The Problem of Empathy With Addiction

Psychiatry has historically seen itself as having little to offer people with alcoholism and other addictions. In my training, the message to patients with substance problems was, “Come back when you’re clean and sober.” If that was sound policy then, it isn’t any more: we know many patients in psychiatric treatment have substance use disorders, and many people with addictions have problems psychiatrists know how to treat. Further, we now have effective psychotherapies and medication to treat addiction itself. But effective treatment requires empathy, and many physicians and mental health professionals have difficulty relating to their patients’ addictive experiences. In this post, I explore the empathy clinicians need to provide effective treatment to people with addiction.

By “addiction,” I am referring not only to substance use disorders—heroin, cocaine, and marijuana; prescription opioids, benzodiazepines, and stimulants; alcohol and tobacco—but also to non-chemical behavior problems in which craving and loss of control are important elements, such as pathological gambling and internet gaming, and some sexual and eating disorders.

Empathy here is the psychophysiological process of experiencing the emotions and thoughts of another person. It involves emotional sharing, cognitive perspective-taking, and self-regulation to prevent excessive identification. Empathy with patients also involves a desire to help. Functional MRI studies have identified separate but interconnected brain circuits for each of these components of empathy, and when we empathize with another person’s experience, these circuits activate as if we were having the experience ourselves.

Empathy was long ago identified as a critical element in doctor-patient relationships. Most psychiatrists and psychotherapists value it as an essential element of clinical practice. Research now supports this wisdom: clinician empathy predicts treatment outcome for a number of medical and psychiatric disorders, including addiction. Interestingly, the patient’s rating of her treater’s empathy is the strongest predictor, followed by observers’ ratings. Clinicians’ assessments of their own empathy turn out to be least predictive.

For many people, addiction implies personal weakness or moral degeneracy, and research consistently finds that professionals stigmatize addicts as difficult to help. Discussions with colleagues as well looking at my own reactions to addicted patients have convinced me that part of this clinical pessimism is rooted in difficulty empathizing with addiction itself. It is relatively easy to relate to patients’ losses, victimization, shame, and guilt. But the core phenomena of addiction—craving, inability to control use of a substance, and prioritizing substance use over other aspects of life—are much more difficult to understand on an emotional level. In my residency, Elvin Semrad, a teacher revered for getting to the heart of the most disturbed patients’ distress, refused to interview known alcoholics, commenting that a relative of his had “drunk away a perfectly good farm.” For many years, I too could not relate to how my patients knowingly ruined their careers, families, and health for the sake of a chemical substance.

For some clinicians, the solution is to avoid treating addicts. Few of my friends in private practice will prescribe buprenorphine (Suboxone,) an effective medication for opioid addiction. Those willing to see addicts often take one of two risky tacks. Some avoid discussing their patients’ addictive experiences, focusing instead on what they are comfortable treating—anxiety, mood disorders, psychosis, or relationship problems. Others view addiction as primarily self-medication and assume that treating an underlying mental health problem will eliminate craving and loss of control. We now know that most “dual diagnosis” patients need treatment for both addiction and their other psychiatric problems.

Some patients have other resources to deal with their substance use—twelve-step programs, drug counselors, or medication to reduce craving. Those with less severe addictions may to learn handle cravings on their own. But without compassionate understanding of what it means to lose control of substance use, a clinician is likely to miss signs of impending or actual relapse, which can quickly destroy any progress in other areas of treatment. Perhaps more important, a clinician who lacks empathic understanding of his patient’s addiction is unlikely to be able to provide the trust and support that comes from with accepting a patient with all his problems.

So we have a conundrum: empathy is a core skill espoused by all health professions, and research shows it is an important predictor of treatment outcome. Clinicians learn to empathize with the experiences of other patients who have strange, disturbing, or unappealing problems—schizophrenia, cancer, leprosy, and AIDS come to mind. But empathy for patients’ addictive experiences, while important for effective treatment, is often hard to come by.

And there is the question of what it means to empathize with addiction. Does effective empathy require emotional sharing of the “high” from activating the brain’s pleasure circuits? Patients’ experiences with active addiction differ markedly from those in withdrawal or early recovery. And long-term abstinence encompasses everything from “white-knuckle sobriety,” where the need to stop is recognized but little else has changed, to the deeper healing some patients in twelve-step programs and long-term psychotherapy are able to achieve. What sort of empathy is needed in these situations?

In coming posts I use findings from the biology and psychology of both empathy and addiction to explore why empathy with addiction is difficult and how it can be improved.

Further reading: Teresa B. Moyers and William R. Miller, Is Low Therapist Empathy Toxic. Psychol Addict Behav 2013 Sep. 27(3) 878-84):

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