necessarily responding to the same thing.

2. Protecting the future self

One of the less obvious parts of Khantzian’s framework concerns self-care: the capacity to recognise danger, protect oneself and act in one’s longer-term interest (Khantzian, 1990, 1997).

We often treat self-preservation as automatic. If someone knows that something is harming them, surely they will want to avoid it. When they repeatedly fail to do so, we may conclude that they do not care enough about their life.

Yet wanting to survive and reliably protecting oneself are not identical. A person can be frightened by what is happening and still struggle to act on that fear. They may genuinely want things to change without being able to make that wish count when the urge to use returns.

Tonight’s distress is present. Tomorrow’s consequences have to be imagined. The person who will deal with them later can feel strangely remote, even when the consequences are familiar and have occurred many times before.

It is tempting to hear this as an elaborate excuse for a bad decision. But it raises a practical question: what does the safer decision require? The person may need to endure a difficult evening without the relief they know, while holding on to a reason that feels less convincing as the distress increases.

Knowing which choice is safer does not guarantee that someone can reliably make it. The contradiction is painful precisely because the person may understand it. They can be using something to make life bearable while watching it damage the life they want to keep.

3. Depending on other people

Khantzian also placed relationships within his account of self-regulation (Khantzian, 1997). Much of what we call managing our feelings happens with somebody else. A conversation helps us think again. Being understood makes an experience less isolating. Sometimes another person’s presence is enough to make an evening manageable.

We do not always notice how much this asks of us. To receive comfort, we have to let someone matter, reveal something of what we need and accept that their response is not entirely under our control.

People can care about us and still misunderstand. They may be unavailable, distracted or uncertain about how to help. Even a good relationship cannot provide comfort whenever and however we need it.

For someone who finds dependence frightening or humiliating, seeking help can therefore produce its own distress. A substance may seem to offer a more predictable arrangement. There is no explanation to give, no reaction to interpret and no possibility of feeling rejected by the answer.

I would be careful about calling this a substitute for love. People with addictions can be deeply loved. Someone may have a person they could call and still find it almost impossible to make the call, admit what is happening or believe that the response will help. The presence of love does not tell us how easily it can be received.

Over time, using can also weaken the relationships that might provide another source of support. Trust deteriorates, shame makes contact harder and withdrawal leaves the person more isolated. The substance may come to feel increasingly necessary as other possibilities become less available.

That is a difficult cycle to understand from either side. The person using may experience a loss of support; those around them may be exhausted from repeatedly offering it.

4. Maintaining a tolerable sense of worth

Self-esteem, the fourth area in Khantzian’s formulation, is easily confused with confidence (Khantzian, 1990, 1997). Someone may appear assured and still have an unstable sense of their own worth. Looking confident tells us little about what happens when they are disappointed, criticised or left alone with themselves.

Can a mistake remain a mistake, or does it become evidence that the whole person is defective? Can someone feel unremarkable without feeling worthless? These are less visible difficulties than a lack of confidence, and they are not necessarily resolved by achievement or reassurance.

There is a considerable difference between enjoying approval and needing it to feel acceptable. When that feeling depends heavily on what has just happened, a disagreement, an unanswered message or a disappointing day can become difficult to put aside.

Substances can temporarily change that experience, producing social ease, energy or a feeling of competence. Sometimes the effect is quieter: less self-consciousness, a pause in the internal criticism, some distance from shame.

From outside, a few hours of relief may seem a poor exchange for the consequences. From inside, those hours may feel like the only time being oneself is not such hard work.

But using can generate further reasons for self-reproach. A broken promise or another damaged relationship remains after the effect has passed. What briefly interrupted shame may then leave the person with more of it.

When the difficulties begin feeding one another

These areas rarely remain separate. An overwhelming feeling may lead to use; shame about using can then damage self-esteem and make contact with others harder. Isolation leaves less support available, while accumulating consequences make it more difficult to look after oneself.

By this point, “you need to stop” may be true without telling us enough about what stopping will involve.

Khantzian’s framework gives us a way to ask more precise questions. Its limitation is that we can become too attached to the explanation. Khantzian acknowledged that empirical findings did not consistently support every version of the hypothesis (Khantzian, 1997). It is a way of investigating someone’s experience, not a story to impose on every person with an addiction.

There is also a danger in becoming so absorbed in the psychological meaning that the substance itself recedes from view. Withdrawal may require medical care. Craving, neuroadaptation, medication, relapse prevention and the person’s environment can all matter. A persuasive account of someone’s distress does not, by itself, address those needs.

What recovery still has to build

Removing alcohol does not automatically make anxiety tolerable. Giving up a substance that temporarily produces confidence does not create stable self-worth. Losing a familiar source of comfort does not suddenly make depending on another person feel safe.

Psychodynamic treatment informed by this framework asks how those capacities can develop, rather than assuming that abstinence creates them on its own (Schneider & Khantzian, 1992; Khantzian, 2003).

This is where our expectations can become confused. Someone has stopped, so we expect them to be better. In one important respect, they may be. But some of the experiences they were trying to alter may still be there, now without the familiar means of changing them.

The questions become more specific:

• Can a powerful feeling be experienced without immediately having to change it?
• Can someone act on a danger they recognise when the safer choice brings discomfort?
• Can comfort be received without dependence feeling humiliating or unsafe?
• Can disappointment be survived without becoming a judgement on the whole self?

These questions do not make the damage less real. An addiction can hurt people who did not choose it. They may need distance or an end to an arrangement that has become intolerable, and understanding why someone uses does not oblige them to keep living with the consequences.

Still, if we want to understand the repetition, the damage alone cannot tell us everything. The person may already know what they stand to lose. Repeating it more forcefully may add little to what they know about the consequences and nothing to their ability to get through the next difficult evening.

A sincere promise can tell us that someone wants things to be different. It cannot tell us whether they can manage the feeling that returns tomorrow, ask for help when they need it or bear a disappointment without reaching for the same relief. Those are things that have to become possible in practice.

The question I would keep beside Why can’t you stop? is What becomes difficult to bear when you do? The answer will not explain every addiction, but it may help us see what still needs attention after the substance is gone.

Stopping matters. So does being able to live through an ordinary, difficult day without needing to return.

References and further reading

Khantzian, E. J. (1990). “Self-regulation and self-medication factors in alcoholism and the addictions: similarities and differences.” Recent Developments in Alcoholism, 8, 255–271.

Khantzian, E. J. (1997). “The self-medication hypothesis of substance use disorders: a reconsideration and recent applications.” Harvard Review of Psychiatry, 4(5), 231–244.

Khantzian, E. J. (2003). “Understanding Addictive Vulnerability: An Evolving Psychodynamic Perspective.” Neuropsychoanalysis, 5(1), 5–21.

Schneider, R. J. & Khantzian, E. J. (1992). “Psychotherapy and Patient Needs in the Treatment of Alcohol and Cocaine Abuse.” Recent Developments in Alcoholism, 10, 165–178.