The role of hatred in medicine

Most Saturdays, I join a therapy session down the hall from where I do my walk-in clinic. A patient of mine has a weekly session just before the Alcoholics Anonymous meeting at noon in our big conference room.

Last weekend he told my behavioral health colleague that the people in the AA group who have the most solid recovery seemed to be the ones who claimed to carry a lot of hatred for alcohol.

Later that day as David and I wrapped up our week, we talked about this. Generally, we don’t think of hatred as particularly healthy or therapeutic. Hatred for others is thought to always eventually create negative feelings towards oneself and even illness. “Depression is anger turned inward” is a common saying attributed to Sigmund Freud. He used the word “ambivalence” for the coexistence of love and hate, which many others have also written about.

(Freud’s linkage of love and hate now have a functional MRI correlate: According to a ten-year-old article, “The Origin of Hatred” in Scientific American, the areas of the putamen and insula that are activated by individual hate are the same as those for romantic love. “This linkage may account for why love and hate are so closely linked to each other in life,” neurobiologist Semir Zeki, of University College London’s Laboratory of Neurobiology wrote in 2008.)

But is there a place for pure, single-focused hatred? Freud, again, “defined hate as an ego state that wishes to destroy the source of its unhappiness, stressing that it was linked to the question of self-preservation.”

David had already asked our patient to write down for next week if there was anything about alcohol that he hated, and he asked me as the primary care physician to list each of my patient’s health problems that could be related to alcohol. Of course, we can’t be sure, but it’s like the question on Maine death certificates whether smoking contributed to the death: There is a “probably” answer option. Before next Saturday I’ll have to go through the chart and make my list. I know it won’t be short.

Will our respective lists bring this patient to hatred of alcohol according to Freud’s definition?

But will such hatred, if not coexisting with its opposite, eventually cause this man to be depressed because of anger turned inward? In fact, he is already on medication for depression, and it seems to be working well.

Maybe hatred of an inanimate object is different from hatred of any of our fellow humans, like hatred of plastic, pesticides or pollution. Maybe hatred for alcohol, once the spreadsheet we’ll create together makes its many negative effects on this person’s life and health undeniably and objectively evident, will make ambivalence impossible?

But maybe alcohol has more than two dimensions in my patient’s life. In his current ambivalent state of seemingly equal parts love and hate there is a tiebreaker, or maybe this one is a third and equal part of a complicated triangle: Habit. It isn’t for nothing we speak of someone’s alcohol habit. Alcohol is a strong one, linked to food, celebration, socialization, and relaxation. It is for many people a strongly conditioned response to all kinds of external and internal triggers.

I believe anger and hatred could have a catalytic effect, because few of us make purely logical decisions from lists of pros and cons. Rather, we use logic to justify the emotional split-second decisions we have already, at least almost, made.

I believe in the possibility that something emotional uncovered or triggered through this exercise might become the seed of hatred we are hoping for. Maybe it will be the sheer size of the list; maybe a health issue he never realized alcohol’s connection to; maybe a single item on the list will trigger a flashback to some childhood impression related to alcohol.

The more I think of it, I believe hatred is necessary because we are fighting both “love” and a very strong habit in this case. And I do think you can hate a thing without hurting yourself.