Neurobiology of Holiday Relapses

Why does your car stop at a red light? Sure, you press the brake, but do you really think about it? For experienced drivers, the answer is no — it just seems to happen on its own.

A vaguely appreciated or unsensed cue (e.g., stoplight) causes a driver to bring their vehicle to a stop. Photo: Ludovic Simon, et al.

This is the miracle of the brain: it can automate processes so you don’t need to consciously think about them. But this is also the challenge of addiction. Unhelpful mental scripts keep executing themselves, even when you sincerely want them to stop.*

What causes the scripts to execute? The Big Book contains various clues that have since been verified by modern science. The biggest drivers are

  • Negative affect
  • Stress
  • Cues

The Big Book famously describes those with addiction as “restless, irritable and discontented.” This is the best description of negative affect that I have ever seen.

Stress occurs when “environmental demands tax or exceed the adaptive capacity of an organism.”

Cues are environmental triggers — “people, places, things” — that have previously been paired with drug use. Sometimes you are consciously aware that cues are present, for example, you notice bottles of wine in a restaurant. But in many cases, they are unsensed. The brain registers the cues but there is no conscious appreciation that they are there.

The vignette in Chapter 3 of the Big Book brings this all together. Jim, the salesman, reported, “I felt irritated” after a dust-up with his boss. (Negative affect) He might have been stressed over a sales goal. He stopped at a roadhouse to grab a sandwich. The place “was familiar for I had been going to it for years.” (Cues) Despite “no intention of drinking” and “no thought of drinking,” Jim inexplicably “ordered a whiskey and poured it into [my] milk.”

What was responsible for this “plain insanity”?

Negative affect, stress and cues.

Why are alcohol and other drugs “cunning, baffling, powerful”?

Because “addictive behaviour appears to involve processes outside of the sufferer’s personal consciousness by which cues are registered and acted upon by evolutionary primitive regions of the brain before consciousness occurs.” Spooky functional imaging studies have shown this to be true.

The holidays often involve negative affect and stress. And there are often a lot of cues, both sensed and unsensed, in holiday environments. This “perfect storm” can initiate a behavior chain that often leads to unintended problem behaviors (alcohol or drug use).

I will be talking with my patients about countermeasures for the next month. ✸

* St. Paul lamented, “I do not understand my own actions. For I do not do what I want, but I do the very thing I hate” (Romans 7:15; NRSV). This gets into the realm of reversal learning, which is part of the neurobiology of addiction.

Remembering Wes Thomsen — 2

I knew Wes Thomsen for the last 7 or 8 years of his life. His recent celebration of life gave me a small sense for the decades prior. And what a life it was!

Toward the end of the service (01:23), someone noted that Wes was a rock star. Not in the current colloquial sense — but member of a band. A soulish song, perfect for the occasion, followed.

I looked for the song on streaming services as soon as I got to my car but couldn’t find it anywhere. An old post on Pegtop led me to Matt Patrick. He graciously e-mailed the track* to me with permission to post it here.

The moon is shining on the waterline
and it makes me think of you.
Venus and Mars all the trees and the stars
make me think about you too.

A GoFundMe for Wes’s family is so close to its goal. Please give generously. ✸

* “I Believe In You” is the final track (11) on Just Us (album).

Addiction Treatment in Jail

I’m happy to be back at the Minnesota Sheriffs’ Association annual Correctional Health Division Conference. This year, I’m presenting on withdrawal management and disease-modifying medications.

Click Image to Launch PowerPoint

Many thanks for Holly Compo and the organizing committee for including me in this event! ✸

Remembering Wes Thomsen

News of Wes Thomsen’s sudden passing reached me Saturday afternoon at a wedding. I found myself struggling with the juxtaposition of beginnings and endings, joy and sadness — and, ultimately, future versus finality.

I’m going to remember Wes in innumerable ways: his ready smile; his unhurried manner; his palpable sense of contentment; his vision and creativity; his deft leadership skills; his deep desire to help those touched by addiction; his amazing portfolio of work at Hazelden Publishing (example here); and so forth.

Wes Thomsen (left) on set at Westminster Presbyterian Church in Minneapolis, Minn., on August 3rd, 2021.

But I will mainly remember Wes as a friend surrounded by lights and cameras who blessed me with amazing conversations. ✸

Kate Gillette created a GoFundMe campaign to benefit Andrea and Margot. Please give generously.

P.S. A lovely memorial service occurred on October 1st. I appreciated the photographs of Wes, hearing the various recollections and tributes, and the remarkable closing song by Pegtop. A recording of the livestream captures most of this. I’m currently trying to find a stream of “I Believe in You,” a track on Just Us.


Joan and I got married on September 15th, 2001. I was still a newish family medicine resident and was rounding in a hospital on the morning of 9/11.

Steven Frenz; Dan McCarrell, Jr.; David Frenz; Matt Bergerson; Ashley Brandt | Photo Credit: Joe Treleven

Jamie Santilli, our attending physician, told the residents to take some time to process what was occurring. I remember her tremendous humanitarianism when the anniversary of 9/11 rolls around each year.

Our wedding and surrounding events happened as scheduled. Tom Johnson, a retired pitcher for the Minnesota Twins, officiated. Sara Renner made wonderful music. We were missing a bridesmaid and a few guests — but many converted cancelled flights into roadtrips to Minneapolis.

We honeymooned in Ely instead of Italy. Joan’s Jetta, ever trouble, dropped its muffler on our drive north. We burned some wedding cash at a repair shop as we passed through Duluth.

I still have my wedding coat and tie and wear them a few times a year — generally to weddings! ✸

Symbols — No. 1

For a few years, our family attended a Christian church that met in a Jewish community center. I’d often get bored with the service and hung out in its art gallery instead.

And so it was that I was playing hooky on February 15th, 2015. I came upon a placard that encouraged me to take a key out of a large jar nearby.

I encourage you to do the same — find a key and “think about what you would unlock in your your personal life to ensure a better future.” Add it to your key chain or maybe keep it on your person as a constant reminder of your “truest self.” ✸

I regret that I didn’t capture the artist’s name at the time. I believe that it was either Aviva Klein (and here) or the Jewish Family and Children’s Service of Minneapolis. I’m happy to update this post if someone provides me with better attribution.

Carl G. Jung. Man and His Symbols. New York: Anchor Press, 1964

CBT Cookies

No, not CBD! CBT, as in, cognitive behavioral therapy.

I fished this out of a fortune cookie last night:

Inspired, I’m thinking about ordering some custom cookies to hand out during sessions. The fortunes would take the form of rational emotive behavior therapy (REBT):

  • What was the activating event (A)?
  • What was the emotional and/or behavioral consequence (C)?
  • What did you tell yourself (B) about A to cause C?
  • Is that belief (B) logical? Empirical? Pragmatic?

I somehow think that Albert Ellis, who made therapy playful and engaging, would approve. ✸

Postscript. How do I know that Ellis was playful and engaging? I’ve read published transcripts of his sessions, and they are masterpieces. During one session, he advised a client thus: “Every time a human being gets upset—except when she’s in physical pain—she has always told herself some bullshit the second before she gets upset” (p. 228). That not only got the client’s attention, I can guarantee the lesson stuck.

Rural Recovery Resources

Mental illness and addiction are big issues everywhere — but especially in rural areas like Osceola, Wisconsin, that lack local treatment resources. As my partner, Nicole Smith, M.D., said well, “What we lack at Osceola, is we don’t have integrated behavioral health, we don’t have therapists on staff. For better or for worse, Osceola doesn’t have mental health beds.”

All of that is about to change!

Exist Media Company — Lakeland, Minn.

Osceola Medical Center (OMC), a rural health clinic and critical access hospital, has committed to rapidly creating local services for mental illness and addiction. The Osceola Community Health Foundation (OCHF) recently raised $61,000 at its annual gala to launch an integrated behavioral health program. And OMC’s board of directors just prioritized creating “psych safe” hospital beds so we can stop boarding patients in the emergency department and transferring them far from home.

“We want to be known as the people who show up in the best and worst of times for our patients and their families,” said Kelly Macken-Marble, OMC’s chief executive officer.

Many thanks to Jill Leahy, Director of the OCHF; Exist Media Company; and countless others for imaging a better future for our community. ✸