Treating the “Mind” Versus the “Brain” in Substance Dependence
June 24, 2013
By Arjune Rama, MD
Note: The patient below has been completely de-identified in order to protect his/her health information.
“You
don’t have any idea what you’re dealing with, do you?” asked Mr Johnson
a mere 2 minutes into my interview. The scene is the Crisis
Intervention Unit. The time is 3 AM. I have a feeling my breath is
terrible. The hospital pizza I engulfed earlier in the evening has
decided to stage a churning acidic protest in my guts. However, far
worse than my half-closed eyes, my halitosis or my gastrointestinal
distress is the fact that he’s absolutely right. Mr Johnson is here
because he has come to the realization that living sober is about as
awful as living as an alcoholic. As a result, he has decided life is
simply not worth living.
As a practitioner, patients caught in
this double-bind are among the most frustrating to treat. They are
living proof that substance dependence treatment can be quite
shortsighted. The logic is charmingly simple and irritatingly
simplistic: if you’re drinking too much, then you should probably stop.
Once you stop, all will be better.
To properly understand the
failure of this logic, we need to distinguish the brain from the mind.
Although our medications and therapies are effective in removing alcohol
from the brain, we are less successful filling the empty space left in
the mind. Mr Johnson’s alcohol use started as a coping strategy and
slowly evolved into a way of navigating the world: a drink to take the
edge off at a dinner party; a libation or five to take the edge off of a
bad day at the office; a quick stop at the corner bar after work to
steel himself against a troubled marriage and a wayward teen. Alcohol
played prominently in the way his mind functioned for years.
After
“treatment,” suddenly there was no sedative to bring out the best “Mr
Johnson” when he attended a dinner party. Frustration from days at the
office lingered long into the evening. Problems at home, at one time
nicely obscured by liquor, were now seen in sharp relief.
When Mr
Johnson accurately noted that I couldn’t appreciate his situation, I was
reminded of my personal development thus far. Like most physicians, I
am a person suited to delayed gratification, long-term goal-setting, and
possessed of a persistence to achieve these goals. This isn’t to say
that I’m superior to him. Rather, for reasons as arbitrary as genetics
and birthright, the decision centers of my brain do not have to compete
with the influence of a substance such that my mind can look at the ups
and downs of life with balance. As a result, I have little to no
tangible life experience with which to help his mind function without
the aid of a substance.
So after staring blankly for a few seconds
(which seemed like minutes) at Mr Johnson, I dispensed momentarily with
my medical training regarding suicide risk assessment or attempting to
present treatment options to achieve sobriety. Instead, I sat on the
edge of his bed and said, “You’re right. I don’t know what I’m dealing
with. This sounds absolutely awful, though . . . tell me what it’s
like.” Given the constrictions of a busy crisis unit, I still had to
complete my evaluation, disposition decision, and documentation within
an hour. Eventually he was voluntarily admitted to the hospital out of
concern for serious potential harm to self.
I have no delusions
that my brief talk filled the void in his mind left by the removal of
alcohol. However, during our discussion it occurred to me that patients
like Mr Johnson are constantly marginalized in the hospital setting.
Throughout medical school and into residency I have heard the phrase,
“He’s just going to go out and drink after discharge anyway . . .” more
times than I can count in reference to the disposition of patients like
Mr Johnson. It’s true, the relapse rate for patients who are newly sober
is staggeringly high. So what are we as practitioners to do?
We
need to listen. And I mean, really listen. We need to be taught by our
substance-dependent patients because, more than likely, we have zero
background with which to help them. Listening in this way may be very
uncomfortable, as it requires us to step away from the familiar books
and diagrams that put us in the revered position of “Doctor” and step
toward the unfamiliar thought processes of those who have put their
lives in our hands. We cannot hear our patients if we try to remain on
this imaginary pedestal: our ears are simply too far away to catch
anything helpful.
As a result, I strongly encourage my medical
students to read actual descriptions of real patients’ experiences with
addiction and better yet, listen to one or more of their patients who is
willing to describe their personal addiction stories. I believe that
the more and varied stories we read and hear, the better equipped we are
to understand the cold vacuum left behind when alcohol is removed from
the equation. As we accumulate a greater war chest of patient
experiences, we can better apply our skills as physicians to fill a
space once occupied with alcohol-lubricated decision-making with smooth
yet sober coping strategies. In this way, we can help change their
minds.
[Editor’s Note: Our thanks to
Hum Magazine, which has granted permission to post this article, published on their website at
http://hummagazine.com/?p=4567.]
ation.
“You don’t have any idea what you’re dealing with, do you?” asked Mr
Johnson a mere 2 minutes into my interview. The scene is the Crisis
Intervention Unit. The time is 3 AM. I have a feeling my breath is
terrible. The hospital pizza I engulfed earlier in the evening has
decided to stage a churning acidic protest in my guts. However, far
worse than my half-closed eyes, my halitosis or my gastrointestinal
distress is the fact that he’s absolutely right. Mr Johnson is here
because he has come to the realization that living sober is about as
awful as living as an alcoholic. As a result, he has decided life is
simply not worth living.
- See more at:
http://www.psychiatrictimes.com/blogs/residents-blog/treating-mind-versus-brain-substance-dependence#sthash.9eyM2Olh.dpuf
ation.
“You don’t have any idea what you’re dealing with, do you?” asked Mr
Johnson a mere 2 minutes into my interview. The scene is the Crisis
Intervention Unit. The time is 3 AM. I have a feeling my breath is
terrible. The hospital pizza I engulfed earlier in the evening has
decided to stage a churning acidic protest in my guts. However, far
worse than my half-closed eyes, my halitosis or my gastrointestinal
distress is the fact that he’s absolutely right. Mr Johnson is here
because he has come to the realization that living sober is about as
awful as living as an alcoholic. As a result, he has decided life is
simply not worth living.
- See more at:
http://www.psychiatrictimes.com/blogs/residents-blog/treating-mind-versus-brain-substance-dependence#sthash.9eyM2Olh.dpuf
ation.
“You don’t have any idea what you’re dealing with, do you?” asked Mr
Johnson a mere 2 minutes into my interview. The scene is the Crisis
Intervention Unit. The time is 3 AM. I have a feeling my breath is
terrible. The hospital pizza I engulfed earlier in the evening has
decided to stage a churning acidic protest in my guts. However, far
worse than my half-closed eyes, my halitosis or my gastrointestinal
distress is the fact that he’s absolutely right. Mr Johnson is here
because he has come to the realization that living sober is about as
awful as living as an alcoholic. As a result, he has decided life is
simply not worth living.
- See more at:
http://www.psychiatrictimes.com/blogs/residents-blog/treating-mind-versus-brain-substance-dependence#sthash.9eyM2Olh.dpuf
ation.
“You don’t have any idea what you’re dealing with, do you?” asked Mr
Johnson a mere 2 minutes into my interview. The scene is the Crisis
Intervention Unit. The time is 3 AM. I have a feeling my breath is
terrible. The hospital pizza I engulfed earlier in the evening has
decided to stage a churning acidic protest in my guts. However, far
worse than my half-closed eyes, my halitosis or my gastrointestinal
distress is the fact that he’s absolutely right. Mr Johnson is here
because he has come to the realization that living sober is about as
awful as living as an alcoholic. As a result, he has decided life is
simply not worth living.
- See more at:
http://www.psychiatrictimes.com/blogs/residents-blog/treating-mind-versus-brain-substance-dependence#sthash.9eyM2Olh.dpuf
ation.
“You don’t have any idea what you’re dealing with, do you?” asked Mr
Johnson a mere 2 minutes into my interview. The scene is the Crisis
Intervention Unit. The time is 3 AM. I have a feeling my breath is
terrible. The hospital pizza I engulfed earlier in the evening has
decided to stage a churning acidic protest in my guts. However, far
worse than my half-closed eyes, my halitosis or my gastrointestinal
distress is the fact that he’s absolutely right. Mr Johnson is here
because he has come to the realization that living sober is about as
awful as living as an alcoholic. As a result, he has decided life is
simply not worth living.
- See more at:
http://www.psychiatrictimes.com/blogs/residents-blog/treating-mind-versus-brain-substance-dependence#sthash.9eyM2Olh.dpuf
ation.
“You don’t have any idea what you’re dealing with, do you?” asked Mr
Johnson a mere 2 minutes into my interview. The scene is the Crisis
Intervention Unit. The time is 3 AM. I have a feeling my breath is
terrible. The hospital pizza I engulfed earlier in the evening has
decided to stage a churning acidic protest in my guts. However, far
worse than my half-closed eyes, my halitosis or my gastrointestinal
distress is the fact that he’s absolutely right. Mr Johnson is here
because he has come to the realization that living sober is about as
awful as living as an alcoholic. As a result, he has decided life is
simply not worth living.
- See more at:
http://www.psychiatrictimes.com/blogs/residents-blog/treating-mind-versus-brain-substance-dependence#sthash.9eyM2Olh.dpuf
ation.
“You don’t have any idea what you’re dealing with, do you?” asked Mr
Johnson a mere 2 minutes into my interview. The scene is the Crisis
Intervention Unit. The time is 3 AM. I have a feeling my breath is
terrible. The hospital pizza I engulfed earlier in the evening has
decided to stage a churning acidic protest in my guts. However, far
worse than my half-closed eyes, my halitosis or my gastrointestinal
distress is the fact that he’s absolutely right. Mr Johnson is here
because he has come to the realization that living sober is about as
awful as living as an alcoholic. As a result, he has decided life is
simply not worth living.
- See more at:
http://www.psychiatrictimes.com/blogs/residents-blog/treating-mind-versus-brain-substance-dependence#sthash.9eyM2Olh.dpuf
o
read actual descriptions of real patients’ experiences with addiction
and better yet, listen to one or more of their patients who is willing
to describe their personal addiction stories. I believe that the more
and varied stories we read and hear, the better equipped we are to
understand the cold vacuum left behind when alcohol is removed from the
equation. As we accumulate a greater war chest of patient experiences,
we can better apply our skills as physicians to fill a space once
occupied with alcohol-lubricated decision-making with smooth yet sober
coping strategies. In this way, we can help change their minds.
[Editor’s Note: Our thanks to
Hum Magazine, which has granted permission to post this article, published on their website at
http://hummagazine.com/?p=4567.]
Arjune Rama, MD
Resident Physician, PGY-2
Yale University School of Medicine
Department of Psychiatry
- See more at:
http://www.psychiatrictimes.com/blogs/residents-blog/treating-mind-versus-brain-substance-dependence#sthash.9eyM2Olh.dpuf
o
read actual descriptions of real patients’ experiences with addiction
and better yet, listen to one or more of their patients who is willing
to describe their personal addiction stories. I believe that the more
and varied stories we read and hear, the better equipped we are to
understand the cold vacuum left behind when alcohol is removed from the
equation. As we accumulate a greater war chest of patient experiences,
we can better apply our skills as physicians to fill a space once
occupied with alcohol-lubricated decision-making with smooth yet sober
coping strategies. In this way, we can help change their minds.
[Editor’s Note: Our thanks to
Hum Magazine, which has granted permission to post this article, published on their website at
http://hummagazine.com/?p=4567.]
Arjune Rama, MD
Resident Physician, PGY-2
Yale University School of Medicine
Department of Psychiatry
- See more at:
http://www.psychiatrictimes.com/blogs/residents-blog/treating-mind-versus-brain-substance-dependence#sthash.9eyM2Olh.dpuf
o
read actual descriptions of real patients’ experiences with addiction
and better yet, listen to one or more of their patients who is willing
to describe their personal addiction stories. I believe that the more
and varied stories we read and hear, the better equipped we are to
understand the cold vacuum left behind when alcohol is removed from the
equation. As we accumulate a greater war chest of patient experiences,
we can better apply our skills as physicians to fill a space once
occupied with alcohol-lubricated decision-making with smooth yet sober
coping strategies. In this way, we can help change their minds.
[Editor’s Note: Our thanks to
Hum Magazine, which has granted permission to post this article, published on their website at
http://hummagazine.com/?p=4567.]
Arjune Rama, MD
Resident Physician, PGY-2
Yale University School of Medicine
Department of Psychiatry
- See more at:
http://www.psychiatrictimes.com/blogs/residents-blog/treating-mind-versus-brain-substance-dependence#sthash.9eyM2Olh.dpuf
o
read actual descriptions of real patients’ experiences with addiction
and better yet, listen to one or more of their patients who is willing
to describe their personal addiction stories. I believe that the more
and varied stories we read and hear, the better equipped we are to
understand the cold vacuum left behind when alcohol is removed from the
equation. As we accumulate a greater war chest of patient experiences,
we can better apply our skills as physicians to fill a space once
occupied with alcohol-lubricated decision-making with smooth yet sober
coping strategies. In this way, we can help change their minds.
[Editor’s Note: Our thanks to
Hum Magazine, which has granted permission to post this article, published on their website at
http://hummagazine.com/?p=4567.]
Arjune Rama, MD
Resident Physician, PGY-2
Yale University School of Medicine
Department of Psychiatry
- See more at:
http://www.psychiatrictimes.com/blogs/residents-blog/treating-mind-versus-brain-substance-dependence#sthash.9eyM2Olh.dpuf
o
read actual descriptions of real patients’ experiences with addiction
and better yet, listen to one or more of their patients who is willing
to describe their personal addiction stories. I believe that the more
and varied stories we read and hear, the better equipped we are to
understand the cold vacuum left behind when alcohol is removed from the
equation. As we accumulate a greater war chest of patient experiences,
we can better apply our skills as physicians to fill a space once
occupied with alcohol-lubricated decision-making with smooth yet sober
coping strategies. In this way, we can help change their minds.
[Editor’s Note: Our thanks to
Hum Magazine, which has granted permission to post this article, published on their website at
http://hummagazine.com/?p=4567.]
Arjune Rama, MD
Resident Physician, PGY-2
Yale University School of Medicine
Department of Psychiatry
- See more at:
http://www.psychiatrictimes.com/blogs/residents-blog/treating-mind-versus-brain-substance-dependence#sthash.9eyM2Olh.dpuf
Treating the “Mind” Versus the “Brain” in Substance Dependence
Treating the “Mind” Versus the “Brain” in Substance Dependence
- See more at:
http://www.psychiatrictimes.com/blogs/residents-blog/treating-mind-versus-brain-substance-dependence#sthash.9eyM2Olh.dpuf
Treating the “Mind” Versus the “Brain” in Substance Dependence
Treating the “Mind” Versus the “Brain” in Substance Dependence
- See more at:
http://www.psychiatrictimes.com/blogs/residents-blog/treating-mind-versus-brain-substance-dependence#sthash.9eyM2Olh.dpuf
Treating the “Mind” Versus the “Brain” in Substance Dependence
Treating the “Mind” Versus the “Brain” in Substance Dependence
- See more at:
http://www.psychiatrictimes.com/blogs/residents-blog/treating-mind-versus-brain-substance-dependence#sthash.9eyM2Olh.dpuf