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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

Peer Perspective Podcast

I recently joined Kyle VanBlaircom on his show, The Peer Perspective Podcast. We discussed a wide range of topics: opioids, stimulants, stigma, recovery in rural areas (links below).

Many thanks to Penny Austad, one of Kyle’s earlier guests, for introducing us! ✸

Here’s the blog post that Kyle mentioned at 4:43. Substance use is often a coping mechanism (“self medication”) for another problem. People frequently relapse because the underlying driver has not been addressed.

Thinking Problems

Paul O., a physician, was the author of Acceptance Was the Answer, a beloved chapter in the Big Book.1 He expanded on his philosophy in a subsequent book.2

At the very outset Paul O. noted:

Alcoholism is both a drinking and thinking problem.3

In Chapter 3 — “Mental Sobriety” — he cleverly tweaked Robert Seliger’s “liquor test”4 by replacing drink(ing) with think(ing):

  1. Do you lose time from work due to your thinking?
  2. Is your thinking making your home life unhappy?
  3. Do you think because you are shy with other people?
  4. Is your thinking affecting your reputation?
  5. Have you ever felt remorse after thinking?
  6. Have you gotten into financial difficulty as a result of thinking?
  7. Do you turn to lower companions or an inferior environment when thinking?
  8. Does your thinking make you careless of your family’s welfare?
  9. Has your ambition decreased since thinking?
  10. Do you crave a think at a definite time daily?
  11. Do you want to think the next morning?
  12. Does thinking cause you to have difficulty in sleeping?
  13. Has your efficiency decreased since thinking?
  14. Is thinking jeopardizing your job or business?
  15. Do you think to escape from worries or trouble?
  16. Do you think alone?
  17. Have you ever had a complete loss of memory as a result of thinking?
  18. Has your physician ever treated you for thinking?
  19. Do you think to build up your self-confidence?
  20. Have you ever been to a hospital or institution on account of your thinking?5

A few pages later Paul O. observed:

All my problems today are thinking problems. I don't even have a problem unless I think I do. If I think I have a problem, I have a problem; if I don't think I have a problem, I don't have a problem. Never have I thought I had a problem and been wrong.

Not only do I alone decide whether or not I have a problem; I alone determine the size of my problems. I don't have many little problems; I don't bother with them. [...] When I do have a little problem, all I have to do to make it a big problem is to think about it.6

Humorous, simple, profound. ✸

  1. Alcoholics Anonymous, 4th ed. New York: Alcoholics Anonymous World Services, 2001, pp. 407–420
  2. There’s More to Quitting Drinking Than Quitting Drinking. Torrence, CA: Capizon Publishing, 1995
  3. There’s More, p. cover
  4. Alcoholics Are Sick People. Baltimore: Alcoholism Publications, 1945, pp. 9–12
  5. There’s More, p. 39
  6. There’s More, p. 54

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Received Wisdom #30

Be Here Now

Some lessons take take a long time to learn.

I took Induction to Non-Western Religions during my first semester of college in 1988. Here’s the description from the course catalog:

An introduction to the study of non-Western religious traditions in south and east Asia (Hinduism, Buddhism, Taoism, Confucianism, and Shinto). Open to everyone but especially appropriate for first and second year students. Fall semester.1

James W. Laine, Ph.D., was our professor.

First edition of “Be Here Now,” the perennial bestseller by Ram Dass. Image: Burnside Rare Books

I have three memories of the course. First, our classroom was in Old Main, a gorgeous stone building dating back to 1889. It looked and felt like college in the movies.

Second, one of my classmates was a Theravada Buddhist monk — shaved head, orange robe, sandals — from Sri Lanka. Dr. Laine would banter with him in another language (Sinhala? Pali?) during class.

The third and most important memory is a lesson that took decades for me to internalize. This is part of an e-mail that I sent to Dr. Laine in June 2020:

I remember bits and pieces [of the course] including a parable that you shared during class. The details are probably distorted by time, but it involved someone escaping a tiger and a cliff. The person, despite great personal peril, was able to pause to enjoy some succulent berries growing on the side of the cliff.

Dr. Laine helpfully replied:

The story you allude to has many versions and interpretations. Tolstoy learned of it from the Tale of Barlaam and Josaphat, a medieval Christian tale whose origins are in fact Buddhist (Josaphat being a garbled version of bodhisattva). Gandhi, I believe, learned the tale from Tolstoy. So a Buddhist tale went west, turned north and came back east.  Who knows, maybe Gandhi passed it on to Martin Luther King or Mandela or Cesar Chavez, all of whom he influenced.

With that lead, I was able to track down this version of the parable:

A man traveling across a field encountered a tiger. He fled, the tiger after him. Coming to a precipice, he caught hold of the root of a wild vine and swung himself down over the edge. The tiger sniffed at him from above. Trembling, the man looked down to where, far below, another tiger was waiting to eat him. Only the vine sustained him.

Two mice, one white and one black, little by little started to gnaw away the vine. The man saw a luscious strawberry near him. Grasping the vine with one hand, he plucked the strawberry with the other. How sweet it tasted!2

This parable wound up being the most important thing that I learned in college, although I didn’t know it at the time. It took years of subsequent seeking and suffering for it to become lived experience.

There is just the eternal now. The tigers of the past and future are memories and imagination:

Nothing ever happened in the past; it happened in the Now.

Nothing will ever happen in the future; it will happen in the Now.

What you think of as the past is a memory trace, stored in the mind, of a former Now. When you remember the past, you reactivate a memory trace—and you do so now. The future is an imagined Now, a projection of the mind.3

Be here now. ✸

  1. 1988/90 Catalog. St. Paul, MN: Macalester College, 1988, p. 159
  2. Paul Reps. Zen Flesh, Zen Bones. Rutland, VT: Charles E. Tuttle Co., 1957, pp. 28–29
  3. Eckhart Tolle. The Power of Now. Vancouver: Namaste Publishing, 1997, pp. 41–42

Endnote. Be Here Now, which was published in 1971, consolidated these earlier materials into a single volume.

Image: Burnside Rare Books

Make It Four

The 77th (!!) edition of Conn’s Current Therapy is now in print and with it my chapter on alcohol use disorder.1 I’ve been the chapter author since 2022.

I’m eternally grateful to my old partner, Tim Scanlan, M.D., for passing my name along to the editorial team at Elsevier. I also want to thank my editors, Rick Kellerman, M.D., and Kevin Travers.

This year’s chapter contains a new section on withdrawal management. There’s also an update related to the newish edition of The ASAM Criteria.

I’ve been invited back for 2026. For the past few years, I’ve been pondering whether risks related to alcohol truly “start from the first drop.” The Surgeon General’s recent cancer advisory probably requires me to finally wade into this controversy. ✸

  1. Page 865ff.

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