Dr. Anna Lembke: Understanding & Treating Addiction

00:00:00.000 | - Welcome to the Huberman Lab Podcast,

00:00:02.260 | where we discuss science and science-based tools

00:00:04.880 | for everyday life.

00:00:05.900 | I'm Andrew Huberman,

00:00:10.480 | and I'm a professor of neurobiology and ophthalmology

00:00:13.160 | at Stanford School of Medicine.

00:00:15.200 | Today, I have the pleasure of introducing Dr. Anna Lemke.

00:00:18.800 | Dr. Lemke is a psychiatrist

00:00:20.560 | and the chief of the Addiction Medicine

00:00:22.280 | Dual Diagnosis Clinic

00:00:23.600 | at Stanford University School of Medicine.

00:00:26.240 | She's a psychiatrist who treats patients

00:00:28.640 | struggling with addiction.

00:00:30.580 | She has successfully treated patients

00:00:32.620 | dealing with drug addiction, alcohol addiction,

00:00:35.920 | and behavioral addictions,

00:00:37.620 | such as gambling and sex addiction,

00:00:40.020 | as well as other types of addiction.

00:00:42.360 | In fact, during our discussion,

00:00:43.720 | I learned that there are a huge range of behaviors

00:00:46.560 | and substances to which people can become addicted to,

00:00:49.960 | and that there is a common biological underpinning

00:00:52.900 | of all those addictions.

00:00:54.740 | I also learned that there's a common path

00:00:57.340 | to the treatment and recovery

00:00:59.040 | from essentially all addictions.

00:01:01.200 | Dr. Lemke explained that to me

00:01:03.320 | and explained how to think about and conceptualize

00:01:06.620 | our own addictions,

00:01:08.020 | as well as the addictions of other people

00:01:10.120 | who are struggling to get treatment,

00:01:11.920 | move through treatment,

00:01:13.280 | and stay sober from their addictions.

00:01:15.320 | In addition to treating patients,

00:01:16.680 | Dr. Lemke is an author

00:01:18.160 | and was featured in the 2020 Netflix documentary,

00:01:21.120 | "The Social Dilemma."

00:01:22.980 | I'm excited to tell you that she has a new book coming out

00:01:25.560 | called "Dopamine Nation,

00:01:27.280 | Finding Balance in the Age of Indulgence."

00:01:29.760 | The book comes out August 24th

00:01:31.860 | and is an absolutely fascinating read into addiction

00:01:35.160 | and ways to treat various types of addiction.

00:01:38.000 | I've read the book cover to cover,

00:01:40.080 | and all I'll tell you is that at the very first chapter

00:01:43.620 | and throughout, you're going to be absolutely blown away.

00:01:46.600 | The stories about her patients are extremely engaging.

00:01:51.240 | It brings forward the real struggle of addiction

00:01:54.080 | and the incredible, I think it's fair to say,

00:01:56.680 | heroic battles that people fight

00:01:58.720 | in order to get through addictions of various kinds.

00:02:01.760 | And all of that is woven through with story,

00:02:04.060 | with science, and ways that make it very accessible

00:02:07.080 | to anyone, whether or not you have a science background

00:02:09.140 | or not, I can't recommend it highly enough.

00:02:11.500 | So again, the book is "Dopamine Nation,

00:02:13.740 | Finding Balance in the Age of Indulgence."

00:02:15.800 | It comes out August 24th of this year, 2021,

00:02:19.240 | and you can pre-order that book by going to Amazon.

00:02:22.000 | We will provide a link to that in the show caption.

00:02:24.920 | Before we begin, I just want to mention that this podcast

00:02:28.560 | is separate from my teaching and research roles at Stanford.

00:02:31.560 | It is, however, part of my desire and effort

00:02:33.740 | to bring zero cost to consumer information about science

00:02:36.480 | and science-related tools to the general public.

00:02:39.320 | In keeping with that theme,

00:02:40.400 | I'd like to thank the sponsors of today's podcast.

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00:06:57.720 | And now for my discussion with Dr. Anna Lemke.

00:07:01.780 | All right, great to have you here.

00:07:04.720 | - Thank you for having me.

00:07:05.640 | I'm excited to be here.

00:07:07.060 | - Yeah, I have a lot of questions for you.

00:07:08.580 | I and many listeners of this podcast

00:07:13.520 | are obsessed with dopamine, and what is dopamine?

00:07:17.720 | How does it work?

00:07:18.560 | We all hear that dopamine is this molecule

00:07:20.660 | associated with pleasure.

00:07:22.740 | I think the term dopamine hits,

00:07:25.660 | like I'm getting a dopamine hit from this,

00:07:27.500 | from Instagram or from likes or from praise

00:07:30.580 | or from whatever, is now commonly heard.

00:07:35.980 | What is dopamine, and what are maybe some things

00:07:39.720 | about dopamine that most people don't know

00:07:41.980 | and probably that I don't know either?

00:07:44.820 | - So dopamine is a neurotransmitter,

00:07:47.220 | and neurotransmitters are those molecules

00:07:49.440 | that bridge the gap between two neurons.

00:07:52.740 | So they essentially allow one neuron,

00:07:55.040 | the presynaptic neuron,

00:07:56.740 | to communicate with the postsynaptic neuron.

00:07:59.700 | Dopamine is intimately associated

00:08:03.260 | with the experience of reward,

00:08:05.580 | but also with movement,

00:08:06.900 | which I think is really interesting

00:08:08.320 | because movement and reward are linked, right?

00:08:10.940 | If you think about early humans,

00:08:14.540 | you had to move in order to go seek out the water

00:08:18.660 | or the meat or whatever it was.

00:08:21.620 | And even in the most primitive organisms,

00:08:24.420 | dopamine is released when food is sensed in the environment,

00:08:27.540 | for example, sea elegance, a very primitive worm.

00:08:32.860 | So dopamine is this really powerful,

00:08:36.780 | important molecule in the brain

00:08:39.860 | that helps us experience pleasure.

00:08:43.360 | It's not the only neurotransmitter involved in pleasure,

00:08:46.120 | but it's a really, really important one.

00:08:48.380 | And if you wanna think about something

00:08:51.420 | that most people don't know about dopamine,

00:08:53.260 | which I think is really interesting,

00:08:54.740 | is that we are always releasing dopamine

00:08:57.920 | at a kind of tonic baseline rate,

00:09:00.700 | and it's really the deviation from that baseline

00:09:04.240 | rather than hits of dopamine in a vacuum

00:09:06.980 | that make a difference.

00:09:08.180 | So when we experience pleasure,

00:09:10.180 | our dopamine release goes above baseline,

00:09:12.980 | and likewise, dopamine can go below that tonic baseline,

00:09:16.980 | and then we experience a kind of pain.

00:09:19.940 | - Interesting, so is it fair to say

00:09:22.420 | that one's baseline levels of dopamine,

00:09:24.940 | how frequently we are releasing dopamine

00:09:27.860 | in the absence of some, I don't know, drug or food

00:09:31.560 | or experience just sitting, being,

00:09:34.580 | is that associated with how happy somebody is,

00:09:38.260 | their kind of baseline of happiness or level of depression?

00:09:41.620 | - There is evidence that shows that people who are depressed

00:09:46.220 | may indeed have lower tonic levels of dopamine.

00:09:51.220 | So that's a really reasonable thought,

00:09:53.840 | and there's some evidence to suggest that that may be true.

00:09:57.680 | The other thing that we know,

00:09:58.920 | and this is really kind of what the book is about,

00:10:03.920 | is that if we expose ourselves chronically

00:10:08.740 | to substances or behaviors

00:10:11.240 | that repeatedly release large amounts of dopamine

00:10:15.580 | in our brain's reward pathway,

00:10:17.140 | that we can change our tonic baseline

00:10:20.180 | and actually lower it over time

00:10:22.500 | as our brain tries to compensate for all of that dopamine,

00:10:26.200 | which is more really than we were designed to experience.

00:10:31.200 | - Interesting, and is it the case

00:10:34.020 | that our baseline levels of dopamine

00:10:35.940 | are set by our genetics, by our heredity?

00:10:39.100 | - Well, I think if you think about

00:10:41.140 | sort of the early stages of development in infancy,

00:10:44.460 | certainly that is true.

00:10:45.920 | You're kind of born with probably

00:10:48.740 | whatever is your baseline level,

00:10:50.280 | but obviously your experiences can have a huge impact

00:10:54.620 | on where your dopamine level ultimately settles out.

00:10:59.620 | - So if somebody's disposition is one of constant excitement

00:11:05.300 | and anticipation or easily excited,

00:11:08.340 | these are, I think, about the kind of people where you say,

00:11:10.300 | hey, do you want to check out this new place for tacos?

00:11:12.180 | And they're like, yeah, that'd be great.

00:11:13.420 | And other people are a little more cynical,

00:11:16.640 | harder to budge, like my bulldog Costello.

00:11:19.280 | Very, very stable low levels of dopamine

00:11:23.200 | with big inflections in his case.

00:11:24.960 | Do you think that's set in terms of our parents

00:11:31.660 | and obviously nature and nurture interact,

00:11:34.960 | but is dopamine at the core of our temperament?

00:11:39.080 | - I don't really think we know the answer to that,

00:11:42.940 | but I will say that people are definitely born

00:11:46.800 | with different temperaments,

00:11:49.100 | and those temperaments do affect their ability

00:11:53.320 | to experience joy.

00:11:55.660 | And we've known that for a long time,

00:11:57.880 | and we describe that in many different ways.

00:12:00.380 | One of the ways that we describe that in the modern era

00:12:02.740 | is to use psychiatric nomenclature,

00:12:05.160 | like this person has a dysthymic temperament,

00:12:07.940 | or this person has chronic major depressive disorder.

00:12:11.480 | In terms of looking specifically

00:12:14.260 | at who's vulnerable to addiction,

00:12:17.420 | that's an interesting sort of mixed bag,

00:12:19.720 | because when you look at the research

00:12:22.140 | on risk factors for addiction,

00:12:24.140 | so what kind of temperament of a person

00:12:26.900 | makes them more vulnerable to addiction,

00:12:29.100 | you see some interesting findings.

00:12:31.220 | First, you see that people who are more impulsive

00:12:33.900 | are more vulnerable to addiction.

00:12:35.420 | So what is impulsivity?

00:12:37.020 | That means having difficulty putting space

00:12:39.900 | between the thought or desire to do something

00:12:42.860 | and actually doing it.

00:12:44.140 | And people who have difficulty putting a space there,

00:12:47.200 | who have a thought to do something and just do it impulsively

00:12:51.460 | are people who are more vulnerable to addiction.

00:12:53.920 | - Interesting.

00:12:55.420 | In terms of impulsivity,

00:12:57.020 | is this something that relates literally

00:12:59.300 | to the startle reflex?

00:13:01.080 | Like I, for instance, as a lab director,

00:13:03.660 | I'm familiar with walking around my lab,

00:13:05.180 | and when I decide, deciding I'm going to talk to my people,

00:13:08.260 | of course, when they knock on my door,

00:13:09.460 | it's always like, "Wait, why am I being bothered right now?"

00:13:11.900 | Even though I love to talk to them,

00:13:12.980 | but I walk around my lab from time to time,

00:13:14.820 | and some people I notice I'll say, "Do you have a moment?"

00:13:18.380 | And they'll slowly turn around and say, "Yeah,"

00:13:20.740 | or "No," in some cases.

00:13:22.400 | And other people will jump the moment I say their name.

00:13:26.120 | They actually have a kind of a heightened startle reflex.

00:13:30.700 | Is that related to impulsivity

00:13:32.320 | or is what you're referring to an attempt

00:13:35.100 | to withhold behavior that's very deliberate

00:13:38.880 | under very deliberate conditions?

00:13:40.480 | - Yeah, so I don't think that that startle reflex

00:13:43.200 | is necessarily related to impulsivity.

00:13:45.360 | That can be related to anxiety.

00:13:47.360 | So people who are high anxiety,

00:13:49.100 | people will tend to have more of a startle reflex.

00:13:52.160 | Impulsivity is a little bit different.

00:13:54.200 | And by the way, impulsivity is not always bad, right?

00:13:57.940 | Impulsivity is that thing where

00:14:01.780 | there's not a lot of self-editing

00:14:04.580 | or worrying about future consequences.

00:14:07.800 | You know, you have the idea to do something and you do it.

00:14:10.980 | And of course, we can imagine many scenarios

00:14:13.980 | where that's absolutely wonderful.

00:14:16.180 | You know, there can be a sort of,

00:14:18.940 | let's say, intimate interactions between people

00:14:23.940 | where you wouldn't really want to be

00:14:25.600 | super inhibited about it, right?

00:14:27.060 | You would want to be disinhibited and impulsive.

00:14:30.640 | I can also imagine like sort of fight or flight scenarios,

00:14:35.020 | like battle scenarios, right?

00:14:36.760 | Where it would really be good to be impulsive

00:14:39.660 | and just go, rah, you know, just go.

00:14:41.420 | - Where hesitation can cost you your life.

00:14:43.040 | - Right, yes, that's right, that's right.

00:14:44.900 | But, you know, and I think this brings up a really,

00:14:47.880 | something that I've come to believe

00:14:50.980 | after 25 years of practicing psychiatry

00:14:54.240 | is that what we now conceptualize

00:14:57.460 | in our current ecosystem as mental illness

00:15:02.460 | are actually traits that in another ecosystem

00:15:06.500 | might be very advantageous.

00:15:08.580 | They're just not advantageous right now

00:15:11.580 | because of the world that we live in.

00:15:13.300 | And I think impulsivity is potentially one of those, right?

00:15:18.180 | 'Cause we live in this world that's sort of like

00:15:20.540 | you have to constantly be thinking sort of rationally

00:15:25.540 | about the consequences of X, Y, or Z.

00:15:29.580 | And it's such a sensory rich environment, right?

00:15:32.580 | That we're being bombarded with all of these opportunities,

00:15:36.100 | these sensory opportunities,

00:15:37.660 | and we have to constantly check ourselves.

00:15:39.620 | And so impulsivity is something that right now

00:15:43.720 | can be a difficult trait,

00:15:45.580 | but isn't in and of itself a bad thing.

00:15:48.540 | - I see. - Yeah.

00:15:49.380 | - Yeah, and it's, I'm beginning to realize

00:15:51.140 | it's a fine line between spontaneity and impulsivity.

00:15:53.860 | - Yeah.

00:15:54.700 | - What is pleasure and how does it work

00:15:59.720 | at the biological level and if it feels right

00:16:03.420 | at the psychological level?

00:16:05.100 | I think we, and if you don't mind painting a picture

00:16:09.180 | of sort of the range of things

00:16:12.500 | that you have observed in your clinic or in life

00:16:16.740 | that people can become addicted to.

00:16:18.480 | But just to start off really simply,

00:16:20.460 | what is this thing that we call pleasure?

00:16:23.140 | - Well, I think it's actually really hard

00:16:25.580 | to define pleasure in any kind of succinct way,

00:16:29.080 | because certainly there is the seeking out of high

00:16:34.980 | or a euphoria or I think the kind of experience

00:16:39.060 | that most anybody would associate with the word pleasure.

00:16:42.900 | But also the seeking out of those same substances

00:16:47.580 | and behaviors is often a way to escape pain.

00:16:51.660 | So for example, when I talk to people with addiction,

00:16:55.360 | sometimes their initial foray into using a drug

00:17:01.940 | is to get pleasure, but very often it's a way

00:17:05.500 | to escape their suffering, whatever their suffering may be.

00:17:09.260 | And certainly as people become addicted,

00:17:12.820 | even those who initially were seeking out pleasure

00:17:15.940 | are ultimately just trying to avoid the pain of withdrawal

00:17:20.460 | or the pain of the consequences of their drug use.

00:17:23.660 | So I think it's very hard to actually define it

00:17:29.360 | as this unitary thing, and it's certainly not

00:17:32.360 | just getting a high.

00:17:33.880 | There are so many ways in which people

00:17:36.840 | sort of want to escape, which is not the same thing

00:17:39.800 | as sort of this hedonic wanting to feel pleasure.

00:17:43.640 | - So someone could decide that they want to go out and dance

00:17:46.540 | or get up and dance because of the pleasure of dancing.

00:17:49.020 | I can imagine that.

00:17:50.160 | And maybe it's very difficult for them to stay seated

00:17:56.140 | when a particular song comes on, for instance.

00:17:59.220 | But seeking what we would call pleasure

00:18:03.620 | in order to eliminate pain,

00:18:05.380 | that evokes a different picture in my mind.

00:18:07.340 | That evokes a picture of somebody that feels lost

00:18:11.360 | or depressed or underwhelmed.

00:18:13.480 | I definitely want to get into the precise

00:18:17.400 | and general description of addiction and what that is.

00:18:20.060 | But in a previous conversation we had,

00:18:22.020 | you said something that really rung in my mind,

00:18:23.660 | which is that many people who become addicted to things,

00:18:27.900 | let's call them addicts, have this feeling

00:18:31.540 | that normal life isn't interesting enough,

00:18:35.280 | that they are seeking a super normal experience

00:18:39.040 | and that the day-to-day routine, balance,

00:18:42.300 | which is actually in the title of your book,

00:18:44.340 | Dopamine Nation, Finding Balance in the Age of Indulgence,

00:18:47.280 | that the word balance itself can sometimes be a bit

00:18:51.460 | of an aversive term for people.

00:18:54.860 | And I'm struck by this idea,

00:18:59.140 | and the reason I want to explore it

00:19:00.540 | is because so much of what I see online

00:19:03.380 | is about generating a lack of balance,

00:19:06.760 | about being tilted forward at all times,

00:19:10.700 | really leaning into life hard, experiencing life,

00:19:13.820 | living a full life.

00:19:15.660 | Even the commencement speech given by Steve Jobs

00:19:18.340 | on this campus was really about finding passion, digging.

00:19:22.580 | That's so much in the narrative now.

00:19:25.240 | So maybe you could just tell us a little bit

00:19:28.480 | about your experience with this association,

00:19:31.580 | if it really exists,

00:19:32.420 | between people's sense of the normalcy

00:19:35.580 | or maybe even how boring life can be

00:19:38.020 | and their tendency to become addicts of some sort.

00:19:40.680 | - Yeah, well, I mean, I think that life for humans

00:19:46.780 | has always been hard,

00:19:49.980 | but I think that now it's harder in unprecedented ways.

00:19:54.980 | And I think that the way that life is really hard now

00:19:59.340 | is that it actually is really boring.

00:20:02.120 | And the reason that it's boring

00:20:03.660 | is because all of our survival needs are met, right?

00:20:07.860 | I mean, we don't even have to leave our homes

00:20:10.620 | to meet every single physical need,

00:20:13.260 | as long as you're of a certain level of financial wellbeing,

00:20:17.420 | which frankly, we talk so much about the income gap,

00:20:22.420 | and certainly there is this enormous gap

00:20:24.360 | between rich and poor,

00:20:25.500 | but that gap is smaller than it's ever been

00:20:28.300 | in the history of humans.

00:20:30.900 | Even the poorest of the poor have more excess income

00:20:35.660 | to spend on leisure goods

00:20:36.960 | than they ever have before in human history.

00:20:40.140 | If you look at leisure time, for example,

00:20:42.700 | so people without a high school education

00:20:45.740 | have 42% more leisure time than people with a college degree.

00:20:50.740 | So my point here is that life is hard now

00:20:56.840 | in this really weird way

00:21:00.700 | in that we don't really have anything that we have to do.

00:21:04.580 | So we're all forced to make stuff up,

00:21:08.420 | whether it's being a scientist or being a doctor

00:21:13.620 | or being an Olympic athlete or climbing Mount Everest,

00:21:18.620 | and people really vary in their need for friction.

00:21:23.820 | And some people need a lot more than others.

00:21:26.300 | And if they don't have it, they're really, really unhappy.

00:21:29.660 | And I do think that a lot of the people that I see

00:21:32.780 | with addiction and other forms of mental illness

00:21:35.620 | are people who need more friction.

00:21:38.860 | Like they're unhappy,

00:21:40.940 | not necessarily because there's something wrong

00:21:43.020 | with their brain,

00:21:43.860 | but because their brain is not suited to this world.

00:21:47.200 | - And do you think they have that sense,

00:21:49.620 | my brain isn't suited to this world,

00:21:51.340 | or they simply feel a restlessness

00:21:55.780 | and they're constantly seeking stimulation?

00:21:58.600 | - I think that's right.

00:22:00.280 | Yeah, I think it's not really knowing what's wrong with me,

00:22:04.420 | and why am I unhappy, how can I be happier?

00:22:08.300 | And of course, as you talk about what's so pervasive

00:22:11.100 | in our narrative now is like,

00:22:12.700 | find your passion, find your whatever it is

00:22:17.700 | to save the world.

00:22:18.540 | And in a way that's good,

00:22:20.340 | because it has people out in the world and seeking.

00:22:23.580 | But in a way, it can also be misleading in the sense

00:22:27.980 | that I think people aren't entirely aware

00:22:31.780 | that the world is a hard place and that life is hard

00:22:36.340 | and that we're all kind of making it up.

00:22:40.780 | Do you know what I mean?

00:22:41.740 | - Yeah, well, there's a book by Cal Newport.

00:22:44.380 | I don't know if you know Cal Newport's work,

00:22:45.800 | but you guys are very symbiotic in your messages.

00:22:49.980 | He's a professor of computer science at Georgetown.

00:22:52.720 | Yes, at Georgetown.

00:22:54.740 | And wrote a book some years ago, really ahead of its time,

00:22:58.080 | called "So Good They Can't Ignore You,"

00:22:59.640 | which is about not meditating or doing much work

00:23:04.640 | to try and figure out what one's passion is by thinking,

00:23:08.340 | but rather go out and acquire skills

00:23:11.100 | and develop a sense of passion for something

00:23:14.220 | by your experience of hard work

00:23:16.260 | and getting better and feedback.

00:23:18.060 | A little bit of the growth mindset

00:23:19.300 | thing of our colleague, Carol Dweck.

00:23:21.000 | But he's gone on to write books, "Deep Work,"

00:23:25.060 | which is all about removing yourself from technology

00:23:27.540 | and doing deep work.

00:23:29.060 | And he's been a big proponent of the evils of context

00:23:32.580 | switching too often throughout the day

00:23:35.100 | for sake of productivity, mostly.

00:23:36.600 | His new book is called "A World Without Email."

00:23:39.500 | I'm beginning to realize as I cite off these books

00:23:41.820 | and your book, "Dopamine Nation,"

00:23:43.820 | finding balance in the age of indulgence,

00:23:45.980 | that maybe the reason why you two don't know

00:23:48.180 | about one another is because neither of you

00:23:49.900 | are on social media.

00:23:50.940 | - That's it, that's it. - Right.

00:23:51.780 | And yet you're two of the most productive people

00:23:54.020 | that I know, including productive authors.

00:23:56.660 | So that's a discussion unto itself.

00:23:58.140 | But I find this fascinating.

00:23:59.900 | So let's talk about the pleasure, pain, balance,

00:24:04.700 | and addiction.

00:24:06.040 | And I've heard you use this seesaw or balance scale analogy

00:24:10.800 | before, and I think it's a wonderful one

00:24:13.440 | that really, for me, clarified what addiction is,

00:24:18.440 | at least at the mechanistic level.

00:24:20.600 | - Yeah, so to me, one of the most significant findings

00:24:24.200 | in neuroscience in the last 75 years

00:24:26.360 | is that pleasure and pain are co-located,

00:24:29.400 | which means the same parts of the brain

00:24:31.100 | that process pleasure also process pain.

00:24:34.040 | And they work like a balance.

00:24:35.880 | So when we feel pleasure, our balance tips one way.

00:24:38.660 | When we feel pain, it tips in the opposite direction.

00:24:41.740 | And one of the overriding rules governing this balance

00:24:44.940 | is that it wants to stay level.

00:24:46.520 | So it doesn't want to remain tipped very long

00:24:48.340 | to pleasure or to pain.

00:24:49.900 | And with any deviation from neutrality,

00:24:52.420 | the brain will work very hard to restore a level balance,

00:24:55.900 | or what scientists call homeostasis.

00:24:58.420 | And the way the brain does that

00:25:00.260 | is with any stimulus to one side,

00:25:03.340 | there will be a tip an equal and opposite amount

00:25:06.460 | to the other side.

00:25:07.740 | - It's like you have principal laws of physics.

00:25:09.660 | - Yes, right, right.

00:25:11.040 | So I like to watch YouTube videos.

00:25:13.220 | When I watch YouTube videos of "American Idol,"

00:25:16.300 | it tips to the side of pleasure.

00:25:18.180 | And then when I stop watching it,

00:25:20.940 | I have a comedown, right,

00:25:22.300 | which is a tip to the equal and opposite amount

00:25:25.700 | on the other side.

00:25:26.600 | And that's that moment of wanting to watch

00:25:28.500 | one more YouTube video, right?

00:25:30.140 | - Yeah, and I just want to interject there.

00:25:33.120 | So this moment of wanting to watch another

00:25:37.700 | that is associated with pain, I think,

00:25:40.620 | is are we always aware of that happening?

00:25:43.560 | Because you just described it in a very conscious way.

00:25:46.340 | But when I indulge in something I enjoy,

00:25:49.800 | I'm usually thinking about just wanting more of that thing.

00:25:52.940 | I don't think about the pain, I just think about more.

00:25:56.140 | - Right, so really excellent point,

00:25:58.580 | because we're mostly not aware of it.

00:26:00.660 | And it's also reflexive.

00:26:02.420 | So it's not something that consciously happens

00:26:05.600 | or that we're aware of

00:26:06.560 | unless we really begin to pay attention.

00:26:09.720 | And when we begin to pay attention,

00:26:12.660 | we really can become very aware of it in the moment.

00:26:15.940 | Again, it's like a falling away,

00:26:18.160 | like you're on social media

00:26:20.600 | and you get a good tweet of something,

00:26:23.340 | and then you can't stop yourself,

00:26:26.080 | because there's this awareness, a latent awareness,

00:26:28.760 | that as soon as I disengage from this behavior,

00:26:31.420 | I'm going to experience a kind of a pain,

00:26:34.440 | a falling away, a missing that feeling,

00:26:37.820 | a wanting more of it.

00:26:39.820 | And of course, one way to combat that

00:26:42.180 | is to do it more and more and more and more.

00:26:45.160 | So I think that is really what I want people to tune into

00:26:48.860 | and get an awareness around,

00:26:50.780 | because once you tune into it, you can see it a lot.

00:26:53.740 | And then when you begin to see it,

00:26:55.500 | you have, and if you keep the model of the balance in mind,

00:26:58.660 | I think it gives people kind of a way to imagine

00:27:03.660 | what they're experiencing on a neurobiological level

00:27:07.260 | and understand it.

00:27:08.540 | And in that understanding, get some mastery over it,

00:27:11.700 | which is really what this is all about,

00:27:13.740 | because ultimately we do need to disengage, right?

00:27:17.080 | We can't live in that space all the time, right?

00:27:21.160 | We have other things we need to do.

00:27:23.140 | And there are also serious consequences

00:27:25.860 | that come with trying to repeat and continue that experience

00:27:30.280 | or that feeling.

00:27:31.580 | - Yeah, so if I understand this correctly,

00:27:33.560 | when we find something or when something finds us

00:27:37.420 | that we enjoy, that feels pleasureful, social media,

00:27:41.820 | food, sex, gambling, whatever happens to be in,

00:27:46.120 | we will explore the full range of these.

00:27:48.480 | There's some dopamine release

00:27:50.260 | when we engage in that behavior.

00:27:52.360 | And then what you're telling me is that very quickly.

00:27:55.260 | - Yes.

00:27:56.100 | - And beneath my conscious awareness,

00:27:58.260 | there's a tilting back of the scale

00:28:01.560 | where pleasure is reduced by way of increasing pain.

00:28:05.220 | - Right.

00:28:06.340 | - And I've heard you say before

00:28:07.780 | that the pain mechanism has some competitive advantages

00:28:12.780 | over the pleasure mechanism,

00:28:16.260 | such that it doesn't just bring the scale back to level.

00:28:19.140 | It actually brings pain higher than pleasure.

00:28:23.420 | Could you tell us a little bit more about that?

00:28:25.220 | - Yeah, yeah, so what happens again,

00:28:28.420 | so the hallmark of any addictive substance or behavior

00:28:31.900 | is that it releases a lot of dopamine

00:28:34.140 | in our brain's reward pathway, right?

00:28:35.840 | Like broccoli just doesn't release a lot of dopamine,

00:28:38.600 | just doesn't, right?

00:28:40.380 | - I'm trying to imagine, I was about to say maybe,

00:28:42.460 | and I stopped myself because no, broccoli is good.

00:28:46.160 | It can be really good, but broccoli is never amazing.

00:28:49.940 | - Right, broccoli is never amazing.

00:28:52.660 | - Honestly, we can probably find somebody on the planet

00:28:54.980 | for whom broccoli is amazing.

00:28:56.060 | And of course, if I'm starving, broccoli is amazing.

00:28:59.180 | - Rich Roll, Rich Roll is big on plants,

00:29:01.220 | and he has a good relationship to plants.

00:29:03.980 | Rich, tell us how to make broccoli amazing.

00:29:07.540 | If anyone could do it, it'd be rich.

00:29:08.980 | - Yeah, yeah, but what happens right after I do something

00:29:13.060 | that is really pleasurable and releases a lot of dopamine

00:29:15.540 | is again, my brain is going to immediately compensate

00:29:18.440 | by down-regulating my own dopamine receptors,

00:29:21.060 | my own dopamine transmission to compensate for that, okay?

00:29:24.820 | And that's that come down or the hangover,

00:29:27.940 | that after effect, that moment of wanting to do it more.

00:29:30.500 | Now, if I just wait for that feeling to pass,

00:29:34.160 | then my dopamine will re-regulate itself

00:29:36.100 | and I'll go back to whatever my chronic baseline is.

00:29:38.060 | But if I don't wait, and here's really the key,

00:29:40.260 | if I keep indulging again and again and again,

00:29:43.160 | ultimately I have so much on the pain side, right?

00:29:48.280 | That I've essentially reset my brain to what we call

00:29:51.740 | like an anhedonic or lacking in joy type of state,

00:29:56.000 | which is a dopamine deficit state.

00:29:58.400 | So that's really the way in which pain

00:30:01.800 | can become the main driver is because I've indulged so much

00:30:05.360 | in these high reward behaviors or substances

00:30:08.480 | that my brain has had to compensate

00:30:10.720 | by way down-regulating my own dopamine,

00:30:13.240 | such that even when I'm not doing that drug,

00:30:16.400 | I'm in a dopamine deficit state,

00:30:18.040 | which is akin to a clinical depression.

00:30:20.000 | I have anxiety, irritability, insomnia, dysphoria,

00:30:22.680 | and a lot of mental preoccupation with using again

00:30:25.440 | or getting the drug.

00:30:26.600 | And so that's the piece there.

00:30:28.280 | There's the single use, which easily passes,

00:30:32.840 | but it's the chronic use that can then reset

00:30:36.800 | really our dopamine thresholds.

00:30:38.720 | And then nothing is enjoyable, right?

00:30:41.680 | Then everything sort of pales in comparison to this one drug

00:30:45.760 | that I want to keep doing.

00:30:47.040 | And that one drug could be a person, right?

00:30:50.080 | I mean, I know people in my life

00:30:52.080 | that are still talking about this one relationship,

00:30:56.120 | this one person that was just so great

00:30:58.960 | despite all the challenges of that thing,

00:31:01.440 | that it's almost like they're addicted to the narrative.

00:31:04.280 | They were maybe or still are addicted to the person.

00:31:07.840 | So it could be to any number of things,

00:31:09.520 | video games, sex, gambling, a person, a narrative.

00:31:13.520 | To me, and because of the way you described this mechanism,

00:31:17.340 | this pleasure pain balance,

00:31:18.860 | that all speaks to the kind of generalizability

00:31:24.240 | of our brain circuitry.

00:31:26.680 | And this is something that fascinates me,

00:31:28.840 | and I know it fascinates you as well,

00:31:30.400 | which is that nature did not evolve

00:31:34.400 | 20 different mechanisms

00:31:35.720 | for 20 different types of addiction.

00:31:38.240 | Just like anxiety is a couple of core sets of hormones

00:31:41.760 | and neurotransmitters and pathways.

00:31:43.240 | And one person is triggered by social interactions,

00:31:46.800 | another person is triggered by spiders,

00:31:50.240 | but the underlying response is identical.

00:31:52.880 | It sounds like with addiction as well,

00:31:54.720 | there may be some nuance,

00:31:56.520 | but that they're sort of a core set of processes.

00:31:59.120 | So it doesn't really matter

00:32:01.320 | if it's gambling or video games or sex

00:32:03.360 | or a narrative about a previous lover or partner or whatever.

00:32:07.340 | It's the same addictive process underneath that.

00:32:11.100 | Is that correct?

00:32:11.940 | - Yes, exactly.

00:32:13.280 | And that's where this whole idea of cross-addiction comes in.

00:32:16.320 | So once you've been addicted to a substance,

00:32:18.860 | severely addicted,

00:32:19.880 | that makes you more vulnerable to addiction

00:32:22.220 | to any substance.

00:32:23.520 | - And when you say substance does the same,

00:32:26.240 | is what you just said also true for behavior?

00:32:28.000 | - Yes, so when I use the word drug,

00:32:30.240 | I'm talking about substances and behaviors really.

00:32:32.880 | And I'm talking about behaviors like gambling, sex,

00:32:36.160 | gaming, porn, absolutely, shopping, work.

00:32:41.040 | - You've accused me, just for the record,

00:32:43.140 | Anna, Dr. Lemke has accused me, not accused me,

00:32:47.020 | has diagnosed me outside the clinic

00:32:50.240 | in a playful way of being work addicted.

00:32:51.940 | You're probably right.

00:32:53.260 | The first thoughts I have when I wake up

00:32:54.860 | are typically about work,

00:32:56.120 | certainly within 50 milliseconds or so of waking.

00:32:59.240 | And probably the last thoughts I have,

00:33:01.180 | I would hope are not about work,

00:33:02.580 | but yeah, I work constantly.

00:33:04.280 | I don't, I do other things,

00:33:06.080 | but I have to actively turn that off.

00:33:08.420 | - Yes, that's exactly right.

00:33:10.160 | And you're certainly not alone in that.

00:33:12.520 | And of course-

00:33:13.360 | - At Stanford, no, no, no, no.

00:33:14.200 | - Right, I mean, here in Silicon Valley,

00:33:15.680 | it's highly rewarded, right?

00:33:16.900 | So that kind of addiction.

00:33:18.020 | - It's embedded in the culture, absolutely, yeah.

00:33:20.840 | And there's this other city,

00:33:22.400 | I think it's called New York,

00:33:23.480 | where they also work a lot out here

00:33:25.360 | and it's heavily rewarded.

00:33:26.840 | I once said, and I'm sure

00:33:30.960 | that I'm not the first person to say it,

00:33:32.620 | but I was thinking about addiction

00:33:34.780 | and I was thinking about the underlying circuits

00:33:36.520 | and I posted something to social media,

00:33:40.760 | which said that addiction is a progressive narrowing

00:33:43.320 | of the things that bring you pleasure.

00:33:45.240 | That was the way that I kind of crystallized

00:33:47.080 | the literature in my mind.

00:33:48.000 | And then we met and you of course came

00:33:50.220 | and gave these amazing lectures

00:33:52.200 | in the neuroanatomy course for the medical students

00:33:54.680 | and the rest is history.

00:33:56.560 | But I tossed out a kind of mirroring statement

00:34:03.680 | for that as well, which was a bit overstepping, I admit,

00:34:07.540 | which I said, "Addiction is a progressive narrowing

00:34:10.000 | "of the things that bring you pleasure."

00:34:12.280 | And I said, dare I say,

00:34:14.300 | "Enlightenment is a progressive expansion

00:34:16.600 | "of the things that bring you pleasure."

00:34:17.960 | Not that anybody knows what enlightenment is,

00:34:20.160 | but it was my attempt to take a little bit of a jab

00:34:22.400 | at the fact that nobody knows.

00:34:23.720 | And so why not, why wouldn't I throw

00:34:25.280 | a neurobiological explanation?

00:34:26.680 | Just to kind of sample the waters.

00:34:28.800 | And people had varying levels of response.

00:34:32.580 | But the reason I bring that up is that I would imagine

00:34:37.260 | that being able to derive pleasure from many things

00:34:41.040 | would be a wonderful attribute.

00:34:43.660 | We know people like this that can experience pleasure

00:34:48.280 | in little things and in big events,

00:34:51.180 | not just the big milestones of life,

00:34:54.200 | but also the subtle, like the yogis would say,

00:34:59.000 | the subtle ripples of life.

00:35:00.560 | So if such an ability exists,

00:35:04.820 | do you think that that reflects

00:35:06.380 | a healthily tuned dopamine system?

00:35:09.680 | One that can engage and enjoy, but then disengage?

00:35:13.000 | Is that what we should be seeking?

00:35:14.860 | And to underscore, I know nothing about enlightenment,

00:35:18.180 | meditation, or any of it.

00:35:20.140 | I just, I use these as opportunities to explore.

00:35:23.140 | - Yeah, so it's a great question.

00:35:26.460 | And I understand the question as,

00:35:29.860 | so what should we be striving for, right?

00:35:32.260 | Where should we settle out?

00:35:34.720 | And in my book, I really hold out people in recovery

00:35:39.720 | from severe addiction as sort of modern day profits

00:35:44.220 | for the rest of us, because I do think that people

00:35:47.140 | who have been addicted and then get into recovery

00:35:50.780 | do have a hard-won wisdom that we can all benefit from.

00:35:56.580 | And the wisdom, I guess, you know, to distill it down,

00:36:01.580 | I mean, it's many things.

00:36:03.940 | But in terms of, you know, dopamine,

00:36:08.180 | the wisdom is there are adaptive ways to get your dopamine,

00:36:13.020 | and there are less than adaptive ways.

00:36:16.860 | And in general, you could describe the adaptive ways

00:36:21.220 | as not too potent, so not tipping that balance too hard,

00:36:26.660 | or too fast to the side of pleasure.

00:36:28.740 | - So does that mean never allowing myself

00:36:31.320 | to be absolutely in complete bliss?

00:36:34.540 | Or does it mean not allowing myself

00:36:36.200 | to stay in that state too long?

00:36:38.180 | - The latter, I think the latter.

00:36:40.220 | So, and then that gets to temperament.

00:36:42.420 | So I'm going to get that to a second.

00:36:43.660 | So in general, what we want is some kind of flexibility

00:36:48.660 | in that balance and the ability

00:36:50.740 | to easily reassert homeostasis.

00:36:53.220 | We don't want to break our balance,

00:36:55.060 | which is possible if we overindulge

00:36:57.320 | for enough period of time and end up with a balance tip

00:37:00.500 | to the side of pain, this dopamine deficit state

00:37:02.660 | we've been talking about.

00:37:03.880 | We want a flexible, resilient balance, right?

00:37:07.620 | Which can be sensitive to things going on

00:37:09.620 | in the environment, which can experience pleasure

00:37:12.300 | and approach, which can experience pain and recoil, right?

00:37:16.340 | This is all adaptive and healthy and necessary and good.

00:37:19.780 | We would never want a balance that doesn't tilt, right?

00:37:22.740 | That would be a disaster.

00:37:23.900 | We wouldn't be human and we wouldn't want that.

00:37:26.300 | It'd be really, really boring.

00:37:28.060 | On the other hand, what people in recovery

00:37:29.980 | from addiction talk about is to some extent

00:37:33.220 | having to learn to live with things being a little boring

00:37:37.740 | a lot of the time, right?

00:37:39.440 | So trying to avoid some of this intensity

00:37:42.500 | and thrill seeking and escapism

00:37:46.280 | that really is at the core of addictive tendencies.

00:37:49.220 | - Sorry to interrupt, but when you say boring,

00:37:51.700 | can we add stressful and boring?

00:37:53.860 | - Yes.

00:37:54.700 | - Because there are days where I'm not,

00:37:57.380 | I'm one of these people, I have to remind myself

00:37:59.340 | to have fun because I sort of forgot what the term means

00:38:02.460 | because I like to think that I experience

00:38:04.780 | a lot of pleasure in little things,

00:38:06.020 | but I'm a pretty hard driving guy.

00:38:08.140 | I like goals and big milestones, all that stuff.

00:38:10.460 | Anyway, the point being that many days I'm not bored

00:38:15.460 | thinking, oh, there's nothing to do,

00:38:18.380 | but I am kind of overwhelmed by the number of things

00:38:21.460 | that are really not pleasureful that I have to do.

00:38:25.380 | I won't mention what they are

00:38:26.620 | 'cause I don't want my colleagues to be like,

00:38:29.380 | so that's why you don't respond to emails.

00:38:32.700 | No, just your emails.

00:38:33.840 | Not yours, Anna, but theirs.

00:38:36.860 | In any event, so anxiety and boredom

00:38:40.340 | can hang out together, right?

00:38:42.340 | Am I correct in-

00:38:43.660 | - Oh, for sure.

00:38:44.500 | I mean, actually boredom is highly anxiety provoking.

00:38:47.580 | - Okay, that's good to know

00:38:48.780 | 'cause I think people hear boredom

00:38:50.020 | and they think like, oh, there's nothing to do here.

00:38:53.060 | I feel like we have a ton to do,

00:38:55.820 | we just don't really want to do it

00:38:57.980 | as opposed to something that we're excited to do.

00:38:59.980 | - Right, okay, so this gets to sort of

00:39:02.380 | some of the core things also we were talking about earlier

00:39:05.260 | about finding your passion.

00:39:06.540 | So I'm going to try to link it all together.

00:39:08.920 | But basically is boredom,

00:39:11.100 | first of all, boredom is a rare experience for modern humans

00:39:14.780 | because we're constantly distracting ourselves

00:39:17.480 | from the present moment

00:39:18.500 | and we have an infinite number of ways to do that, right?

00:39:22.740 | But boredom is really, I think,

00:39:24.780 | an important and necessary experience.

00:39:28.260 | But it is scary because when you allow yourself to be bored,

00:39:32.340 | and let's say you had that list

00:39:33.780 | of all the things you hate to do

00:39:34.620 | and you actually got them all done.

00:39:36.600 | Imagine that and you got your forthcoming book done

00:39:40.340 | and you did all your interviews and then-

00:39:42.860 | - It could happen, lightning could strike.

00:39:45.180 | - And you walked your dog and you cleaned your house

00:39:47.740 | and you went shopping.

00:39:49.700 | Imagine that for a moment.

00:39:51.060 | You would be sitting in your house

00:39:53.240 | and my guess is you would be terrified

00:39:56.620 | because wow, what am I supposed to do now, right?

00:40:01.060 | There's nothing I really have to do.

00:40:03.180 | And that is really, really scary.

00:40:05.140 | That can feel like free fall.

00:40:06.780 | And yet that's really an important

00:40:09.500 | and good experience to have.

00:40:11.100 | And I think that is an experience out of which

00:40:13.880 | we can have a lot of creative initiative,

00:40:18.020 | but also really consider our priorities and values.

00:40:20.760 | Okay, here I am on planet earth.

00:40:23.620 | What the hee-haw am I gonna do with my life?

00:40:26.020 | What do I really care about?

00:40:27.100 | How do I really wanna spend my time

00:40:29.040 | when I'm not distracting myself in order to spend it?

00:40:33.240 | And then this gets back to our conversation

00:40:36.460 | a little bit earlier about finding your passion.

00:40:38.720 | So I think that one of the big problems now

00:40:41.740 | that's very misguided about this idea of finding your passion

00:40:45.160 | it's almost as if people are looking to fit the key

00:40:48.000 | into the lock of the thing that was meant for them to do.

00:40:51.340 | - Right, and then everything will feel

00:40:52.420 | like a natural progression.

00:40:53.260 | - Right, and then everything will be wonderful.

00:40:55.180 | - I can attest to the fact that is not how it works

00:40:57.540 | in any endeavor. - Yeah, right.

00:40:59.080 | And that you'll have all this great success.

00:41:01.620 | And here's where I really think the answer lies.

00:41:06.260 | And I really, really believe this.

00:41:07.840 | Stop looking for your passion.

00:41:11.100 | And instead look around right where you are.

00:41:15.500 | Stop distracting yourself.

00:41:18.040 | Look around right where you are

00:41:20.340 | and see what needs to be done.

00:41:23.380 | So not what do I want to do,

00:41:25.840 | but what is the work that needs to be done?

00:41:28.820 | And more importantly,

00:41:29.640 | it doesn't have to be some grandiose work.

00:41:32.260 | Like does the garbage need to be taken out, right?

00:41:35.780 | Is there some garbage on your neighbor's lawn

00:41:38.580 | that someone threw there that you could actually bend over

00:41:40.980 | and pick up and put into the garbage can?

00:41:44.620 | Look around you.

00:41:46.500 | There is so much work that needs to be done

00:41:49.580 | that nobody wants to do that is really, really important.

00:41:53.460 | And if we all did that,

00:41:55.620 | I really think the world would be a much better place.

00:41:58.140 | And this is what people who have severe addiction

00:42:00.900 | who get into recovery realize.

00:42:02.580 | They're like, it's not about me and my will

00:42:06.460 | and what I'm going to will in my life or in the world.

00:42:09.900 | It's about looking around what needs to be done.

00:42:13.220 | What is the work that I am called to do in this moment?

00:42:17.900 | Which also is incredibly freeing

00:42:19.960 | because I don't have to search for the perfect thing.

00:42:22.700 | There's a lot of burden now on young people

00:42:24.980 | that they have to find that perfect thing.

00:42:26.760 | And until they've found that perfect thing,

00:42:28.220 | they're going to be miserable.

00:42:29.560 | You don't have to do that.

00:42:31.140 | Look at the life you were given.

00:42:32.820 | Look at the people around you.

00:42:34.580 | Look at the jobs that present themselves to you

00:42:37.860 | and do that job simply and honorably one day at a time

00:42:42.860 | with a kind of humility.

00:42:44.620 | I think this is really what's so striking to me

00:42:47.140 | about the wisdom of people in recovery.

00:42:49.380 | There's this incredible humility

00:42:51.620 | that comes out of that experience.

00:42:53.300 | You feel so broken, so ashamed,

00:42:55.940 | but you pick yourself up one day at a time

00:42:58.940 | and you build a life that's around what can I do

00:43:03.500 | right in this moment that might benefit another person

00:43:06.760 | and thereby benefit me.

00:43:09.340 | - Yeah, it's a really important point.

00:43:11.900 | And if you're willing,

00:43:14.380 | I'd like to actually stay on this issue of passion

00:43:17.900 | because I think the dopamine systems,

00:43:22.900 | if I understand them correctly,

00:43:24.900 | the dopamine systems merge with this work

00:43:29.520 | that you're referring to,

00:43:30.360 | this immediacy of things calling to us

00:43:32.520 | like taking out the trash,

00:43:33.780 | which sounds frankly really boring.

00:43:36.600 | To be honest, I hate taking out the trash, but I do it

00:43:40.160 | 'cause I like a clean home

00:43:41.240 | and I like a home that smells good

00:43:43.160 | or at least doesn't smell bad.

00:43:46.580 | So we do these things and not that we want to offer

00:43:50.200 | some larger carrot as a consequence of doing those things,

00:43:54.260 | but if I understand correctly, what you're saying is

00:43:56.660 | in the act of looking at one's immediate environment,

00:44:01.320 | acting on that immediate environment,

00:44:03.820 | we cultivate a relationship to these circuits in our brain

00:44:08.820 | about action and reward that, at least to my mind,

00:44:13.040 | span the range of small things being rewarding

00:44:16.640 | and then lead us to bigger things being rewarding.

00:44:19.000 | It's not like all we're going to do

00:44:20.200 | is take out trash and tend to house.

00:44:22.280 | We eventually will venture out

00:44:23.640 | and we eventually will find careers and work on those.

00:44:27.440 | But if I understand correctly,

00:44:28.420 | you're talking about getting into a sort of functional

00:44:31.640 | or adaptive action step.

00:44:34.060 | And it's the action step that these days we tend to overlook

00:44:37.180 | because most of our mindset is in things

00:44:39.860 | that are truly outside of our immediate reality.

00:44:43.140 | Do I have that correct?

00:44:44.200 | - Yeah, that was beautifully said.

00:44:45.640 | And I would just add to that.

00:44:47.440 | I see a lot of young people who, for example,

00:44:50.800 | spend most of their waking hours playing video games

00:44:53.660 | and they come to me and they say, "I'm anxious and depressed.

00:44:56.860 | "I'm majoring in computer science.

00:44:58.700 | "I hate it.

00:44:59.540 | "I thought I would like it.

00:45:01.220 | "If I could only find that thing

00:45:02.920 | "that I was really meant to do, my life would be better."

00:45:06.380 | And my first intervention for the many, many people like that

00:45:10.580 | that I see in clinical care is you have it backwards.

00:45:14.240 | I don't say it quite like that.

00:45:16.000 | You were waiting for that thing to pull you out

00:45:18.780 | of the video game world and you're never going to find it

00:45:22.160 | as long as you're playing video games.

00:45:24.020 | 'Cause video games are so powerfully dopaminergic

00:45:27.520 | that you have this distorted sense of really pleasure

00:45:31.400 | and pain and you will not be able to find that thing

00:45:34.380 | that you enjoy.

00:45:35.280 | And so of course the intervention is abstain

00:45:37.300 | from video games, reset your reward pathways,

00:45:40.120 | start with a level balance.

00:45:42.160 | And what invariably happens, and I've just seen it

00:45:44.360 | over 20 years, so many times, I've become really

00:45:47.140 | a believer in this.

00:45:49.140 | All of a sudden it's like, "Oh wow,

00:45:51.920 | "my computer science class is interesting this quarter."

00:45:56.000 | It's like, "Okay."

00:45:58.080 | You have a receptivity then to experiencing pleasure

00:46:02.560 | and reward in a way you just don't have

00:46:04.920 | when you're bombarding your reward pathways

00:46:06.980 | with these high dopamine drugs.

00:46:08.680 | - Very interesting.

00:46:10.200 | And just to underscore this notion that tending

00:46:13.140 | to the immediate things can lead to super performance.

00:46:16.520 | I may have mentioned it earlier this episode,

00:46:20.220 | but if I didn't, I'll mention now, which is,

00:46:22.800 | I have the great privilege of having some close friends

00:46:25.240 | that were in the SEAL teams and doing some work

00:46:26.820 | with those communities.

00:46:27.660 | And it's a remarkable community for reasons

00:46:30.200 | that I think most people don't understand.

00:46:31.780 | People think they see the images carrying logs

00:46:33.920 | down the beach and all the blowing stuff on,

00:46:35.600 | all the stuff that's fun for guys like that.

00:46:38.200 | But all of the guys I know who are in the SEAL teams

00:46:42.260 | have this sense of duty about immediate things.

00:46:46.160 | And not just holding the door and helping with the dishes

00:46:48.720 | and moving things around.

00:46:49.700 | They are constantly scanning their environment

00:46:52.180 | for what can be done.

00:46:53.900 | They essentially conquer every environment they're in.

00:46:56.960 | They are also some of the most competitive human beings

00:47:00.780 | in the world.

00:47:01.620 | And they do it unless they're in the act of war fighting,

00:47:04.680 | which is their real job.

00:47:06.400 | They do it in every environment in a very benevolent way.

00:47:10.420 | And it's a remarkable thing because I think it's what

00:47:14.080 | is part of what they're selected for.

00:47:16.340 | And there's a range there.

00:47:18.700 | But I think when we hear about tending

00:47:20.820 | to the immediate things or this phrase,

00:47:24.080 | how you do one thing is how you do anything.

00:47:25.700 | That's a tricky one for me because there are certain things

00:47:28.000 | I just don't do well.

00:47:29.060 | But should we always be trying?

00:47:32.000 | I think that the tending to setting the horizon in closely

00:47:36.220 | and tending to things in one's immediate environment

00:47:39.640 | I think is very powerful and translates.

00:47:42.060 | Because again, I think the nervous system,

00:47:44.320 | it performs algorithms, it has action steps.

00:47:46.800 | The brain doesn't evolve to do one thing.

00:47:49.920 | It evolves to be able to use the same approach

00:47:52.660 | to doing lots of different things.

00:47:53.880 | - Yes.

00:47:55.160 | I just want to add, so even beyond that,

00:47:56.880 | 'cause that totally resonates for me

00:47:58.960 | and is very consistent with people in recovery

00:48:01.620 | from addiction who learn to take it one day at a time,

00:48:04.880 | which is one of the standard lingo from Alcoholics Anonymous

00:48:09.000 | and other 12 step groups.

00:48:10.360 | But I think also, as you say,

00:48:12.560 | our brain is really wired for the 24 hour period.

00:48:16.460 | We're not very good at sort of the 10 year, 20.

00:48:20.960 | I mean, we have these huge frontal lobes

00:48:22.500 | and yes, we're great planners and we can,

00:48:24.500 | but if we live too much in that space,

00:48:27.680 | we can really get very anxious and depressed and lost

00:48:30.540 | and either catastrophize or get grandiose.

00:48:33.240 | But if you can chunk it down to a day,

00:48:36.320 | what people in recovery talk about

00:48:38.260 | is how if I can just do today right,

00:48:41.360 | then I will get a chain of days

00:48:44.420 | that seem insignificant in their individual units.

00:48:48.960 | But after six months or a year or two years

00:48:51.780 | of those good days, I've got two very good years, right?

00:48:55.900 | And I look back and it's like,

00:48:56.880 | oh wow, I guess I did all that.

00:48:59.600 | But I think that's really one of the keys

00:49:01.800 | is really taking it one day at a time,

00:49:03.400 | which your seals and also this connecting

00:49:06.160 | with the environment, right?

00:49:07.440 | So being awake and alert to your environment

00:49:10.440 | and connecting with your environment,

00:49:12.240 | not trying to escape it.

00:49:13.720 | And of course, escapism is what we all want and desire,

00:49:16.600 | that experience of non-being.

00:49:18.420 | And we get it from the internet or from drugs

00:49:20.900 | or whatever it is, but it's the booby prize

00:49:23.940 | because ultimately it takes you further and further away

00:49:27.480 | from your immediate environment,

00:49:28.560 | which is where we really have to connect

00:49:30.780 | to get that sense of groundedness and authenticity

00:49:33.520 | and like of being in our own lives.

00:49:36.580 | - Well, I think the unit of the day

00:49:37.920 | is something that comes up again and again

00:49:40.100 | of in my discussions with colleagues

00:49:42.640 | who are extremely successful

00:49:45.200 | and who also have balanced lives.

00:49:47.640 | This actually came up in the discussion

00:49:49.240 | with Carl Deisseroth, who is also a successful scientist

00:49:53.880 | and clinician and manages a family, et cetera.

00:49:56.920 | So the unit of the day I think is fundamental

00:49:59.820 | and those stack up as you mentioned.

00:50:02.280 | So along those lines, I've heard you say

00:50:05.200 | that in order to reset the dopamine system,

00:50:08.480 | essentially in order to break an addictive pattern,

00:50:12.240 | to become unaddicted, 30 days of zero interaction

00:50:17.240 | with that substance, that person, et cetera, is that correct?

00:50:22.680 | - Yeah, and 30 days is in my clinical experience,

00:50:25.840 | the average amount of time it takes for the brain

00:50:28.140 | to reset reward pathways for dopamine transmission

00:50:31.040 | to regenerate itself.

00:50:32.760 | There's also a little bit of science

00:50:34.740 | that suggests that that's true.

00:50:36.780 | Some imaging studies showing that our brains

00:50:39.640 | are still in a dopamine deficit state two weeks

00:50:43.000 | after we've been using our drug.

00:50:44.800 | And then a study by Schuck, Hitt and Brown,

00:50:47.580 | which took a group of depressed men

00:50:51.160 | who also were addicted to alcohol,

00:50:53.680 | put them in a hospital where they had received

00:50:57.420 | no treatment for depression,

00:50:58.440 | but they had no access to alcohol in that time.

00:51:01.160 | And after four weeks, 80% of them no longer met criteria

00:51:04.640 | for major depression.

00:51:06.400 | So again, this idea that by depriving ourselves

00:51:10.000 | of this high dopamine, high reward substance or behavior,

00:51:14.520 | we allow our brains to regenerate its own dopamine

00:51:17.080 | for the balance to really correlate,

00:51:18.720 | and then we're in a place

00:51:19.920 | where we can sort of enjoy other things.

00:51:22.600 | - So that progressive narrowing

00:51:24.720 | of what brings one pleasure eventually expands.

00:51:27.400 | So I'd like to dissect out that 30 days a little more,

00:51:30.760 | finally, and I also want to address

00:51:35.400 | how does one stop doing something for 30 days

00:51:38.480 | if the thing is a thought?

00:51:40.680 | So we'll kind of put that on the shelf for a moment.

00:51:43.900 | So days one through 10,

00:51:45.700 | I would imagine will be very uncomfortable.

00:51:50.080 | They're going to suck, basically, to be quite honest,

00:51:52.840 | because the way you describe this pleasure pain balance,

00:51:56.240 | to my mind says that if you remove

00:52:00.240 | what little pleasure one is getting,

00:52:02.280 | or a lot of pleasure from engaging in some behavior,

00:52:05.320 | that's gone, the pain system is really ramped up,

00:52:08.820 | and nothing is making me feel good.

00:52:11.680 | I'll just use myself as an example.

00:52:13.240 | I'm not in recovery,

00:52:14.720 | but that 10 days is going to be miserable.

00:52:19.240 | Anxiety, trouble sleeping, physical agitation

00:52:23.520 | into the point where maybe impulsive, angry,

00:52:28.360 | should one expect all of that?

00:52:30.820 | Should the family members of people expect all of that?

00:52:34.080 | - Yeah, so what I say to patients,

00:52:36.240 | and it's a really important piece of this intervention,

00:52:39.160 | is that you will feel worse before you feel better.

00:52:42.720 | - For how long? - Yeah.

00:52:43.560 | - This is probably the first question they ask, right?

00:52:45.680 | - And I say, usually in my clinical experience,

00:52:49.080 | you'll feel worse for two weeks,

00:52:50.800 | but if you can make it through those first two weeks,

00:52:53.600 | the sun will start to come out in week three,

00:52:56.240 | and by week four,

00:52:57.600 | most people are feeling a whole lot better than they were

00:53:00.840 | before they stopped using their substance.

00:53:03.200 | So yeah, you have to, it's a hard thing.

00:53:07.160 | Like you have to sign up for it.

00:53:09.120 | And I will say, obviously,

00:53:10.340 | there are people with addictions that are so severe

00:53:12.860 | that as long as they have access to their drug or behavior,

00:53:16.040 | they're not able to stop themselves.

00:53:17.740 | And that's why we have higher levels of care

00:53:20.440 | or residential treatment.

00:53:21.740 | So this is not going to be for everybody, this intervention,

00:53:24.120 | but it's amazing how many people

00:53:26.500 | with really severe addictions to things like heroin, cocaine,

00:53:31.320 | very severe pornography addictions.

00:53:33.960 | I posit this, and I do it as an experiment.

00:53:36.760 | I said, you know what, let's try this experiment.

00:53:39.480 | I'm always amazed, number one,

00:53:41.220 | how many of them are willing,

00:53:42.400 | and number two, how many of them are actually able to do it?

00:53:45.020 | They are able to do it.

00:53:46.600 | And so that little nudge is sort of just what they need.

00:53:50.040 | And the carrot is, you know,

00:53:53.160 | there's a better life out there for you,

00:53:54.880 | and you'll be able to taste it in a month.

00:53:58.080 | You really will be able to begin to see

00:54:00.860 | that you can feel better and that there's another way.

00:54:04.200 | - So the way you describe it seems like it's hard,

00:54:09.200 | but it's doable for most people, not everybody.

00:54:12.800 | And we'll return to that category of people

00:54:15.920 | who can't do that on their own.

00:54:17.600 | Well, then days 21 through 30, people are feeling better.

00:54:24.380 | The sun is starting to come out, as you mentioned,

00:54:27.900 | which translates in the narrative we've created here.

00:54:30.420 | And supported by biology,

00:54:32.400 | that dopamine is starting to be released

00:54:34.840 | in response to the taste of a really good cup of coffee.

00:54:38.160 | - Yes, exactly.

00:54:39.560 | - Whereas before it was only to insert addictive behavior.

00:54:44.240 | - Right, that's right.

00:54:45.300 | - Whichever it happens to be.

00:54:46.140 | - Of course coffee can be addictive too,

00:54:47.240 | but we'll leave that aside.

00:54:48.760 | - Yeah, I feel like coffee

00:54:50.360 | has a kind of consumption limiting mechanism built in

00:54:54.120 | where at some point you just can't ingest anymore,

00:54:58.120 | but maybe that's wrong.

00:54:59.380 | Sorry to give lift to the caffeine addicts out there

00:55:03.720 | as I clutch my mug.

00:55:07.060 | So days 21 through 30.

00:55:09.880 | I've seen a lot of people go through addiction

00:55:14.280 | and addiction treatment.

00:55:15.240 | I've spent a lot of time in those places actually,

00:55:18.360 | looking at it, researching.

00:55:19.560 | I've got friends in that community.

00:55:20.960 | I'm close with that community.

00:55:22.700 | One thing I've seen over and over again,

00:55:26.040 | sadly, often in the same individuals,

00:55:28.360 | is they get sober from whatever.

00:55:33.300 | They're doing great.

00:55:35.060 | These are people with families.

00:55:36.580 | These are people that you discard your normal image

00:55:39.480 | of an addict and insert the most normal, typical,

00:55:44.140 | whatever healthy person you can imagine.

00:55:46.140 | 'Cause a lot of these people you wouldn't know were addicts.

00:55:49.920 | And then all of a sudden you get this call.

00:55:52.880 | So-and-so's back in jail.

00:55:55.800 | So-and-so's wife is going to leave him

00:55:57.840 | because he drank two bottles of wine

00:56:01.080 | and took a Xanax at 7 a.m., crashed his truck into a pole.

00:56:05.160 | He's got two beautiful kids.

00:56:06.400 | How did this happen again?

00:56:09.600 | To the point where by the fourth and fifth time,

00:56:12.160 | people are just done.

00:56:14.680 | I mean, maybe people,

00:56:15.960 | you might be able to detect the frustration in my voice.

00:56:17.820 | I'm dealing with this with somebody that's like,

00:56:20.080 | I don't even know that I want to help this time.

00:56:22.760 | It's been so many times.

00:56:25.160 | To the point where I'm starting to wonder,

00:56:27.520 | is this person just an addict?

00:56:29.520 | This is just kind of what they do and who they are.

00:56:32.680 | And you never want to give up on people,

00:56:34.460 | but, and I'm hanging in there for them,

00:56:37.000 | but I will say that many people have given up on them.

00:56:41.740 | And so what I'd like to talk about in this context is

00:56:44.580 | what sorts of things help other people

00:56:47.960 | that we know that are addicted?

00:56:49.320 | What really helps?

00:56:51.480 | Not what could help, but what really helps.

00:56:56.040 | And are there certain people for whom it's hopeless?

00:57:01.040 | I mean, I don't like to hold the conversation that way,

00:57:03.580 | but I wouldn't be close to the real life data

00:57:06.240 | if I didn't ask, is it hopeless?

00:57:08.520 | Are there people who just will not be able

00:57:11.780 | to quit their substance use or their addictive behavior,

00:57:16.200 | despite, I have to assume, really wanting to?

00:57:19.280 | - Yeah.

00:57:20.160 | - Yeah, so there are people who will die

00:57:23.640 | of their disease of addiction.

00:57:25.520 | I think conceptualizing it as a disease is a helpful frame.

00:57:29.480 | There are other frames that we could use,

00:57:31.740 | but I do think given the brain physiologic changes

00:57:36.000 | that occur with sustained heavy drug use

00:57:40.360 | and what we know happens to the brain,

00:57:42.800 | it is really reasonable to think of it as a brain disease.

00:57:47.160 | And for me, the real window of, let's say,

00:57:52.560 | being able to access my compassion around people

00:57:55.960 | who are repeat relapses,

00:57:57.660 | even when their life is so much better,

00:57:59.720 | when they're- - Oh, yeah.

00:58:00.560 | - Yeah, it's like a no-brainer, right?

00:58:03.080 | Is to conceptualize this balance

00:58:05.440 | and the dopamine deficit state

00:58:06.840 | and a balance tilted to the side of pain.

00:58:09.840 | And to imagine that for some people,

00:58:13.120 | after a month or six months, or maybe even six years,

00:58:16.940 | their balance is still tipped to the side of pain,

00:58:20.140 | that on some level, that balance has lost its resilience

00:58:24.140 | and its ability to restore homeostasis.

00:58:26.620 | - It's almost like the hinge on that balance

00:58:28.140 | is messed up. - Yes, exactly.

00:58:30.140 | And so, I mean, for someone who's never experienced

00:58:33.460 | addiction like yourself,

00:58:35.060 | maybe one way to conceptualize it is-

00:58:37.420 | - Well, I didn't say that.

00:58:38.360 | - Oh, okay.

00:58:39.200 | - No, I was not, to be clear, I was not referring to myself,

00:58:42.900 | but in this example I was given,

00:58:45.260 | if I were, I would come clean, I would reveal that.

00:58:49.780 | But I think that, especially after hearing

00:58:52.020 | some of your lectures and descriptions

00:58:54.520 | of the range of things that are addictive,

00:58:56.460 | I think I've been fortunate

00:58:58.580 | I don't have a propensity for drugs or alcohol.

00:59:00.680 | - Right, okay.

00:59:01.520 | - I'm lucky in that way that, frankly,

00:59:04.140 | if they remove all the alcohol from the planet,

00:59:05.820 | I'll just be relieved because no one will offer it to me.

00:59:07.820 | - Right, right.

00:59:08.660 | - So don't send me any alcohol, it won't go to me.

00:59:12.260 | But I don't have that,

00:59:17.560 | I like to think I have the compassion,

00:59:20.280 | but I don't have that empathy for

00:59:25.080 | taking a really good situation

00:59:29.620 | and what from the outside looks to be throwing it

00:59:33.000 | in the trash. - Right, right.

00:59:33.840 | Yeah, so okay, so is that let me,

00:59:35.400 | and this is really, I think, important

00:59:36.920 | because I also had to come to an understanding of this

00:59:40.980 | and I feel that I have in my 20 years

00:59:43.520 | of seeing these patients.

00:59:45.060 | And of course, addiction is a spectrum disease, right?

00:59:47.220 | And so you've got the severe end of things.

00:59:49.420 | Imagine that you had an itch somewhere on your body, okay?

00:59:54.840 | And it was, I mean, we've all had that,

00:59:56.500 | like whatever the source, it was super, super itchy.

00:59:59.980 | You can go for, if you really focus,

01:00:03.900 | you could go for a pretty good amount of time

01:00:06.860 | not scratching it.

01:00:08.260 | But the moment you stopped focusing on not scratching it,

01:00:12.660 | you would scratch it.

01:00:13.500 | And maybe you do it while you were asleep, right?

01:00:16.340 | And that is what happens to people with severe addiction.

01:00:21.340 | That balance is essentially broken.

01:00:24.380 | Homeostasis does not get restored

01:00:26.380 | despite sustained abstinence.

01:00:28.900 | They're living with that constant specter of that pull.

01:00:33.380 | It never goes away.

01:00:35.080 | So let me say there are lots of people with addiction

01:00:36.740 | for whom that does go away.

01:00:37.940 | And it goes away at four weeks for many of them.

01:00:40.260 | But in severe cases, that's always there and it's lingering.

01:00:45.300 | And it's the moment when they're not focusing on not using,

01:00:49.100 | it's like a reflex.

01:00:50.140 | They fall back into it.

01:00:51.880 | It's not purposeful.

01:00:53.140 | It's not because they want to get high.

01:00:55.200 | It's not because they value using drugs

01:00:57.020 | more than they do their family.

01:00:58.600 | None of that.

01:00:59.440 | It's that really they cannot not do it

01:01:04.440 | when given the opportunity and that moment

01:01:07.540 | when they're not thinking about it.

01:01:08.900 | Does that make sense?

01:01:09.740 | - That's a great description.

01:01:10.820 | And actually in that description,

01:01:12.420 | I can feel a bit of empathy because the way you describe

01:01:16.860 | scratching an itch in your sleep,

01:01:18.460 | I've done that with mosquito bites.

01:01:21.020 | In summer, you're scratching and you're like,

01:01:22.340 | oh, you wake up scratching that mosquito bite.

01:01:26.300 | And I also have to admit that I've experienced

01:01:31.300 | not feeling like I want to pick up my phone

01:01:33.580 | because it's so rewarding, but just finding myself doing it.

01:01:36.780 | - Yes, of course.

01:01:37.620 | - Like I'm not going to use this thing.

01:01:38.700 | I'm not going to use this thing.

01:01:40.140 | And then just finding myself doing it.

01:01:41.620 | Like, what am I doing here?

01:01:43.020 | Sort of the, how did I get back here again?

01:01:45.780 | And I know enough about brain function to understand

01:01:49.400 | that we have circuits that generate deliberate behavior

01:01:53.460 | and we have circuits that generate reflexive behavior.

01:01:55.500 | And one of the goals of the nervous system

01:01:58.340 | is to make the deliberate stuff reflexive

01:02:01.080 | so you don't have to make the decision

01:02:02.380 | because decision-making is a very costly thing to do.

01:02:06.180 | Decision-making of any kind.

01:02:08.300 | So that does really help.

01:02:10.600 | And the, I want to just try and weave together

01:02:15.160 | this dopamine puzzle, however, because if by week,

01:02:20.160 | so first phase of this 30 or 40 day detox,

01:02:25.560 | it's like a dopamine fast, right?

01:02:28.000 | Okay, first 10 days are miserable.

01:02:30.480 | Middle 10 days, the clouds are out.

01:02:32.980 | There may be some shards of sunlight coming through

01:02:35.080 | and then all of a sudden sun starts to come out.

01:02:38.040 | It gets brighter and brighter.

01:02:39.720 | Why is it then that people will relapse,

01:02:42.640 | not just after getting fired from a job

01:02:44.920 | or their spouse leaving them,

01:02:45.880 | but when things are going really well?

01:02:48.040 | Is it this unconscious mechanism?

01:02:50.680 | 'Cause I've seen this before is they have a great win.

01:02:53.960 | I have a friend who's a really impressive creative.

01:02:57.680 | I don't want to reveal any more than that,

01:03:00.400 | and relapsed upon getting another really terrific opportunity

01:03:05.340 | to create for the entire world.

01:03:07.640 | And I was like, how can that happen?

01:03:09.160 | But now I'm beginning to wonder,

01:03:10.440 | was it the dopamine associated with that win

01:03:13.160 | that opened the spigot on this dopamine system?

01:03:16.720 | Because it happened in a phase

01:03:19.340 | of a really great stretch of life.

01:03:22.240 | - Yeah, right.

01:03:23.860 | Yeah, so you raised that great point about triggers, right?

01:03:27.640 | And triggers are things that make us want

01:03:30.880 | to go back to using our drug.

01:03:32.960 | And the key thing about triggers, whatever they are,

01:03:35.300 | is they also release a little bit of dopamine, right?

01:03:39.020 | So just thinking about whatever the trigger is

01:03:43.260 | that we associate with drug use,

01:03:45.200 | or just thinking about drug use,

01:03:47.200 | can already release this anticipatory dopamine,

01:03:50.000 | this new little mini spike.

01:03:51.180 | But here's the part that I think is really fascinating.

01:03:53.680 | That mini spike is followed by a mini deficit state.

01:03:57.200 | So it goes up and then it doesn't go back down to baseline.

01:03:59.760 | It goes below baseline tonic levels,

01:04:02.520 | and that's craving, right?

01:04:04.440 | So that anticipation is immediately followed

01:04:08.520 | by wanting the drug.

01:04:11.140 | And it's that dopamine deficit state

01:04:12.860 | that drives the motivation to go and get the drug.

01:04:16.760 | So many people talk about dopamine

01:04:18.020 | as not really about pleasure,

01:04:19.580 | but about wanting and about motivation.

01:04:22.180 | And so it is that deficit state

01:04:24.420 | that then drives the locomotion to get it.

01:04:27.280 | - And earlier, your description of dopamine

01:04:29.140 | being involved in the desire for more,

01:04:31.340 | giving the sense of reward, but also movement.

01:04:33.540 | - Right.

01:04:34.380 | - I have to assume that those things

01:04:35.300 | are braided together in our nervous system

01:04:37.400 | for the specific intention of when you feel something good,

01:04:41.000 | then you feel the pain, maybe you don't notice it.

01:04:43.680 | And then the next thing you know,

01:04:44.580 | you're pursuing more of the thing that you're looking for.

01:04:46.520 | - And I love the way you use the word braided together.

01:04:48.240 | That's beautiful.

01:04:49.080 | And let me also just say something

01:04:50.800 | that I find also fascinating in my work with patients,

01:04:54.200 | and I see this all the time.

01:04:55.620 | There are people for whom bad life experiences,

01:04:59.000 | loss in any form, stress in many different forms,

01:05:03.540 | that's a trigger.

01:05:04.380 | But there are absolutely people for whom

01:05:07.420 | the trigger is things going well.

01:05:09.920 | And the things going well

01:05:11.700 | can be like the reward of the things going well,

01:05:13.580 | but very often what it is

01:05:15.500 | is the removal of the hypervigilant state

01:05:18.600 | that's required to keep their use in check.

01:05:21.380 | So it's this sense of, I wanna celebrate,

01:05:24.620 | or I wanna, this reward happened,

01:05:26.820 | I wanna put more reward on there.

01:05:29.380 | And it's really, really fascinating

01:05:31.200 | because when people come to that realization

01:05:34.120 | about themselves,

01:05:35.520 | that they're most vulnerable when things are going well,

01:05:40.020 | that's really a valuable insight

01:05:41.820 | because then they can put some things in place

01:05:43.840 | or barriers in place or go to more meetings

01:05:46.160 | or whatever it is that they do to protect themselves.

01:05:50.320 | - Along those lines, I have a friend, 40 years sober,

01:05:53.880 | who was a severe drug and alcohol addict

01:05:56.020 | from a very young age, a really impressive person,

01:05:58.020 | does a lot of important work in the kind of at-risk

01:06:00.960 | youth community out in Hawaii.

01:06:02.800 | And he said something to me.

01:06:03.840 | He said, as former addicts often do,

01:06:06.980 | they got these great sayings,

01:06:09.300 | but I think it fits very well with what you're describing.

01:06:11.220 | He said, "No matter how far you drive,

01:06:14.360 | you're always the same distance from the ditch."

01:06:17.300 | And I said, "Well, that's kind of depressing."

01:06:19.860 | And he said, "No, that's actually what gives me peace."

01:06:23.060 | Because what would happen is for so many years

01:06:25.680 | of relapsing and relapsing and recovering and relapsing,

01:06:30.140 | he felt like it was hopeless.

01:06:33.220 | And then somehow conceptualizing that the vigilance

01:06:36.800 | can never go away instead of making him feel burdened,

01:06:41.620 | it made him feel relieved.

01:06:43.000 | So I often think about that statement,

01:06:46.080 | no matter how far you drive,

01:06:47.280 | you're always the same distance from the ditch.

01:06:48.840 | Because in my mind, I conceptualize that as,

01:06:50.680 | gosh, that's a tough way to drive down the road.

01:06:53.740 | But actually on a road where you know where the ditch is

01:06:57.400 | and where you know where the lane lines are,

01:06:59.240 | it's actually a pretty nice drive.

01:07:00.960 | It's when you don't know where the shoulder is

01:07:02.560 | that you constantly have to be looking around.

01:07:04.220 | So there's this, we're speaking now in analogies

01:07:07.700 | and imagery and science.

01:07:11.400 | But one of the things I find so incredible

01:07:14.280 | about this community of 12-step,

01:07:16.280 | and there are a variety of them,

01:07:18.720 | are the communities that they create for themselves

01:07:22.380 | and some of these sayings,

01:07:24.760 | which I do believe link back

01:07:27.220 | to really core biological mechanisms.

01:07:29.080 | - Yes, yes.

01:07:30.320 | - I do want to ask about those communities.

01:07:32.440 | I have a question which might be a little bit controversial.

01:07:36.680 | - Great.

01:07:37.520 | - Which is,

01:07:38.360 | is it possible that people who were addicted to drugs

01:07:42.960 | or alcohol or some gambling or some other behavior

01:07:46.000 | get addicted to the addiction community?

01:07:49.160 | Because one thing that I think I observe over and over

01:07:53.440 | is that there's some circuit in the brain of human beings

01:07:56.520 | that has to tell you about the dream

01:07:59.080 | they had the night before, for whatever reason.

01:08:01.280 | [laughing]

01:08:02.540 | There's another circuit that leads people to wake you up

01:08:06.120 | if they themselves can't sleep.

01:08:07.440 | I don't know what the circuit is.

01:08:08.900 | I'm being facetious here.

01:08:10.320 | But there does seem to also be a circuit

01:08:13.080 | in the brain of addicts to discuss

01:08:16.360 | and want to kind of talk about their recovery a lot.

01:08:21.360 | And I mentioned this not to poke at them,

01:08:23.880 | but rather the opposite,

01:08:25.280 | because I think that one thing that is challenging,

01:08:29.120 | at least for me and having friends

01:08:30.720 | that have a propensity for drug or alcohol addiction,

01:08:33.540 | not all of them, but certainly some of them,

01:08:35.480 | is when they're talking about their recovery,

01:08:37.480 | I feel like it's all they talk about.

01:08:40.760 | This meeting, that meeting, that meeting.

01:08:42.760 | How are we, so what I'm really asking here is,

01:08:46.920 | is that some, can we become addicted to sobriety?

01:08:51.520 | - Right.

01:08:53.680 | So this is a great question.

01:08:55.460 | And it links into some of the other things

01:08:56.960 | we've been talking about having to do with

01:08:59.640 | where do we settle out?

01:09:01.620 | What is the way to live between pleasure and pain?

01:09:04.520 | And I implied earlier that ultimately

01:09:07.140 | we want a resilient balance

01:09:08.620 | that's sensitive to pleasure and pain,

01:09:10.200 | but that can easily restore homeostasis after we indulge,

01:09:14.240 | even when we indulge greatly.

01:09:16.220 | But the truth of the matter is that

01:09:18.880 | people with severe addiction, I believe,

01:09:21.560 | temperamentally want those extremes.

01:09:25.200 | And they're wired for that kind of intensity

01:09:28.480 | that is more than just these slight adjustments

01:09:31.360 | around the fulcrum, right?

01:09:32.500 | It's like, they want the big highs and the big lows.

01:09:35.160 | - They'll say, "Great meeting."

01:09:36.520 | - Yeah, right.

01:09:37.360 | - They're like, "That was such an amazing meeting."

01:09:38.180 | Or they find a group, they find a group in a location.

01:09:41.360 | Like we see, this is almost an inside joke

01:09:43.920 | in those communities.

01:09:44.740 | Again, I'm not reporting,

01:09:45.800 | I'm not talking about a "friend" in quotes,

01:09:47.360 | this isn't me reporting.

01:09:48.400 | Well, they'll talk about how attractive people are

01:09:52.120 | at a given meeting or how bonded they feel

01:09:54.720 | to people at a given meeting,

01:09:55.840 | that the meetings themselves become their own form

01:09:59.360 | of dopamine hit.

01:10:00.600 | - Yes, yes.

01:10:01.440 | - And again, I'm not being disparaging,

01:10:02.880 | I just, I want to understand this.

01:10:04.840 | - Right, so yes, so a lot of times patients will say to me,

01:10:08.480 | "Oh, you know, I don't want to go to AA, it's a cult."

01:10:11.160 | And my response to that is,

01:10:12.860 | because it's a cult is exactly why it works, okay?

01:10:18.560 | Because yes, it is much better for you

01:10:21.900 | to be addicted to AA and to recovery

01:10:24.800 | than almost any other addiction I could think of.

01:10:28.440 | And we know from Rob Malenka's work,

01:10:30.260 | who's here at Stanford,

01:10:31.640 | that oxytocin is the hormone that's involved

01:10:35.520 | in human pair bonding and relationships and love.

01:10:39.920 | And it directly links to dopamine neurons

01:10:42.520 | and causes the release of dopamine.

01:10:44.000 | So yes, when we connect with other humans,

01:10:46.680 | especially in a kind of transcendent spiritual way,

01:10:49.460 | that's a huge dopamine hit.

01:10:51.000 | And it does replace the dopamine that people get from drugs.

01:10:53.960 | And for people who have this addiction temperament,

01:10:58.400 | they need it on a more intense level.

01:11:00.760 | They're not going to be generally satisfied

01:11:03.880 | with kind of, you know, a sort of acquaintanceship, right?

01:11:08.160 | They want that intensity of the intimacy that you get

01:11:11.900 | with people when you're cathartically exposing,

01:11:15.080 | you know, warts and all.

01:11:16.560 | So yes, people can get addicted to recovery

01:11:19.160 | and good for them, go for it, you know?

01:11:22.400 | And of course, this can be disruptive for friendships

01:11:25.560 | and relationships where the one person is not in recovery.

01:11:28.600 | Like you're going to so many meetings,

01:11:30.280 | you're always talking about recovery, but you know what?

01:11:31.960 | Much better than them being intoxicated, right?

01:11:34.500 | I mean, so although you may tire of your friends

01:11:37.000 | talking about their, you know, meetings all the time,

01:11:39.000 | I'm sure you would rather have them do that

01:11:40.880 | than, you know, be in their addiction.

01:11:43.040 | - Yeah, absolutely.

01:11:44.280 | And this is now the second time you've done this

01:11:46.360 | during this discussion, but now I have empathy

01:11:48.380 | because the way you describe their enthusiasm

01:11:51.240 | about meetings is probably the way that people feel

01:11:54.320 | about me and your work and in neuroscience.

01:11:57.880 | I mean, I've been getting up in front of the class

01:12:00.880 | since I was eight years old

01:12:02.360 | and talking about things I read over the weekend.

01:12:04.160 | Now I just happen to have this thing called a podcast.

01:12:07.440 | I've been doing it since I was little,

01:12:08.400 | and it annoys a lot of people, right?

01:12:11.080 | I've learned to suppress it a little bit.

01:12:12.680 | Some people like it, but I'm poking fun at myself

01:12:16.520 | just to say that I now can understand

01:12:20.080 | that the way I feel about their reports

01:12:21.760 | about yet another amazing meeting,

01:12:23.640 | or for, there's a different form of this,

01:12:27.560 | but there are some people for which

01:12:29.560 | they just love intense experiences.

01:12:32.080 | They're always like trying to pull me off to Bali

01:12:35.160 | because they're talking about how sensual it is all the time.

01:12:37.560 | I'm sure Bali's wonderful,

01:12:39.100 | but there's this kind of ratcheting up.

01:12:41.180 | It's like seeking Burning Man all year long.

01:12:43.900 | I've never been to Burning Man,

01:12:44.880 | no desire to go to Burning Man.

01:12:49.480 | But inside of academia,

01:12:51.360 | I mean, if I were to just turn the mirror at myself,

01:12:54.320 | inside of academia or here in Silicon Valley, work,

01:12:58.600 | and the pursuit of more success,

01:13:01.680 | even if money is kind of divorced from that,

01:13:04.500 | sometimes it is, sometimes it isn't,

01:13:05.800 | academic work is for sake of pursuit of knowledge.

01:13:09.640 | It sounds to me like the same mechanism.

01:13:12.000 | In fact, it feels to me very much like the same mechanism.

01:13:16.280 | - So Andrew, here's what I love about you.

01:13:18.240 | First of all, you're willing to bring your own flaws

01:13:21.120 | and foibles to this conversation.

01:13:22.560 | - Well, they're everywhere.

01:13:23.760 | - Well, you know what, it's wonderful.

01:13:26.720 | And then you're really open and curious

01:13:29.280 | and wanting to understand,

01:13:31.220 | 'cause I can't tell you how many people I have met

01:13:33.560 | who really see addiction as some kind of otherness,

01:13:37.080 | but the truth is we're all wired for addiction.

01:13:39.840 | And if you're not addicted yet,

01:13:41.400 | it's just, it's right around the corner.

01:13:43.400 | Do you know what I mean?

01:13:44.500 | Especially with the incredible panoply of new drugs

01:13:47.780 | and behaviors that are out there.

01:13:49.780 | So I love that you're willing to take a moment

01:13:53.200 | and really try to understand this

01:13:55.660 | because it is, we can all relate

01:13:58.400 | and you're relating it to your,

01:14:00.000 | essentially your work addiction is right and apt.

01:14:03.780 | You just happen to be addicted to something

01:14:05.440 | that is really socially rewarded.

01:14:07.940 | You know, you figured that out at an early age.

01:14:10.020 | Oh, when I do X, Y, and Z, all these people go,

01:14:12.840 | look at that smart kid or whatever it is, you know.

01:14:15.360 | - For me, it made me feel safe.

01:14:16.880 | - Okay.

01:14:17.720 | - I felt like, yeah, I just felt like this,

01:14:21.900 | and I paused there 'cause it's like, it's like peace.

01:14:24.600 | I'm like, I can relax for a moment.

01:14:27.560 | - When you're talking about neuroscience.

01:14:28.980 | - No, or just when I feel like I'm on the right path

01:14:33.040 | and I'm onto something,

01:14:34.200 | or if I see something that I'm excited about,

01:14:36.840 | I'm like, I feel filled with, it must be dopamine.

01:14:41.020 | I feel flooded with pleasure, literally from head to toe.

01:14:44.420 | And then my next thought is more.

01:14:46.980 | [laughing]

01:14:47.820 | - So true, you're a true addict, you are.

01:14:51.220 | You are, but you just got really,

01:14:53.340 | you really got lucky with the fact

01:14:55.660 | that what you're drawn to is adaptive essentially, you know.

01:15:00.660 | And then your challenge is going to be

01:15:04.180 | that your life doesn't get too out of balance

01:15:06.340 | in the sense that you're 24/7 work

01:15:08.800 | and you don't stop and do some other things

01:15:11.800 | or think about it.

01:15:12.640 | - And my life admittedly is somewhat asymmetric.

01:15:15.140 | I mean, it has other components of physical health, et cetera,

01:15:17.300 | but it is somewhat asymmetric, which is why I got a dog.

01:15:21.660 | Although I talk about him an awful lot, so.

01:15:24.420 | - But the dog is good because that draws you out of yourself

01:15:27.180 | and a little bit away from the work.

01:15:28.700 | But again, you know, I think the key here is

01:15:30.820 | for people who feel like they don't,

01:15:31.940 | they've never experienced addiction

01:15:33.140 | or they don't know anybody with addiction,

01:15:34.500 | or if they do, they don't get it.

01:15:35.980 | Just think of that one thing

01:15:38.160 | that is the most important thing in your life that you do

01:15:41.100 | that gives you pleasure and meaning and purpose.

01:15:43.460 | And then imagine if you couldn't do it.

01:15:46.080 | - Oh yeah, let's not talk about that.

01:15:47.740 | [both laughing]

01:15:50.120 | - Right.

01:15:51.300 | - Well, I appreciate the feedback

01:15:53.020 | and you can send me a bill at the end.

01:15:54.880 | What is the most ridiculous sounding addiction

01:16:01.280 | that you've ever witnessed

01:16:04.060 | that was actually a real addiction along these lines?

01:16:07.340 | Because I think we all know the standard heroin pill.

01:16:11.900 | You've been very, I should mention,

01:16:13.900 | because it's important in your previous book,

01:16:16.660 | and we will probably have a link to that as well,

01:16:18.860 | focused on the opioid crisis

01:16:20.580 | and what we thought was medication

01:16:23.980 | turned out to be just as bad, if not worse,

01:16:26.740 | than a lot of so-called street drugs.

01:16:29.380 | So we understand those, you know,

01:16:31.300 | gambling, sex addiction, porn addiction.

01:16:33.340 | Now, video games, we'll talk about social media

01:16:35.660 | a little bit more in depth, but what's the most like, wow,

01:16:40.060 | I didn't realize people could get addicted to that.

01:16:42.920 | - Water.

01:16:45.420 | - Really?

01:16:46.980 | - Really, so I had a very lovely patient

01:16:49.940 | who had a severe alcohol addiction,

01:16:52.860 | and she got into recovery from her alcohol addiction

01:16:56.660 | for many years, but she kind of had a sort of a polydipsia

01:17:00.980 | or an urge to be drinking something a lot.

01:17:04.420 | And so she drank a lot of water and slowly over time,

01:17:08.620 | she realized that if she drank enough water,

01:17:10.860 | she could become hyponatremic and delirious

01:17:13.680 | and be out of herself.

01:17:14.940 | - You can die from it, right?

01:17:15.780 | - Right, which is, she just wanted

01:17:17.660 | to be out of her own head.

01:17:19.220 | And so she would periodically intentionally overdose

01:17:23.500 | on water in order to, I know it was so sad, so sad.

01:17:28.500 | - What happened to her?

01:17:30.900 | - She eventually took her own life.

01:17:33.020 | - Wow. - Yeah, it was really.

01:17:34.180 | - That's rough.

01:17:35.020 | - She was a lovely woman, she was so bright,

01:17:37.580 | she had so many interests and passions,

01:17:40.020 | and of course it was very sad when she died.

01:17:44.640 | But that was a wow to me, it was like, wow,

01:17:48.740 | if you have this disease of addiction,

01:17:51.140 | you can even get addicted to water.

01:17:53.020 | - Wow, and I think it just underscores

01:17:55.280 | the generalizability of these circuits.

01:17:58.540 | - Right.

01:17:59.380 | - There isn't a brain circuit for addiction to water

01:18:01.500 | that she happened to have,

01:18:02.460 | there's a brain circuit for pleasure and pain

01:18:04.660 | and addiction and water plugged into that circuit.

01:18:08.260 | - Right, right.

01:18:09.320 | - Wow, that's intense.

01:18:11.240 | In your book, "Dopamine Nation,"

01:18:14.620 | you also describe some amazing paths to recovery.

01:18:19.420 | People that, you know, from reading it,

01:18:23.900 | I won't say which ones and who,

01:18:25.740 | 'cause there's some great surprises in the book too,

01:18:28.100 | both tragic and triumphant, as they say.

01:18:32.420 | You've often described your patients as your heroes.

01:18:35.660 | - Yeah.

01:18:36.500 | - Yeah, tell us a little bit more about that.

01:18:38.180 | - You know, when you think about how hard it is

01:18:41.420 | to give up a drug or a behavior that you're addicted to,

01:18:44.220 | how much courage that takes,

01:18:45.980 | and fortitude and discipline and stick-to-itiveness,

01:18:49.660 | these people are really amazing people.

01:18:52.540 | I mean, that's, I don't know that I could do it,

01:18:55.640 | what they do, you know, it's,

01:18:58.980 | and like, you know, we talked a little bit about,

01:19:01.940 | you know, just the constant, ever-present urge to use,

01:19:05.860 | even after sustained periods of abstinence for some people.

01:19:09.200 | That's really, really hard.

01:19:10.760 | And of course, then you double down on the shame

01:19:14.100 | that they feel because of that urge,

01:19:16.420 | even when their lives are so much better.

01:19:18.660 | I mean, these people are really, really remarkable.

01:19:22.260 | And you take their remarkable accomplishment,

01:19:24.920 | and then you imagine the world that we live in now,

01:19:27.840 | where we are constantly invited and tempted,

01:19:31.540 | and really bombarded with opportunities

01:19:34.380 | to become addicted at every turn.

01:19:35.580 | - It's like you're feeling an itch everywhere.

01:19:37.100 | - Oh yeah, I mean, you can't escape it.

01:19:38.680 | You know, you cannot escape it,

01:19:40.020 | that you'll get an email in your inbox

01:19:41.780 | inviting you to do X, Y, or Z.

01:19:43.580 | And if you're addicted to that thing, you know,

01:19:45.260 | you tried to like delete all your apps and not go here,

01:19:47.580 | all of a sudden your work inbox, you're, you know,

01:19:49.440 | you're getting those images, let's say,

01:19:51.780 | really, really, really hard.

01:19:54.060 | And yet these people find a way to do it.

01:19:56.420 | I think it's absolutely amazing.

01:19:58.080 | And they're really wise people.

01:20:00.100 | They have so much wisdom to offer.

01:20:02.100 | They've taught me a lot.

01:20:03.200 | You know, as I talk about in my book,

01:20:04.340 | I have my own addictions,

01:20:05.480 | and I really just like took a page right out of there,

01:20:07.980 | but I was like, okay, what do I do now?

01:20:09.620 | All right, what did this patient do?

01:20:10.820 | Okay, I'm going to try that.

01:20:12.660 | - It is an amazing community of the people

01:20:15.660 | that are very sage.

01:20:17.860 | I wanted to just touch on something that you mentioned,

01:20:21.460 | which is the shame.

01:20:23.580 | You know, you can't go to a meeting

01:20:26.860 | or talk to addicts without detecting

01:20:30.660 | or hearing about like lies, shame, et cetera.

01:20:34.500 | I heard you say in an interview with somebody else recently

01:20:38.340 | that truth telling and secrets

01:20:42.460 | are sort of at the core of recovery.

01:20:45.400 | And yeah, tell us more about that.

01:20:48.740 | - Yeah, so one of the things that I found

01:20:51.060 | really fascinating about working with people in recovery

01:20:54.420 | was how telling the truth, even about the merest detail

01:20:58.500 | of their lives was central to their recovery.

01:21:01.520 | And I became really curious about that.

01:21:03.440 | Like why would truth telling be so important?

01:21:06.100 | And of course there is the obvious thing

01:21:07.620 | that when people are in their addiction,

01:21:09.060 | they're lying about using, you know,

01:21:10.980 | so part of getting into recovery

01:21:13.780 | is to stop lying to the people they care about

01:21:16.220 | about their use.

01:21:17.360 | But it's really more than that

01:21:19.260 | because what people in recovery have taught me

01:21:21.700 | is that it's not even just not lying about using drugs.

01:21:25.580 | I have to not lie about anything.

01:21:28.100 | I can't lie about why I was late to work this morning,

01:21:30.660 | which we all do.

01:21:31.500 | Oh, I hit traffic.

01:21:32.340 | No, I didn't hit traffic.

01:21:33.340 | I wanted to spend two more minutes reading the paper

01:21:35.580 | and drinking my coffee, right?

01:21:37.660 | Or just lying about, you know,

01:21:39.900 | I don't know where I had dinner.

01:21:41.760 | Like, so people with addiction will get into, you know,

01:21:44.420 | the lying habit where they're lying about random stuff

01:21:46.700 | 'cause they're sort of in the habit of lying.

01:21:48.940 | And how recovery is really about telling the truth,

01:21:53.640 | you know, in all ways.

01:21:54.900 | And so one of the things that I had a lot of fun with

01:21:57.980 | in writing the book is sort of exploring

01:22:00.060 | the neuroscience around why truth telling is important

01:22:04.860 | to leading a balanced life.

01:22:06.420 | And we know like every religion since the beginning of time

01:22:09.160 | is all about telling the truth.

01:22:10.260 | Well, why, right?

01:22:11.340 | And there's really interesting neuroscience behind it

01:22:14.460 | that suggests that when we tell the truth,

01:22:17.640 | we actually potentially strengthen

01:22:19.860 | our prefrontal cortical circuits

01:22:22.540 | and their connections to our limbic brain

01:22:24.760 | and our reward brain.

01:22:26.080 | And of course, these are the circuits that get disconnected

01:22:28.360 | when we're in our addiction, right?

01:22:29.900 | Our balance in our reward pathway, our limbic brain,

01:22:32.540 | our emotion brain is doing one thing.

01:22:34.180 | And our cortical circuits are completely disengaged

01:22:37.040 | from that ignoring what's happening,

01:22:38.420 | which is easy to do because it's reflexive.

01:22:40.400 | We don't need to think about that balance

01:22:42.700 | for the balance to be happening.

01:22:44.460 | But we have to re-engage those circuits,

01:22:47.800 | anticipate future consequences, think through the drink,

01:22:51.300 | not just how am I gonna feel now if I use,

01:22:54.000 | but how am I gonna feel tomorrow or six months from now?

01:22:56.560 | And that telling the truth is in fact a way to do that,

01:23:00.440 | to make these connections stronger.

01:23:02.360 | And I talk about some studies in my book

01:23:04.040 | that kind of indirectly show that.

01:23:06.740 | So I find that really fascinating.

01:23:08.080 | Plus just that like being open and honest with people

01:23:12.280 | really does create very intimate connections.

01:23:16.520 | And those intimate connections create dopamine.

01:23:20.400 | So we were talking a little bit about how you know

01:23:23.120 | a bunch of people who need like intensity in their lives.

01:23:26.160 | For me, I need a lot of intensity in my human connections.

01:23:31.080 | Like I'm really not interested in and bored by

01:23:34.120 | and made anxious by casual interactions.

01:23:39.120 | But like having this kind of discussion with you

01:23:41.920 | that's very intense and also intimate and self disclosing

01:23:46.320 | is very rewarding for me.

01:23:47.840 | So that's an important source of dopamine.

01:23:49.480 | Thank God I became a psychiatrist.

01:23:51.360 | - Yeah, absolutely.

01:23:52.200 | - Like I can't disclose all my stuff,

01:23:53.820 | but I am quite transparent with my patients,

01:23:55.880 | which is a slightly unorthodox.

01:23:57.700 | But you know, when I think it's right,

01:24:00.080 | I'm also transparent with them.

01:24:01.520 | So that's a source of dopamine too,

01:24:03.960 | when we're honest and we disclose

01:24:06.160 | and that you think people are gonna run away from you

01:24:08.360 | if you tell them about all like your weird neuroses,

01:24:10.480 | but really they don't.

01:24:11.820 | What they're like is,

01:24:12.660 | "Oh, thank God, I'm not the only one," right?

01:24:14.920 | - Well, what I love about,

01:24:16.120 | I love many things about your book.

01:24:17.780 | I read it in one sweep.

01:24:19.320 | - Oh, thank you.

01:24:20.160 | - And I was like, wow.

01:24:21.320 | I was pleasantly surprised, but I was like,

01:24:27.140 | wow, she's really opening up in this book

01:24:29.480 | from the very beginning.

01:24:30.720 | And I don't want to give it away,

01:24:33.960 | but it's, yeah, you're very open where it's appropriate.

01:24:40.160 | And also, I think that this question about truth telling,

01:24:44.220 | I always think about like, tell the truth,

01:24:47.660 | be 100% about the truth,

01:24:50.260 | but there's also this element about,

01:24:52.820 | do you report previous lies, right?

01:24:57.280 | Like what about prior behavior?

01:24:59.600 | And I'm fascinated by this,

01:25:01.060 | 'cause to me, telling the truth has many facets,

01:25:03.460 | but the three sides of this thing in my mind are,

01:25:08.000 | one is reporting everything accurately.

01:25:10.800 | The other is, what do you withhold,

01:25:12.560 | what do you not withhold, right?

01:25:14.300 | Because some people will say,

01:25:15.920 | tell the truth or at least don't lie.

01:25:17.760 | That's sort of a-

01:25:18.580 | - Lies of omission, right?

01:25:20.040 | - That's a lies of omission.

01:25:22.160 | Lies of omission.

01:25:23.560 | And then there's what I have to assume for most people

01:25:28.040 | is a small to enormous batch of things

01:25:31.460 | that they lied about in the past

01:25:33.640 | that still thread into the future.

01:25:36.280 | So how important is it for the addict

01:25:38.640 | or the every person really to,

01:25:41.480 | 'cause it sounds like cultivating the circuitry

01:25:43.260 | between prefrontal cortex and the dopamine system

01:25:45.240 | would be great for anybody,

01:25:46.960 | since we're all addicts, everyone should do it.

01:25:49.140 | But in all seriousness,

01:25:50.480 | it sounds like a good thing for everybody to do.

01:25:53.320 | How much work needs to be done on all the priors,

01:25:58.320 | all the stuff we've hidden?

01:26:01.340 | And I mean, not me,

01:26:02.840 | but all the stuff that everybody else has hidden.

01:26:05.160 | (both laughing)

01:26:06.920 | - Yeah, so the steps of the 12 Steps of Alcoholics Anonymous,

01:26:11.920 | a good number of those steps are about that very thing,

01:26:17.660 | the past, the ways that we've harmed people in the past.

01:26:20.920 | And the fourth step is about making amends

01:26:25.680 | by admitting the ways in which that we've contributed

01:26:30.360 | to harming others.

01:26:33.640 | And it is a really big piece of recovery.

01:26:36.560 | So how important, so for people with addiction,

01:26:39.920 | it's really, really important to go back and make amends.

01:26:43.160 | And the key idea there is you just go back

01:26:48.160 | and you apologize.

01:26:50.600 | And you don't have to get any particular kind of response

01:26:53.920 | or you don't need to be forgiven.

01:26:55.480 | It's the act itself of apologizing about the ways

01:27:00.560 | in which we've harmed or lied to people in the past

01:27:04.720 | that is cathartic and renewing

01:27:07.640 | and allows us to kind of shed this skin

01:27:09.880 | and be new in our lives and begin again,

01:27:12.560 | sort of absolved of past sins, so to speak.

01:27:16.560 | So it is really important.

01:27:19.420 | Are there situations when it's maybe not a good idea

01:27:23.120 | because of that person or the nature?

01:27:26.240 | Sure, there are always gonna be,

01:27:28.680 | it doesn't have to be like, it's not, we're talking about

01:27:31.040 | not like Kant's idea about like, never lie,

01:27:33.040 | but robbers in your house and you're stowaway.

01:27:36.160 | You can't lie even about that.

01:27:37.200 | It's like, no, there are probably situations where-

01:27:39.520 | - Absolutely, for sake of other people's safety,

01:27:43.060 | children's safety, sure. - Right, right, right.

01:27:44.480 | I mean, you can think of a million scenarios.

01:27:46.880 | But in general, when we're taking stock,

01:27:51.500 | because I don't know about you,

01:27:52.560 | but I have a lot of regrets and guilt

01:27:55.040 | about a lot of things in my life.

01:27:58.480 | And they kind of haunt me.

01:28:02.060 | You know, and sometimes I'll have nightmares, right?

01:28:05.040 | And I think that's true for most people.

01:28:07.000 | I mean, I occasionally will meet somebody who's like,

01:28:08.680 | oh, I don't have any regrets, and I'm like, wow.

01:28:11.280 | Like, I cannot relate to that at all.

01:28:14.480 | So, you know, this idea of like catharsis and well,

01:28:20.160 | I mean, in the 12 steps, it's telling God

01:28:22.560 | or your higher power, telling another human being

01:28:25.260 | the ways in which you've wronged others,

01:28:26.900 | considering your own character defects

01:28:28.840 | and how those have contributed.

01:28:29.900 | To me, that's a really important piece

01:28:31.540 | and something that we don't do enough in our current culture,

01:28:35.040 | especially in psychiatry, frankly,

01:28:36.520 | where there's a lot of eternally empathizing with patients,

01:28:40.320 | but not a whole lot of likes going,

01:28:41.940 | well, you know, actually you kind of messed that up.

01:28:44.300 | Or like, that was really bad on you, you know?

01:28:47.600 | And in my work, I don't necessarily use that language,

01:28:50.520 | but, you know, patients may say like,

01:28:52.860 | I really feel badly about this thing.

01:28:55.340 | And I'll be like, yeah, I get it.

01:28:57.340 | I understand that you feel-

01:28:59.080 | - Well, guilt is a- - Right.

01:29:00.560 | - There's a circuit for that too.

01:29:01.920 | - Right, and it's important, right?

01:29:04.360 | And it's also important to recovery

01:29:07.520 | and to not becoming addicted, you know,

01:29:09.360 | experiencing a certain amount of appropriate shame

01:29:12.760 | for things that we have done.

01:29:14.720 | And, you know, feeling the pain that comes with shame,

01:29:18.660 | which is an incredibly painful emotion, right?

01:29:21.180 | And I think that may be the one that we all try to avoid

01:29:23.040 | more than any other is like that shame of not being liked

01:29:27.580 | or not being accepted or not being celebrated.

01:29:29.860 | - Or that the thing that we did is really despicable.

01:29:32.920 | - Right, it's really, yeah, like, oh my God,

01:29:34.740 | I did that horrible thing, right, right.

01:29:36.740 | And then, so, I mean, I've done horrible things

01:29:39.300 | that I haven't gone back and said I did this horrible thing,

01:29:43.180 | but maybe I've tried to pay it forward.

01:29:45.580 | Like I've told my kids, you know, when I was younger,

01:29:47.940 | I did this horrible thing and it still haunts me.

01:29:50.940 | So if you're ever tempted to do something like what I did,

01:29:54.080 | you might think about my situation.

01:29:55.980 | So, you know, some kind of way,

01:29:57.780 | but I think wrestling with that is important.

01:30:00.900 | - I think it's a really important element to all this.

01:30:03.160 | And there's not, I love that there's neuroscience

01:30:06.480 | being done on truth-telling and the value of truth-telling.

01:30:09.640 | I think if I were to predict a new and truly exciting area

01:30:14.640 | that people are going to be really curious about

01:30:17.540 | and in this huge sphere we call neuroscience,

01:30:20.540 | I hope they'll continue to do more work.

01:30:22.840 | Also speaks, I'm so glad to hear

01:30:24.240 | that's happening here at Stanford.

01:30:26.300 | - No, well, the literature that I look at

01:30:30.020 | isn't Stanford work, but there's work.

01:30:33.820 | There might be people at Stanford.

01:30:35.340 | - Great, regardless of where it's happening,

01:30:37.140 | more of that and all the rest, please.

01:30:39.660 | I want to ask you about using drugs to treat drug addiction.

01:30:45.500 | These days, there's a growing interest

01:30:47.580 | or at least discussion about Ibogaine,

01:30:50.020 | people going out of country,

01:30:52.060 | because I think it's still illegal here or is illegal here,

01:30:55.180 | going out of country to, I don't know,

01:30:57.140 | either inject it or smoke it or whatever it is,

01:31:00.960 | or people going and doing ayahuasca journeys or MDMA,

01:31:04.860 | which is still an illegal drug in this country,

01:31:07.500 | but there are clinical trials.

01:31:08.540 | There are people on this campus doing experimental studies.

01:31:11.740 | I don't know of clinical trials,

01:31:12.820 | but at Johns Hopkins there are clinical trials, et cetera.

01:31:16.060 | So this is a vast area, right?

01:31:19.360 | Different chemistries for different drugs

01:31:21.120 | and different purposes,

01:31:22.140 | but the rationale, as I understand it,

01:31:25.360 | is take people who are in a pattern of addiction,

01:31:29.320 | launch them into a experience

01:31:33.620 | that's also chemical and extreme,

01:31:35.760 | often of the extreme serotonin and/or extreme dopamine type.

01:31:40.760 | So MDMA, ecstasy, for instance, tons of serotonin dumped,

01:31:44.180 | tons of dopamine dumped, how neurotoxic, if neurotoxic,

01:31:47.900 | debatable, et cetera, et cetera, not a topic for now,

01:31:51.400 | but a lot.

01:31:52.880 | And then somehow that extreme experience

01:31:55.360 | wrapped inside of a supported network in there,

01:31:59.160 | whether or not there's just someone there

01:32:01.000 | or whether or not they're actively working

01:32:02.420 | through something with the patient,

01:32:04.580 | is supposed to eject the person into a life

01:32:08.500 | where drug use isn't as much of interest.

01:32:14.160 | This violates, at a rash, purely rational level,

01:32:17.940 | this violates everything we've talked about

01:32:20.060 | in terms of dopamine biology.

01:32:21.840 | It would, if this arrangement is the way I described it,

01:32:25.700 | cause more addiction, is anything but a dopamine fast,

01:32:30.120 | it's a dopamine feast.

01:32:31.600 | So we hear about successful transitions through this,

01:32:36.400 | at least anecdotally, and maybe some clinical say,

01:32:39.700 | "What is going on?" [laughing]

01:32:43.020 | "What is going on?"

01:32:44.220 | Doesn't make any sense to me.

01:32:45.680 | Yeah. - Yeah.

01:32:49.480 | So I think it's good that you're skeptical.

01:32:52.480 | I think we all should be skeptical.

01:32:54.740 | Having said that, there are clinical studies showing,

01:32:59.740 | you know, and these are small studies

01:33:02.340 | and they're short duration, small number of subjects,

01:33:05.840 | but, you know, taking people, for example,

01:33:07.500 | who are addicted to alcohol and then having them have this,

01:33:12.420 | let's say, psychedelic experience

01:33:14.100 | in a very controlled setting.

01:33:16.160 | - So either, typically it's a high dose psilocybin

01:33:18.660 | or three dose, as I saw it for the MAP study of MDMA,

01:33:22.940 | of ecstasy. - Right.

01:33:23.780 | - Those are sort of the, seem to be the kind of-

01:33:25.460 | - The typical. - The kind of bread and butter

01:33:27.160 | of this kind of work. - Right, right.

01:33:28.500 | But the thing to really keep in mind is that

01:33:31.080 | this is completely interwoven with regular psychotherapy

01:33:36.080 | and that these are highly selected individuals.

01:33:39.300 | - And clinical trials. - Right, right.

01:33:40.820 | - We're referring to legal clinical trials.

01:33:43.100 | - And so, you know, I think the metaphor

01:33:46.860 | that helps me think about this is

01:33:49.260 | there are many ways to the top of the mountain

01:33:51.500 | and these are sort of like taking the gondola

01:33:54.120 | instead of walking up.

01:33:55.980 | It's sort of, instead of doing like a year of psychoanalysis

01:33:59.660 | where you're sitting on the couch every week,

01:34:01.420 | reflecting on your life, it's a condensed version

01:34:05.260 | of psychoanalysis or psychotherapy plus, you know, MDMA,

01:34:09.380 | which gets you there faster.

01:34:11.060 | - Creates the intimacy, presumably, because of this-

01:34:13.540 | - Well, I think the main thing that happens

01:34:16.420 | when it's beneficial is it just allows the person

01:34:21.020 | to get outside of their own head and look at their lives

01:34:26.020 | on a much broader sweep and to consider themselves

01:34:31.220 | not mired in the quotidian sort of details of their life,

01:34:37.180 | but rather as a human on the large planet Earth

01:34:42.180 | in the vast universe.

01:34:43.940 | So I think it takes, it's like when it works,

01:34:47.880 | it's a transformational experience

01:34:50.260 | because it gives the person another lens

01:34:54.800 | through which to view their lives,

01:34:57.820 | which I think for some people is positive and powerful

01:35:02.020 | because they can come back from that and be like,

01:35:04.460 | oh my gosh, I care about my family

01:35:08.340 | and I want X, Y, or Z for them

01:35:10.900 | and I realize that my continuing to drink

01:35:12.700 | is not going to achieve that.

01:35:15.380 | So it's almost like a spiritual or values-based.

01:35:20.020 | So I think it can be very powerful.

01:35:21.860 | But having said that, I truly am quite skeptical

01:35:25.620 | because addiction is a chronic relapsing

01:35:29.180 | and remitting problem.

01:35:30.120 | It's hard for me to imagine that there's something

01:35:32.340 | that works very quickly short-term

01:35:34.640 | that's going to work for a disease

01:35:37.080 | that's really long lasting.

01:35:38.980 | - Yeah, the two addicts I know

01:35:40.280 | that did MDMA-assisted psychotherapy

01:35:43.460 | as part of this thing both got worse.

01:35:46.660 | - Yeah.

01:35:48.220 | - But the people I know who had severe trauma,

01:35:51.720 | who did this, who took this approach

01:35:53.900 | seemed to be doing better.

01:35:55.140 | - Okay, interesting.

01:35:55.980 | - And so I think that the discussion as we hear it now

01:36:00.540 | is just sort of psychedelics,

01:36:02.160 | which is a huge category that includes many different drugs

01:36:05.540 | and compounds with different effects.

01:36:07.240 | And we hear about trauma and addiction lumped together.

01:36:11.460 | And I think that I'm a splitter, not a lumper,

01:36:14.900 | as we say in science.

01:36:16.160 | And I think it's going to be important for people to know

01:36:22.500 | that this is definitely not a one-size-fits-all kind of thing

01:36:27.500 | but it sounds like it may have some utility

01:36:30.140 | under certain conditions.

01:36:31.660 | - Yeah, I think so.

01:36:32.820 | I think I'm trying to be very open-minded

01:36:35.340 | about its potential utility for certain individuals.

01:36:38.440 | But I can tell you in my clinical work,

01:36:40.400 | what is a very concerning unintended consequence

01:36:43.960 | of this narrative is I have a lot of people

01:36:47.340 | who are looking for some kind of spiritual awakening

01:36:49.620 | who on their own, not in the context

01:36:52.060 | of any kind of therapeutic psychological work,

01:36:55.060 | microdose or want to try psilocybin or MDMA

01:37:00.060 | with a friend or wherever,

01:37:01.540 | so they can have this spiritual experience

01:37:03.740 | that they can figure out their lives.

01:37:05.340 | That's a disaster and almost never works out well.

01:37:09.180 | And I've then had people who literally,

01:37:11.200 | supposedly you can't get addicted to psychedelics

01:37:14.460 | because something with the biochemistry,

01:37:16.460 | which I don't fully understand

01:37:17.460 | 'cause it doesn't make any sense to me,

01:37:18.900 | but I have patients clinically who definitely are addicted

01:37:22.140 | to MDMA, to microdosing.

01:37:24.840 | So that's very concerning to me

01:37:27.220 | 'cause like Pollan's "How to Change Your Mind,"

01:37:30.160 | I respect that work, but on the other hand,

01:37:34.580 | it's penetrated the culture- - Michael Pollan's book.

01:37:36.600 | - Yeah, yeah. - Well, and I don't know him

01:37:39.120 | and so I don't have a problem taking a stance.

01:37:43.220 | So I'll just say my stance on that is the narrative

01:37:47.020 | of popular authors can expand and wick out so fast

01:37:52.020 | that pretty soon people are essentially taking

01:37:54.700 | their mental health into their own hands.

01:37:56.800 | And I actually have great optimism for this business

01:38:00.920 | of clinical use of psychedelics, including MDMA.

01:38:05.920 | Matthew Johnson at Johns Hopkins

01:38:08.720 | is doing fabulous work on this.

01:38:10.640 | And there are others too, of course,

01:38:13.780 | but those are controlled settings.

01:38:16.020 | And the pharmacology is being tuned up.

01:38:17.980 | And one thing that I think is coming,

01:38:20.500 | there are several papers published recently

01:38:22.620 | in great journals like "Nature" and "Science," et cetera,

01:38:25.680 | where there are scientists who are removing

01:38:30.100 | the hallucinogenic components of these drugs

01:38:33.260 | and finding that they still have the antidepressant effects.

01:38:38.660 | And so the experience of a psychedelic

01:38:42.540 | and the long-term effects of the psychedelic

01:38:45.000 | might actually be dissociable.

01:38:47.460 | And so I, again, and I'm always careful to say,

01:38:50.260 | I'm neither for something or against it.

01:38:53.300 | I just think that treading carefully is what's important.

01:38:58.300 | - I agree with you.

01:39:00.120 | And I can just tell you that the downstream effect

01:39:03.320 | for the average person, many of whom present in our clinic,

01:39:08.320 | is that they've misconstrued the data

01:39:12.700 | on the use of psychedelics for mental health conditions

01:39:16.400 | to this idea that they're safe

01:39:19.400 | or that anybody can take them in any circumstance

01:39:21.560 | and have this kind of awakening.

01:39:23.440 | And that's not what the data show, right?

01:39:26.500 | The data are these highly controlled settings,

01:39:29.460 | carefully selected patients.

01:39:32.440 | So that's my worry.

01:39:34.740 | - Sure.

01:39:35.580 | And I'm going to be sitting down with Matthew Johnson

01:39:38.000 | at some point and we'll discuss this.

01:39:40.040 | And I think that that care and that cocoon

01:39:45.000 | of real clinical care does seem to be an important component.

01:39:49.440 | Well, I'm glad we could touch on it.

01:39:50.880 | And, you know, I'm sure I'll get a bunch of comments

01:39:53.800 | telling me that, you know, but I think it is important

01:39:58.300 | to explore things from all sides.

01:39:59.800 | And that's what we do as scientists.

01:40:02.200 | And if Michael Pollan wants to chat, we can do that too.

01:40:05.600 | That's fine.

01:40:06.440 | I very much enjoyed the book, actually.

01:40:08.840 | But I think that people run with ideas.

01:40:12.160 | - That's right.

01:40:13.000 | - They don't walk with them, they sprint.

01:40:14.560 | - Right, yeah.

01:40:16.160 | - There are a couple other things I just want to touch on,

01:40:19.860 | but they all relate to social media.

01:40:21.980 | - Okay.

01:40:22.820 | - You were featured in "The Social Dilemma."

01:40:25.200 | It was a powerful movie.

01:40:26.280 | I think many people avoided seeing that movie

01:40:28.280 | because it reflects back on us just how addicted we all are

01:40:32.120 | and how manipulated we all are.

01:40:33.960 | - Yes.

01:40:34.800 | - But it doesn't seem to have changed behavior much.

01:40:37.700 | I have to say that the movie changed my understanding

01:40:41.560 | and my perception, but not my behavior too much.

01:40:44.500 | If we look at addiction as a maladaptive thing,

01:40:48.640 | something that's making our lives worse

01:40:50.660 | or us less functional at work and in relationships,

01:40:54.860 | I could imagine a version of social media

01:40:57.120 | where it's making me more connected.

01:40:59.780 | I mean, this is a podcast after all.

01:41:01.620 | I post videos.

01:41:02.760 | This will show up on YouTube

01:41:04.060 | and elements of it on Instagram as well.

01:41:08.020 | So much like sugar or other things,

01:41:12.400 | I have to imagine that we need to regulate,

01:41:15.220 | not necessarily eliminate this behavior.

01:41:18.340 | So I want to talk about what that looks like.

01:41:20.720 | And I want to talk about what you've referred to

01:41:23.720 | as this narcissistic preoccupation

01:41:26.900 | that social media is creating,

01:41:28.740 | that we are all far more keenly aware of how we look

01:41:33.540 | and how we sound and how we are being perceived

01:41:36.860 | than we were 10 years ago.

01:41:39.800 | - Right.

01:41:40.640 | - So first of all, social media,

01:41:42.420 | how addicting is it really?

01:41:46.000 | And what is healthy social media behavior?

01:41:50.300 | - So the first message I would want to get across

01:41:56.240 | about social media is that it really is a drug

01:42:00.160 | and it's engineered to be a drug.

01:42:01.980 | And it's based on potency, quantity, variety,

01:42:07.920 | the bottomless bowls, the likes,

01:42:10.180 | the way that it's enumerated, all of that,

01:42:12.760 | which doesn't mean that we can't use it,

01:42:16.160 | but we need to be very thoughtful about the way we use it,

01:42:19.460 | just like we need to be thoughtful

01:42:20.800 | about the way we use any drug.

01:42:22.980 | And so that means with intention

01:42:27.080 | and in advance, planning our use, right?

01:42:30.720 | And trying to use it as a really awesome tool

01:42:35.600 | to potentially connect with other people

01:42:38.200 | and not to be used by it or get lost in it.

01:42:42.960 | And of course, people are gonna come

01:42:45.480 | with different propensities for addiction to any drug.

01:42:49.520 | And that's true for social media too.

01:42:51.060 | Some people will have no problem using it in moderation

01:42:54.720 | or using it in a way that's adaptive.

01:42:56.400 | And other people will immediately get sucked in.

01:43:00.280 | And the key thing about getting addicted

01:43:02.040 | is when it's happening, nobody who's getting addicted

01:43:05.280 | thinks they're getting addicted, right?

01:43:06.500 | Let's face it, it's only after the fact that we go,

01:43:09.200 | "Whoops, what was that about?"

01:43:11.280 | - Well, remember texting and driving?

01:43:12.620 | There were all these books about texting and driving,

01:43:14.420 | how terrible it was.

01:43:15.560 | - Yeah.

01:43:16.400 | - Even the governments have largely given up.

01:43:18.540 | You see these billboards, like don't text and drive

01:43:21.620 | or any texts can wait or not worth dying for,

01:43:24.600 | but everybody's texting and driving.

01:43:25.940 | - Right, and if you look at young people today, teenagers,

01:43:28.140 | I mean, they're basically cybernetically enhanced.

01:43:30.740 | The phone is there, it's like they're talking to you

01:43:33.780 | and texting 12 friends at the same time.

01:43:36.320 | And there's no stopping it.

01:43:37.920 | I mean, the genie is out of the bottle.

01:43:40.600 | We're not going back.

01:43:42.440 | So we do need to figure out how to make this tool

01:43:47.440 | something that's gonna be good for us

01:43:51.120 | and not ultimately harmful.

01:43:52.920 | And I don't have all the answers

01:43:55.200 | by any stretch of the imagination,

01:43:57.540 | but I do think some of the wisdom that we have learned

01:44:01.200 | from using other drugs also applies to social media,

01:44:05.200 | which is to say that we have to, again,

01:44:07.780 | put barriers in place that allow us to remain in control

01:44:11.900 | of our use, which means not too much,

01:44:14.640 | not too often, not too potent.

01:44:17.740 | - Do you think in going back to this idea

01:44:19.480 | of the unit of the day being a good tractable unit,

01:44:23.420 | a manageable unit of time for most people?

01:44:25.920 | So you're saying in advance, so allocating two hours

01:44:29.740 | in which you're going to allow yourself

01:44:32.640 | to have free rein use of the phone and all its apps

01:44:35.360 | and all its things, or even more restricted than that,

01:44:38.400 | meaning, okay, I'm only going to allow myself

01:44:41.120 | 30 minutes a day to post and comment,

01:44:43.440 | and then that's a closeout completely.

01:44:46.680 | - Yeah, so I think it depends on the person

01:44:49.180 | and sort of a combination.

01:44:50.080 | We talked earlier about having an itch

01:44:51.880 | and scratching yourself at night.

01:44:53.540 | We've gotten to a point with smartphones.

01:44:55.280 | People are pulling them out

01:44:56.880 | and they are utterly unconscious of doing so.

01:44:59.280 | Pulling them out, a couple texts, a couple,

01:45:02.000 | they don't know they're doing it.

01:45:02.840 | - I have a friend who works and delivers babies,

01:45:06.640 | and many pregnant mothers won't actually deliver

01:45:11.640 | without their phone in hand.

01:45:14.440 | And this used to be the hand

01:45:15.720 | that was connected to their spouse.

01:45:17.000 | This may be a comment on spouses more than on phones,

01:45:20.960 | but it sounds like it's a kind of a security blanket.

01:45:25.960 | - Right, like a transitional object, yeah.

01:45:29.120 | - Actually, that reminds me, you've referred to the phone.

01:45:33.660 | I think it's the phone,

01:45:34.600 | but maybe it's our online persona or ourselves

01:45:38.540 | as we've become sort of infantile in our need for it.

01:45:42.200 | It's like a baby in a bottle.

01:45:44.040 | And so I do wonder if we have regressed,

01:45:46.720 | and I do think we've regressed a bit

01:45:48.480 | in terms of our online behavior,

01:45:51.880 | our inability to act like...

01:45:54.000 | I saw an adult was somebody

01:45:55.400 | that couldn't control their behavior.

01:45:56.800 | That's the difference between a baby and an adult.

01:45:58.400 | You don't have to be a developmental neurobiologist

01:45:59.900 | for very long to understand that a young organism

01:46:01.720 | can't control its behavior and an older one can.

01:46:04.440 | So to me, a mature organism, mature in years,

01:46:08.000 | organism that can't control its behavior is a baby.

01:46:10.440 | It's an immature version of itself.

01:46:13.440 | And there's neuroscience to support that statement.

01:46:16.360 | I look at my own behavior with the phone sometimes,

01:46:19.760 | and I think, "I'm a grown man.

01:46:23.440 | What is the problem here?"

01:46:25.000 | I don't eat baby food,

01:46:28.200 | but I'm acting like a baby with the phone, all right?

01:46:31.580 | In the sense that I'm reflexively picking it up,

01:46:35.520 | I'm not being intentioned and deliberate with it.

01:46:39.520 | Do I need a full 30 days, Anna?

01:46:41.560 | - So, yes.

01:46:43.080 | - 30 days away from my phone?

01:46:43.920 | - As you know, that's my recommendation,

01:46:45.400 | the full 30 days to reset.

01:46:47.160 | If you're severely addicted, I recommend the 30 days,

01:46:50.900 | but if you're just a little bit addicted, like most of us,

01:46:54.000 | you probably don't need 30 days.

01:46:55.280 | In fact, a single day not only would be challenging,

01:46:58.960 | but probably maybe sufficient.

01:47:02.200 | - My phone is off for substantial segments of the day.

01:47:05.360 | - Okay, that's great.

01:47:06.280 | - And it drives other people crazy.

01:47:08.000 | People expect me to respond, but I don't care.

01:47:13.000 | I really don't. - Yeah, right, right.

01:47:14.360 | - And I actually take a little bit of pleasure

01:47:16.860 | in the fact that, well,

01:47:18.000 | because I think the point I'm trying to make

01:47:19.840 | is the right one, which is that it's not just right for me,

01:47:22.040 | but like why, I don't see a clause on text messages

01:47:26.920 | or emails that say must be responded to

01:47:30.240 | within X amount of time or else, or else.

01:47:34.360 | So I take the liberty of replying when I'm able to.

01:47:38.240 | - Yeah, that's right.

01:47:39.080 | - Or want to.

01:47:39.920 | - Yeah, right, but which touches

01:47:41.480 | on one of the big challenges about social media

01:47:44.760 | is that as more and more of us are spending

01:47:47.200 | more and more time on social media,

01:47:49.220 | we're divesting our libidinous energies, et cetera,

01:47:53.160 | from real life interactions.

01:47:55.260 | So that means even when we want to choose

01:47:58.140 | to not be online connecting,

01:48:00.480 | we go outside and there's no there there, right?

01:48:02.900 | There's nobody else there.

01:48:04.720 | So I think our collective challenge,

01:48:07.820 | and it should be our mission,

01:48:10.100 | is to make sure that we are preserving

01:48:13.320 | and maintaining offline ways to connect with each other.

01:48:18.480 | 'Cause if we don't do that,

01:48:19.940 | then we'll be very lonely, right, if we were not online.

01:48:23.920 | But if you have a tribe of folks that you can be with,

01:48:27.940 | none of whom are on their phones while you're together

01:48:31.660 | for that discrete amount of time,

01:48:32.920 | then it's wonderful and liberating and nobody's distracted.

01:48:36.240 | And I think that's really the key.

01:48:38.920 | And I think young people are figuring that out.

01:48:41.860 | They're trying to create these spaces or try to,

01:48:44.440 | let's say instead of doing a dopamine fast by yourself,

01:48:47.200 | do it with your friends, right?

01:48:49.060 | Then there's the FOMO is less, if you're missing out,

01:48:51.720 | because, oh, you're all doing the dopamine fast together.

01:48:54.600 | So these are some of the tricks that we can come up with,

01:48:57.440 | but- - I like that.

01:48:58.280 | - Yeah, okay, good. - I like that.

01:48:59.280 | I don't allow, I have a home gym and I love working out.

01:49:02.740 | I just enjoy it and I always have.

01:49:04.520 | And I don't allow my phone in my gym anymore.

01:49:08.520 | And I live in an area where I don't get any reception,

01:49:11.140 | like two meters outside my door.

01:49:13.040 | So all my dog walks now are just-

01:49:15.200 | And they were boring as hell.

01:49:16.640 | I also have a bulldog, he doesn't like to walk.

01:49:18.160 | It's really slow.

01:49:19.380 | And it was so boring for a while,

01:49:23.160 | 'cause I was so used to taking calls

01:49:24.640 | while I walk and it's super efficient.

01:49:26.500 | Why wouldn't I do that?

01:49:27.600 | The walks now are some of my favorite part of the day.

01:49:32.300 | Because, and if the phone were,

01:49:34.120 | if I were to get a call on one of those

01:49:35.680 | and they brought reception to the area,

01:49:37.040 | I would be very dismayed.

01:49:38.740 | So I can attest to this.

01:49:39.860 | And I don't think I'm a phone addict,

01:49:43.480 | but I do put work into regulating my-

01:49:46.800 | - Yes, so this is the key.

01:49:48.080 | You have to, with intention,

01:49:50.200 | prior to being in that situation,

01:49:52.460 | think of literal physical and metacognitive barriers

01:49:55.860 | that you can put between yourself and your phone

01:49:59.120 | or whatever your drug is,

01:50:00.880 | to create these intentional spaces

01:50:03.380 | where you're not constantly interrupting yourself,

01:50:06.500 | essentially, and distracting yourself.

01:50:08.020 | Because I really do think,

01:50:09.580 | I think we talked just before we started with the interview,

01:50:13.560 | you know, we're losing the ability

01:50:15.960 | to have a sustained thought, right?

01:50:18.860 | I mean, we get so far.

01:50:20.260 | And then you get to that point in the thought

01:50:23.220 | where it's a little bit hard to know what's coming next.

01:50:26.640 | And it's very easy to check your phone or check your email

01:50:30.900 | or look something up on the internet.

01:50:34.540 | And then you never get that opportunity

01:50:36.980 | to finish that thought,

01:50:38.620 | which is really the source of creative energy

01:50:41.180 | and an original thought, right?

01:50:42.720 | You're not just reacting to what's coming at you.

01:50:44.560 | - And something that could contribute to the world.

01:50:46.620 | - That's right.

01:50:48.020 | - I'm a big believer that you're either consuming

01:50:51.500 | or you are creating.

01:50:53.660 | And there is, I should mention, it's important.

01:50:56.800 | I do believe in neutral time.

01:50:58.140 | I think sleep is great.

01:50:59.340 | I'm a big proponent of sleep

01:51:00.700 | and I've talked a lot about it on the podcast.

01:51:02.540 | I care a lot about sleep

01:51:04.740 | and not just for sake of performance.

01:51:06.040 | I actually just really like sleep.

01:51:08.980 | I think that being a constant consumer of visual information

01:51:13.980 | and information of all kinds can be a problem,

01:51:16.860 | but there's some really great sources

01:51:18.980 | of information on the internet.

01:51:20.300 | And I certainly benefit from the fact

01:51:24.380 | that those channels exist.

01:51:26.120 | Narcissistic preoccupation.

01:51:29.220 | Am I a narcissist?

01:51:31.260 | - First of all, there's healthy-

01:51:34.420 | - Or is the fact that I asked, does that take me out of,

01:51:36.820 | would a narcissist never ask that question?

01:51:38.540 | - Oh yes, a highly sophisticated narcissist

01:51:41.140 | would know to do that. - Oh, I see.

01:51:41.980 | Well, I'm not very sophisticated.

01:51:42.820 | (both laughing)

01:51:44.820 | - So there's healthy narcissism,

01:51:46.940 | which means that we all invest our personal energies

01:51:50.360 | into things that we care about.

01:51:52.240 | And if our competence in that arena is threatened,

01:51:54.940 | we would all experience a narcissistic injury

01:51:57.300 | and that's normal and healthy.

01:52:00.060 | But we are living in a narcissistic culture.

01:52:04.340 | I mean, that's not news.

01:52:05.600 | This preoccupation with individual achievement

01:52:08.820 | and individual self-worth and individual self-confidence.

01:52:12.840 | And I think all of that is just fueled by social media

01:52:17.840 | where we're not just seeing ourselves,

01:52:19.760 | but we're seeing people's reactions to ourselves

01:52:21.880 | and every single thing we say or do,

01:52:24.740 | we get likes and this and that.

01:52:26.800 | It's really insidious.

01:52:28.580 | And it contributes, I think,

01:52:30.000 | ultimately to a lot of personal shame

01:52:33.080 | because we're not really meant to be individuals

01:52:36.740 | bouncing around in the universe, we're social animals.

01:52:39.980 | And we're probably generally happiest

01:52:42.960 | even for natural contrarians among us

01:52:45.700 | when we're part of a tribe, right?

01:52:48.180 | And if we do too much to kind of separate ourselves

01:52:51.260 | from that tribe, I think that the brain's natural

01:52:56.260 | and instinctive corrective mechanism against that

01:52:59.120 | is self-loathing and shame.

01:53:01.400 | So it's so ironic because the culture tells us

01:53:06.180 | if we just achieve more, we'll like ourselves more.

01:53:08.760 | But the truth is actually the opposite

01:53:11.200 | that I think when people get these pinnacles

01:53:14.000 | of personal achievement,

01:53:15.600 | you have things like the imposter syndrome or whatever.

01:53:18.720 | - Where you just, we're at Stanford

01:53:21.360 | after a lot of high achievers here, right?

01:53:23.660 | Some phenomenal, amazing people like yourself

01:53:26.640 | and other colleagues of mine that just, I'm always in awe.

01:53:29.280 | Like, it's just amazing.

01:53:30.400 | Like the mean is shifted so high.

01:53:32.240 | And also people who have amazing paths to get here

01:53:35.740 | coming from very little accomplishing so much.

01:53:38.460 | But it's also the pressure, right?

01:53:41.600 | The way that this career was described to me

01:53:45.200 | the day I got my job was one colleague of mine,

01:53:47.880 | the late Ben Baris said, "Welcome to schizophrenia

01:53:50.480 | 'cause you're never going to be able to complete anything

01:53:52.800 | without getting interrupted."

01:53:53.960 | That was partially true, although I've created buffers.

01:53:56.320 | And the other one, very successful scientist,

01:53:59.880 | a member of the National Academy, et cetera, said to me,

01:54:03.020 | "Just remember it's pinball, you never win.

01:54:06.760 | The best you can do is just keep playing."

01:54:09.360 | And I thought, wow, okay, okay.

01:54:13.840 | And then you just go.

01:54:15.360 | But I think that as we achieve more,

01:54:18.540 | not just academics, of course, but as anyone achieves more,

01:54:21.680 | there's the relishing and the accomplishment.

01:54:24.520 | There's often the desire for more,

01:54:26.760 | but there's also the pressure of,

01:54:28.560 | well, now I have to do this for the next 30 years,

01:54:31.260 | even though I love it.

01:54:32.100 | It's the pressure of, well, if the mountain is this high,

01:54:34.720 | then how do I get here and here and here?

01:54:37.140 | And then you start shoveling more dirt on

01:54:38.640 | so you can keep climbing.

01:54:39.520 | And it's a lot of work.

01:54:41.180 | And I think that the perception of success

01:54:44.560 | is that there's a roar of the crowd and you cruise.

01:54:48.100 | You don't cruise, they just give you more to do.

01:54:50.680 | Or you give yourself more to do.

01:54:52.600 | - Well, what I think is, at least in my life experience,

01:54:56.600 | and I've heard this from other people as well,

01:54:59.560 | it's that prize that we're going for,

01:55:03.000 | that if we get it is so unsatisfying.

01:55:07.720 | And it's the prize that we never imagined

01:55:11.080 | that we kind of go, well, how did that happen?

01:55:13.920 | But gee, that feels good.

01:55:16.560 | And so I'm very, it's curious, what's the deal?

01:55:18.280 | - It's like a mirage in the one case.

01:55:20.720 | And it's like a, yeah, it's almost like dopamine

01:55:26.240 | can create these mirages, that there's some place there.

01:55:30.080 | - That's right.

01:55:30.920 | And if I just, it's that pot of gold, right?

01:55:33.280 | - Constant dopamine.

01:55:34.480 | - Right, that's right, that's right.

01:55:36.520 | And I think this really, I think,

01:55:39.200 | is related to our discussion earlier

01:55:41.880 | about this taking it one day at a time

01:55:43.480 | or paying attention to that 24-hour period

01:55:46.800 | in your environment.

01:55:48.560 | I am absolutely fascinated by the ways

01:55:50.840 | in which we accumulate success when we do that

01:55:56.200 | totally independent of the desire for success.

01:56:00.720 | It's really process-oriented.

01:56:02.960 | It's like, where am I today?

01:56:06.480 | How can I make today a good and meaningful day

01:56:09.600 | a little bit better or as good as some other days I've had?

01:56:14.600 | Constantly tweaking and experimenting with this experiment

01:56:18.680 | that we call our human existence.

01:56:21.640 | And when we do that in a way that's authentic

01:56:25.440 | and paying attention and value-driven,

01:56:28.880 | whatever our values are informed by,

01:56:32.440 | it is very, very interesting how those days,

01:56:34.780 | again, accumulate and you find,

01:56:37.240 | well, I guess I contributed something of value there,

01:56:40.000 | but I wasn't trying to do that.

01:56:43.040 | I think that's really, I mean,

01:56:44.880 | what I'm so amazed by is like 20 years ago

01:56:47.720 | when I went to Stanford Medical School 25 years ago,

01:56:50.360 | I was happy to just be a good doctor.

01:56:55.200 | I was like, I guess I'm just gonna try to figure out

01:56:58.000 | how to be a good doctor.

01:56:58.920 | I'm here to learn that.

01:56:59.760 | And now I see these medical students and they're wonderful.

01:57:02.100 | They're brilliant and they're well-intentioned, all that.

01:57:05.460 | But they're like, how can I write the great American novel,

01:57:09.980 | do my startup, go to Africa, apply for that grant?

01:57:14.360 | It's like, really?

01:57:15.480 | I was just trying to learn how to be a doctor.

01:57:17.660 | And as you say, it's a lot of pressure on them.

01:57:20.680 | And it's also kind of a weird leapfrogging

01:57:24.600 | of the real way to accomplish something,

01:57:29.480 | which isn't about like, oh, how can I accomplish something?

01:57:31.980 | It's like, what can I do today that would be of service?

01:57:36.920 | And then finding that of trying to be of service

01:57:39.960 | and not really going for recognition

01:57:43.320 | can sometimes lead to what people call success,

01:57:46.180 | although that wasn't what you were aiming for.

01:57:47.920 | - And it's all the more beautiful

01:57:49.240 | when it's not what you're aiming for.

01:57:50.320 | - Oh, so much better, so much better.

01:57:52.560 | - I'm a big believer that when one can align

01:57:57.560 | their compulsion with some greater good,

01:58:01.120 | a service to humanity or the planet or animals,

01:58:04.080 | whatever it is, that's where the really good stuff emerges.

01:58:09.080 | Because there's a lot of reciprocity there.

01:58:11.680 | The world starts to, you're supporting the world

01:58:14.880 | and then it starts to support you

01:58:16.400 | in a way that feels very fluid.

01:58:17.800 | - And that comes back, right.

01:58:19.120 | And I mean, that speaks to your generosity to me,

01:58:22.160 | vis-a-vis my book.

01:58:24.280 | And I have to say-

01:58:25.120 | - Well, I love the book.

01:58:26.680 | There's like, we're not in a business deal, folks.

01:58:28.840 | It's just purely that I heard Anna lecture in my course.

01:58:31.680 | I wanted to learn more about dopamine.

01:58:33.160 | She taught me, I asked her if she would come on the podcast.

01:58:35.040 | Turned out she wrote this amazing book.

01:58:36.720 | She sent me a man's copy of the book.

01:58:38.840 | I read it in one sweep.

01:58:39.980 | It's incredible and I love it.

01:58:41.700 | So just like the eight-year-old version of me,

01:58:45.260 | now the 45 version of myself,

01:58:48.200 | I can't stop blabbing about the things I love.

01:58:50.520 | - Well, it's awesome, but I have to say,

01:58:52.520 | I have been surprised by your generosity.

01:58:56.700 | It's not something I've encountered frequently at Stanford,

01:59:01.700 | which is a wonderful place.

01:59:03.160 | But there is a general sense that if I give away

01:59:08.160 | to somebody else, I've lost something,

01:59:14.220 | which is not the right way to think about it,

01:59:18.320 | not how you are, and also not how the world works.

01:59:21.600 | 'Cause when we give away to other people,

01:59:24.200 | we get back so much more, but it takes a long time

01:59:29.200 | and it might not come through that path.

01:59:31.920 | - I never think about reciprocity,

01:59:34.940 | but I was weaned by good advisors.

01:59:38.780 | - That's very nice, yeah.

01:59:40.000 | - I think I just sort of got drilled into me

01:59:41.760 | that the more you give, the better your immediate life is.

01:59:46.460 | But I also don't have a long-term vision.

01:59:48.460 | I'm just excited about the book.

01:59:52.820 | I'm excited that people are learning

01:59:55.340 | about the brain and dopamine.

01:59:57.440 | I have to admit, having grown up in neuroscience,

02:00:00.440 | essentially, I did not understand that pleasure

02:00:02.640 | and pain were orchestrated the way that they are.

02:00:05.340 | I'm very mindful of it now.

02:00:07.180 | - Oh, good.

02:00:08.020 | - And it's changed a number of my behaviors.

02:00:10.720 | I know a number of people are going to have questions

02:00:12.620 | and want to get in contact with you.

02:00:14.240 | You are not on social media.

02:00:16.200 | - That's correct, yes.

02:00:17.440 | - You are true to your ideology.

02:00:20.420 | That's great.

02:00:21.680 | - And the reason for that is just,

02:00:22.940 | I wouldn't be able to control myself.

02:00:25.080 | I mean, that really would be my drug.

02:00:26.920 | People are my drug.

02:00:28.260 | Intimacy is my drug, and I wouldn't be able to manage it.

02:00:31.880 | And so it was just easier for me to not do it at all

02:00:35.460 | rather than try to moderate it.

02:00:37.180 | - Well, the book, as you mentioned before,

02:00:39.580 | and as I can attest to, is it has a certain intimacy.

02:00:42.260 | People get to know you through the book.

02:00:43.780 | So definitely check out the book.

02:00:46.260 | If you have questions about the book, et cetera,

02:00:48.780 | you're welcome to send them my way.

02:00:50.420 | I will buffer you from all those questions.

02:00:52.500 | I'll filter them.

02:00:53.500 | Anna, Dr. Lemke, I should be a formal,

02:00:57.960 | forgive me, I've been referring to you

02:00:59.300 | the whole way through. - No, no, that's fine.

02:01:00.700 | - 'Cause we're colleagues,

02:01:01.540 | but thank you so much for sharing this information.

02:01:04.580 | And I know I learned a ton,

02:01:06.820 | and I know everyone else is going to learn a lot more

02:01:09.200 | about addiction and the good side of dopamine.

02:01:12.220 | - That's right.

02:01:13.420 | Thank you for having me.

02:01:14.380 | It's been really, really great to talk with you.

02:01:17.140 | - Great, thank you.

02:01:18.540 | Thank you for joining me

02:01:19.420 | for my discussion with Dr. Anna Lemke.

02:01:21.500 | I hope you enjoyed it as much as I did.

02:01:23.780 | Please be sure to check out her new book,

02:01:26.060 | "Dopamine Nation, Finding Balance in the Age of Indulgence."

02:01:29.480 | You can pre-order it on Amazon

02:01:31.420 | or any places where books are sold.

02:01:33.460 | It's an absolutely fascinating and engaging read,

02:01:36.300 | all about addiction and dopamine.

02:01:38.780 | If you're learning from and/or enjoying this podcast,

02:01:41.540 | please follow us on YouTube by subscribing

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02:02:26.940 | [upbeat music]

02:02:29.520 | (upbeat music)

Dr. Anna Lembke: Understanding & Treating Addiction | Huberman Lab Podcast #33

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