The wrath of grapes versus the self-medication hypothesis

Dr. Khantzian's SMH was initially developed to enhance an etiologic understanding of substance use disorders and to promote appropriate and empathic therapeutic responses through careful listening to the human suffering of addicted patients. In the present review he has combined an intensive look at patients with a full exploration of the modern literature on comorbidity and a discussion of the ways in which this more recent work may support or contradict the SMH. Additional longitudinal research is needed to confirm and delineate the SMH. There is a danger that clinicians could use the SMH in overly reductionistic ways. They must be alert to potential rationalization and retrospective distortion while listening to their patients' accounts of the causes of their substance abuse. In the cart/horse problem, it can be clinically useful to tease apart the temporal sequence of onset of each disorder, the ways in which the two disorders interact, and the ways in which each may amplify the suffering caused by the other. In my view, it is still the wrath of grapes that leads to the greater part of suffering in substance use disorders.