Category: Healing Arts

Find the Switch — 4

The Diagnostic and Statistical Manual of Mental Disorders (DSM) provides criteria sets for diagnosing various mental disorders including addiction.1 The surrounding text contains brief sections on “Development and Course” and “Risk and Prognostic Factors.” These passages are seldom helpful for case conceptualizations, that is, understanding how an illness developed and what factors are sustaining it. Clinicians need to look elsewhere.

The Psychodynamic Diagnostic Manual (PDM) is a great place to start.2 Its S Axis explores patients’ subjective experiences in the following domains:

  • Affective states
  • Cognitive patterns
  • Somatic states
  • Relationship patterns

In the case of addiction, PDM-2 notes:

Psychoactive drugs help people who misuse substances to tolerate intolerable feelings. The effects of drugs and alcohol are specific and temporary; the main emotions the person feels will generally determine which type of substance is preferred. Opiates help a person to feel “calm,” “mellow,” or “normal.” Stimulants counter low energy,feelings of weakness, and feelings of being unloved; they may also be employed by high-energy individuals to augment a preferred hypomanic adaptation or to combat depression. Sedatives (e.g., alcohol, benzodiazepines, barbiturates), in low doses, can overcome feelings of isolation and allow feelings of closeness and warmth (e.g., “I can feel like one of the guys ... I can join the human race”); in high doses, they drown out negative, unwelcome feelings and lead to social isolation.3

This perspective reflects Edward Khantzian’s self-medication hypothesis of addiction:

Clearly, there are other determinants of addiction, but I believe a self-medication motive is one of the more compelling reasons for overuse of and dependency on drugs. Clinical findings based on psychoanalytic formulations have been consistent with and complemented by diagnostic and treatment studies that support this perspective [...]. Rather than simply seeking escape, euphoria, or self-destruction, addicts are attempting to medicate themselves for a range of psychiatric problems and painful emotional states.3

Targeting substance use directly — while often necessary at the onset of treatment — seldom provides durable recovery. Psychiatric problems and painful emotional states are the substrate for substance use. These issues need to be explored and addressed or relapse will likely occur.

Here’s an image that I frequently include in lectures for medical students and residents.5 Everyone received addiction treatment prior to time zero (x-axis) and were abstinent from their drug of choice at discharge (y-axis; 1.00 = 100%). Most resumed using substances over the next year.

(I could show you dozens of data visualization like this. I like this one because it includes four substances in the same figure and has a meaningful time scale.)

There are various causes for relapse, however, unaddressed psychiatric symptoms — depression, anxiety, intrusive thoughts and images — are prominent among them. To reduce or eliminate substance use one must find the “switch.” ✸

  1. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). Washington, DC: American Psychiatric Association, 2022, pp. 543–665
  2. Psychodynamic Diagnostic Manual, 2d ed (PDM-2). New York: Guilford Press, 2017. PDM was first published in 2006. The countdown to PDM-3 is on: it will be available on December 8th, 2025
  3. PDM-2, p. 226
  4. Am J Psychiatry 1985;142(11):1259–1264 (PubMed). This hypothesis generated controversy when people took it farther than Khantzian himself (he never claimed that self-medication was the sole explanation for addiction). His conceptualization, however, has empirical support: see, for example, JAMA Psychiatry 2013;70(7):718–726 (PubMed). The hypothesis is also consistent with my clinical experience. Patients often report that substance use began as chemical coping and eventually turned into addiction
  5. Curr Psychiatry Rep 2011;13(5):398–405 (PubMed)

Series Installments
Find the Switch
Find the Switch — 2
Find the Switch — 3
Find the Switch — 4

The Power of Now

Spiritual masters have long held that we are happiest when our minds are situated in the present. They note that suffering occurs when our minds wander to the past or future. But is this empirically true?

Matt Killingsworth and Daniel Gilbert conducted a brilliant study involving real time experience sampling. This was exceptionally difficult to do before smartphones.

We solved this problem by developing a Web application for the iPhone (Apple Incorporated, Cupertino, California), which we used to create an unusually large database of real-time reports of thoughts, feelings, and actions of a broad range of people as they went about their daily activities.The application contacts participants through their iPhones at random moments during their waking hours, presents them with questions,and records their answers to a database at www.trackyourhappiness.org.1

Here’s what they found:

Figure 1. Mean happiness reported during each activity (top) and while mind wandering to unpleasant topics, neutral topics, pleasant topics or not mind wandering (bottom). Dashed line indicates mean of happiness across all samples. Bubble area indicates the frequency of occurrence. The largest bubble (“not mind wandering”) corresponds to 53.1% of the samples, and the smallest bubble (“praying/worshipping/meditating”) corresponds to 0.1% of the samples.
First, people’s minds wandered frequently, regardless of what they were doing.

[...]

Second, multilevel regression revealed that people were less happy when their minds were wandering than when they were not [...] and this was true during all activities [...].

[...]

Third, what people were thinking was a better predictor of their happiness than was what they were doing.

[...]

In conclusion, a human mind is a wandering mind, and a wandering mind is an unhappy mind.The ability to think about what is not happening is a cognitive achievement that comes at an emotional cost.

What are the implications for living well? Be here now. ✸

  1. Killingsworth MA, Gilbert DT. A wandering mind is an unhappy mind. Science 2010;330(6006):932. PMID: 21071660.

Find the Switch — 3

Jean Strobel introduced me to the the “dry drunk syndrome” years ago and it has guideded my work ever since. A well-known pamphlet on the subject states, “Being dry is not the same as contented sobriety.”1 Bev Lemaniak, another important mentor, said it best: There’s more to recovery than sobriety.”

Dick Solberg, the pamphlet’s author, notes:

Dry drunk refers to attitudes and actions that poison our well-being. We keep acting "drunk," even when we're "dry." What's more, these attitudes and actions often show up after we've been sober for a while. They're a sure sign that we're experiencing discomfort in our lives.2

I’d argue that the attitudes and actions are generally present before struggles with alcohol and other drugs develop. They represent the driver or “switch” (and here) for addiction.

Solberg explored some “obvious traits” of those with substance use disorders including grandiosity, judgmentalism, intolerance and impulsivity.3 Some in recovery refer to these are “character defects.”4 From a clinical standpoint, we think in terms of attachment patterns, personality structure, irrational beliefs,5 and so forth. Treatment involves targeting these underlying issues. ✸

  1. R.J. Solberg. The Dry Drunk Syndrome, Revised Edition. Center City, MN: Hazelden, 1993, p. i
  2. Ibid., pp. 1–2; emphasis in the original
  3. Ibid., pp. 3–8
  4. Alcoholics Anonymous, 4th ed. New York: Alcoholics Anonymous World Services, 2001, pp. 58–71, 72–88 (Step 6)
  5. Irrational beliefs, or iBs, are a core feature of rational emotive behavior therapy (REBT), a form of cognitive behavioral therapy. Those with substance use disorders often address awfulizing, frustration intolerance and self-downing by “chemical coping”

Endnote. According to Hazelden, Solberg’s pamphlet was initially published in 1970. It was revised in 1983 and 1993. There have been many different covers over the years and pamphlets are often undated. The copy that Jean Strobel gave to me appears to be a later printing of the first edition (publishing mark: dry drunk is hyphenated).

Solberg also authored The Dry Drunk Revisited, which was published in 1980 and is now out of print.

Many thanks to Chuck B. for helping me understand the publication history.

Series Installments
Find the Switch
Find the Switch — 2
Find the Switch — 3
Find the Switch — 4

Find the Switch — 2

In an earlier post, I stressed the importance of finding the driver for symptoms and behaviors— the “switch,” as Freud called it. Kyle VanBlaircom referenced this post in a recent podcast and we discussed it for a bit.

I keep this vintage postcard in my consultation room and use it for patient education.

What might the driver or switch be? Typically early attachment experiences that coalesced into personality patterns — patterns that keep showing up in the present and cause suffering.

Finding the driver takes time. According to Drs. Jonathan Shedler and Enrico Gnaulati, “Meaningful change began at about the six-month mark, and clients who stayed in therapy for a year did substantially better. Those who stayed for two years improved still more. There [is] an unmistakable dose-response curve […].” ✸

Series Installments
Find the Switch
Find the Switch — 2
Find the Switch — 3
Find the Switch — 4

Find the Switch

I’ve been fascinated with indirect procedures1 ever since Brian McCullough introduced me to F.M. Alexander.

Consider a toddler with a fever. Administering Advil or Tylenol would be a direct approach to treatment. This might tamp down the fever for a few hours but won’t resolve its underlying cause. Moreover, that strategy might prove dangerous if something like meningitis or cancer is the cause of the fever. In contrast, treating an ear infection (driver for fever) with antibiotics resolves the fever indirectly and permanently.

I keep this vintage postcard in my consultation room and use it for patient education. Please see Endnote.

So, too, in mental health and addiction treatment. One can target symptoms and behaviors directly with medications and certain forms of psychotherapy. By and large, however, this doesn’t resolve root causes.

Freud [...] sometimes used a picture postcard of the most ordinary kind for making his point. A picture showed, for instance, a hillbilly in a hotel room trying to blow out the electric light like a candle. Freud explained: "If you attack the symptom directly, you act in the same way as this man. You must look for the switch."2

Do I use direct approaches? Yes — they are often necessary to stabilize patients. But I generally try to shift to indirect procedures that uncover and resolve root causes. ✸

Postscript. In the case of addiction:

Our liquor was but a symptom. So we had to get down to causes and conditions.3
[Y]our problem is not drinking in spite of what anyone has told you or in spite of the conclusion you may have reached yourself. Forget all that stuff. It's a lot of bunk and probably has you so confused you can't look at yourself with any objectivity. I repeat——drinking is not your problem. [...]

Drinking in your case is a symptom of something wrong. If you can make yourself realize this you may be thankful for your drinking at a future date. Why? If it were not for the particular effect that liquor has on you, you might never search for the underlying trouble.4
  1. Slides 26–39
  2. Theodor Reik. The Need to Be Loved. New York: Farrar, Straus and Company, 1963, p. 271
  3. Alcoholics Anonymous, 4th ed. New York: Alcoholics Anonymous World Services, Inc., p. 64
  4. Charles Clapp, Jr. Drinking’s Not the Problem. New York: Thomas Y. Crowell Company, 1949, p. 17 [emphasis in the original]

Endnote. I contacted the Freud Museum in 2024 to see if it had any postcards in its collection. A research manager replied: “Thank you for your email—what an intriguing question. Good old Theodore Reik! I’ve had a search through and can’t find any postcards matching that description. My guess would be that the postcard that was used for this demonstration wasn’t part of the material that came to London from Vienna—but if you ever are able to track it down—do let me know!”

Series Installments
Find the Switch
Find the Switch — 2
Find the Switch — 3
Find the Switch — 4

Change the Reel

Various teachers have used a movie theater analogy to describe the subject-object relationship. I recently discovered a new example from Emmet Fox with a slightly different frame:

Too often you try to change outer things instead of changing the inner. You are firing at the screen instead of the projector. So nothing happens. But when you start to change your consciousness you are firing at the projector, and then things happen. If you don't like the picture on the screen, change the reel. If you don't like the picture you are seeing, and would like to see some other, you wouldn't get a cloth and rub it off as if from a blackboard. You would take out that reel and put in the reel you want.1

The movie screen is object. That which observes the screen, the observing self, is subject. We are often caught up with objects—wiping the screen, trying to change outer things. Practical solutions, when available, should be pursued. But in many cases, changing the reel is a far better option.

Many thanks to the Reverend Karren Scapple, Ph.D., with the Unity Archives, for providing me with an archival copy of this important essay.

  1. Emmet Fox. Life Is Consciousness. Unity [Magazine]. 1936;85(4):2–12 [October]. Emphasis (highlight) added ↩︎

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.

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.

Understood

I didn’t know Dr. Margaret Keenan but wished that I had. One of her eulogies said this of her:

I think that what her patients craved was not to be healed but to be understood

I pray that my own demise is far off—our kids are still young and I’m just beginning to master my craft. But when I’m gone, I hope that my patients will generally recall that I understood them. §