Treating the “Mind” Versus the “Brain” in Substance Dependence


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.

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, I have found that 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]

Arjune Rama, MD
Resident Physician, PGY-2
Yale University School of Medicine
Department of Psychiatry

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