Emotional Health

Understanding Addictions:
Self-Medication and Self-Harm

Alcoholism is also a deadly disease. More than 80,000 alcohol-related deaths are reported each year, and it is estimated that 60 million suffer from alcohol use disorder. It shares many things with drug-related addictions but one important difference is that drinking is legal and considered socially appropriate, and is even desirable in some social groups. The descent from passing as someone living a normal life to a dysfunctional one is much slower, usually, compared to drug addiction, and it is possible to lead an alcohol-impaired life for many years sometimes without the consequences catching up with you.

Jerome Levin, a psychologist who has studied alcoholism through the lens of self psychology, writes that alcoholic women “are more likely to suffer from depression” than their male counterparts. They are also more “likely drink to alleviate intolerable feelings of worthlessness…and …to suffer from devastatingly low levels of self-esteem.”

Here is an example:

Sarah was a doctor of internal medicine who had been married five years when she started therapy. She had come from an intact family, with two accomplished parents and plenty of money. But her mother had been troubled by mental illness for most of her adult life. She was hospitalized, sometimes for months at a time, for what was finally diagnosed as bipolar illness.

Sarah and her siblings usually had no idea when her mother might slip into one of her manic moods, or when she would plunge into depression. Their lives were kept on track by the household help, but emotional support from her parents was essentially unavailable.

Growing up in this uncertain atmosphere, Sarah became guarded and reserved, adopting a strategy of trying to stay out of the way. Attempts to get attention usually failed and resulted in conflict, as she saw when observing her siblings.

Sarah was insecure, but found she could gain approval and admiration from peers and teachers by being a good student. She eagerly awaited report cards, when she was often delighted but astonished to read how much she was admired for her hard work and achievements. Though her parents were only mildly impressed, Sarah was hooked on the approval that her hard work could bring.

Continuing on this path, she attended a top college and headed for medical school. At each step, she found that the stakes got higher and the competition rougher. She had to push herself harder and further to gain the acclaim and the reassurance she desperately craved.

She discovered as a med student and resident that perfection was impossible and that the education system there was built more around rooting out errors than praising good performance. She continued to push herself harder but when she didn’t get the approval she needed she felt empty and anxious. She began to drink at night and on her days off in an effort to quell her increasing feelings of desperation.

Around this time she met Jake, a handsome architect with a taste for fine wines. He was impressed by her intelligence and achievements, and they had fun and relaxing evenings together, often fueled by liquor. At those times, Sarah felt free, lovable, and warmly accepted in a way she hadn’t really known before.

Before too long, though, things soured as Sarah’s drinking began to affect her performance at work. She tried to cut back, but Jake became angry and petulant when she was not available to join him in a “little fun.”

Sarah was hooked on alcohol for self-soothing, but she was also hooked on approval from Jake. Having no internal sense of self worth, she was dependent on the outside world, especially the people in her world who functioned, like Jake, as “selfobjects.” Kohut defined these as people who exist outside of the self, but who function as part of it. So, for example, Jake served to provide the admiring part of herself that Sarah could not provide.

Sarah’s professors, supervisors, and even patients were also functioning as selfobjects, at least in part. When Sarah began to realize the extent of her drinking problem, she faced a painful conflict. Clashing with Jake over her wish to cut down on drinking, she risked losing her main selfobject. Furthermore, alcohol itself served a selfobject function in that it provided the soothing that Sarah could not find from within. But losing her career, the respect of her patients and colleagues represented a threat too. And losing all this meant she would also be abandoning the road to building an internal sense of self-worth based on her genuine self-respect.

The question for Sarah, as it is for many addicts, was “Am I worth it?” She had to decide whether to give in to the lure of addiction to alcohol and Jake’s approval, with a future that guaranteed dependency, versus the risk of betting that recovery and continuing on her path to self-development would be worth the struggle.

Ultimately, Sarah got sober with the help of therapy and AA, but her relationship with Jake did not survive. Theirs was an example of a co-dependent relationship, meaning they were both contributing to interactions that enabled each other’s weaknesses. Many addicts have the kinds of partners who either participate in, or enable, their use of drugs and alcohol. When one of the partners gets sober, the dynamics of the relationship change and must be recalibrated if it is going to survive.

While there is a wide variation in the backgrounds of people who develop substance use disorders, there are many common themes, which is one of the reasons AA has helped so many recover. In these meetings, available free to everyone all over the world, you can hear the stories of others who have struggled with the challenge of living a sober life. Members are also encouraged to choose a sponsor, someone who has been in the program longer and is readily available to offer advice, guidance, and support.

AA was founded by two men back in the 1930s.

They both had tried every available means and method to quit the bottle, only to relapse over and over. They decided to create a “fellowship” where the support of other alcoholics could reinforce their common goal of abstinence.

Without realizing it, AA intuitively developed and started using the principles of self psychology, long before Kohut made his theory explicit.

Besides the sense of community that the program provides, it gives you a sense of identity, and has the built-in feature of offering the “selfobject” in the form of the other members, and, especially, your sponsor.

A mirroring self-function, like the one we seek from our parents as young children, is provided as the addict accepts the support and feedback of other members. A crucial aspect of these relationships is the complete lack of judgment. AA offers unconditional positive regard—the only “requirement” is that you attend meetings with a desire to stop drinking. For many, the impact can be transformational. A significant number of addicts begin drinking partly to deal with a sense of shame, only to get caught up in a cycle that creates more and more shame and self-loathing.

Recovery focuses on learning the ways of self-love: self-care, such as how to soothe and comfort yourself in positive ways, and when to ask for support, while developing healthier relationships based on strengths rather than weaknesses. Again, treatment programs have lately adopted many adjunct methods that help people feel grounded and in touch with their true selves, including yoga, meditation, and mindfulness treatment. Once again, this underscores the profound role that self problems play in addictions.



Levin, Jerome. The Treatment of Alcoholism and Other Addictions: A Self Psychology Approach. (1987).


Start the conversation

This site uses Akismet to reduce spam. Learn how your comment data is processed.