My social media manager (that would be me) has fallen hopelessly behind. Some catch-up is in order.
I was recently quoted in aNew York Times article on illicit designer drugs as treatments for addiction. The subtitle is a good summary: “Against expert advice, people are using new and unpredictable synthetic drugs to experiment on themselves in hopes of becoming free of addiction.”
The Osceola Sun published a long form interview for Mental Health Awareness Month. I discussed the link between mental health and addiction. Sometimes substance use begins as self-medication for mental health symptoms. Treatment of those symptoms is critical because they drive substance use — addiction treatment generally fails unless they are addressed. In other cases, mental health symptoms are caused by substance use. The priority is thus reducing or eliminating alcohol and other drugs.
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.” ✸
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). Washington, DC: American Psychiatric Association, 2022, pp. 543–665
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
PDM-2, p. 226
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
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.”
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. ✸
Alcoholics Anonymous, 4th ed. New York: Alcoholics Anonymous World Services, 2001, pp. 58–71, 72–88 (Step 6)
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.
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 […].” ✸
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
Theodor Reik. The Need to Be Loved. New York: Farrar, Straus and Company, 1963, p. 271
Alcoholics Anonymous, 4th ed. New York: Alcoholics Anonymous World Services, Inc., p. 64
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!”
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? TheBig 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.”
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.
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.”
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. ✸
About 20 years ago, I ran across this in an essay by C.S. Lewis:
Every age has its own outlook. It is specially good at seeing certain truths and specially liable to make certain mistakes. We all, therefore, need the books that will correct the characteristic mistakes of our own period. And that means the old books.*
Lewis argued, “I do not wish the ordinary reader to read no modern books. But if he must read only the new or only the old, I would advise him to read the old.” He also offered this suggestion: “It is a good rule, after reading a new book, never to allow yourself another new one till you have read an old one in between.”
My reading habits immediately changed. I started reading old books—in many cases, very old books.
And so it is that we will be considering Richard R. Peabody’s The Common Sense of Drinking, which was published in 1931, at an upcoming residential recovery retreat at Hazelden Betty Ford’s Dan Anderson Renewal Center. The book contains ideas and phrases that were later popularized by Alcoholics Anonymous such as “once a drunkard always a drunkard” and “halfway measures are of no avail.”†
The Twins were eliminated by the Astros yesterday, however, it’s still baseball season! In that spirit, I’m “pitching” a split doubleheader today in two different ballparks through the wonders of Zoom.
