HOW WE'RE ALL BECOMING ADDICTED

By: DR. ANNA LEMBKE & MIGHTY PURSUIT

Dr. Anna Lembke is a global authority on addiction and dopamine. She is the director of addiction medicine at Stanford University, author of the New York Times bestseller Dopamine Nation and was featured in the Netflix documentary The Social Dilemma. In this episode of the Mighty Pursuit Podcast, we talk about how everyone is developing addictive behaviors these days, the problem with avoiding pain and how this is all impacting the mental health crisis. Mighty Pursuit:Anna, thank you for being here today. Dr. Anna Lembke:Thank you for inviting me. I'm excited. Mighty Pursuit:Yeah, it's a long time coming. So, we're just really excited that you flew out here to New York and about this conversation. The first time that I was exposed to your work was in Netflix's The Social Dilemma. And then immediately when I picked up Dopamine Nation in the fall of 2021, I couldn't believe what I was reading. It made sense of so many of the problems, in particular with the mental health crisis, that's going on. And I saw myself so much in that book, even just unassuming, behaviors and tendencies. And then you kind of are able to put a name to it, like, "oh, okay that's what's going on." So I kind of want to kick it off and talk about how a lot of people might hear the word addiction and immediately tune out of the conversation. It's kind of like one of those words, I guess that has a meaning or connotation, in the sense that they might not think it applies to them or it's not really an issue. But like the central premise of your book was that this quite literally is affecting everyone. So can you explain, what exactly is going on here? Dr. Anna Lembke: Sure. And you're right that that is the central premise of the book that we are now living in a day and age when we've all become more vulnerable to the problem of addiction, precisely because we've created a world in which almost all substances and behaviors have become drug-ified in some way, or made more reinforcing. They're more accessible, they're more novel, there's more of them. And also, there are so many behaviors now that we can get addicted to, you know, people really didn't think about before. You know and obviously, our digital devices themselves. You know, the digital media that are transmitted through the devices. These are all highly reinforcing. They light up the same reward pathway as drugs and alcohol, such that now these sorts of behaviors that are so deeply interwoven into our everyday life, have the potential to have us engaging in this compulsive way. Mighty Pursuit: Yeah I mean, one of the things that really struck me is you were talking about how we've moved from a place of scarcity for most of human history now to a place of abundance. And so there's kind of been this, like seismic shift, particularly in the last 20 to 30 years. So can you talk about kind of what's changed there, like the different things that have been introduced and how that's different from generations past? Dr. Anna Lembke:Well, I mean, I think one of the important things to realize is that when we're looking at risk factors for addiction, there are many different risk factors, right? There are inborn genetic risk factors. There are risk factors related to the way that were raised. But one of the biggest risk factors that people simply don't consider is access. If we have access to a drug, we're more likely to get addicted to that drug just because we're more likely to try it and it will change our brains over time. So, I mean, what we have access to now is so many different reinforcers, right? I mean, we talked a little bit about digital media and digital drugs. These are highly reinforcing. Dr. Anna Lembke:But food, for example, has become more reinforcing with the addition of salt, fat, sugar or flavorings. Such that now when we're eating, it's very difficult to manage our appetites and stop when we're simply at the point when we have what we need. Instead, we want to keep eating beyond that. And that is because food has become drug-ified, right? There's sugar in it. Sugar lights up the nucleus accumbens, which is part of that reward pathway. So, you know, food is a really good example. Work has become drug-ified, right? When you think about the access that we have to work now, it's kind of 24/7. We can never leave it behind. People can contact us wherever we are with whatever we're doing. Work has been made more potent by reinforcers like bonuses or stock options, at least for people in white collar work. That's not so true for people in jobs that are not high paying. And what you see in those folks is more and more of those individuals are dropping out of the workforce or never entering the workforce. In large part because the work is separated from the meaning of the work or the final product. So, yeah, there's this sense of alienation, and especially young men are not entering the workforce and/or are dropping out of the workforce. And some data suggests that they're spending a lot of their time playing video games and online. So, I mean, if you think of it, it's become drug-ified in some way. Mighty Pursuit: Yeah. It's interesting. One of the other guests we've had on this podcast is Doctor Marion Nestle, who is one of the top food researchers in the world. She's a nutritionist and molecular biologist. And so she was talking about the idea of food, to your point that companies have intentionally created these products so that there's like a bliss point, right? Do the companies behind these products are actually the ones that are like engineering them to be addictive. That thruline that I saw in The Social Dilemma with all the work that you do that and what they're talking about is there are actually companies digitally as well, they're trying, in essence, to get you addicted, maybe you wouldn't use that word, but it's hacking into human psychology, and understanding the reward pathways. And creating things that will literally get people hooked. And so, yeah, can you speak to that a little bit? Dr. Anna Lembke: Yeah. I mean, because we really do understand the biology of the reward pathway. And because psychologists have spent so much time analyzing what is the sequence of events that get somebody to persist in a certain behavior, tech companies have hired neuroscientists who understand these basic mechanisms and intentionally use that science to inform the creation of their -- Mighty Pursuit: So they actually hired scientists on the payroll? Dr. Anna Lembke: Yes. It is well known that they hired neuroscientists on the payroll to help them understand how to keep people engaged on their platform or on their site. And so there are a lot of little ways that this is done. You know, through the bottomless balls, through the push notifications, the alerts. Which, by the way, are reinforcing in and of themselves and then create a state of craving, which then makes it almost impossible not to pursue that final product. The tracking is a huge part of this. So seeing what people have liked before, where they've spent their time and then push notifying them similar digital media or digital products in order to engage that kind of treasure seeking function. Looking for something. You know, another reward. So, yeah it's well known that both the digital devices and the platforms were really engineered to be addictive. Mighty Pursuit: I mean, if you think about, you know, what are we in 2024? If you transported back 100 years to 1924, you wrote in your book that our brains are not evolved for this world of plenty. So like, none of these things existed. And even if you think about our food supply, like the way that our food supply has been kind of hacked into is a very different food supply than 100 years ago. And so then all of a sudden you start getting this picture of what exactly is happening. And so how do you feel like this is impacting our day to day life? Dr. Anna Lembke:Well, what it means is that we are essentially bombarding our reward pathway in ways large and small, throughout any given day. And I think in many ways, modern life, we almost organize our lives now around these rewards, whether we do it consciously or unconsciously. You know it starts with reaching for our phone first thing in the morning to see what came in, then the caffeinated beverage of our choice, and then what we listen to throughout the day, the breaks that we take to watch YouTube videos or whatever it is. All the way to the pot that we smoke at the end of the day, or the glass of wine or the shows that we watch. They're all basically potentially equivalent. Dr. Anna Lembke:So all addictive substances work on the same common pathway. They all release dopamine, which is our pleasure and reward neurotransmitter. I think the net effect is that we are just essentially bombarding our reward pathway all day long with dopamine. And as a result, our brains really were not evolved for this much pleasure. We were really evolved to have to work very hard, walk tens of kilometers every day in order to get even a small bit of something to eat or to drink or to find another person to socialize with. And today, that's all just so easy and so abundant and so potent. So I think our brains really are effectively reeling from this kind of firehose of dopamine that we're getting. And I do think it's causing real physiologic changes in the form of a kind of chronic dopamine deficit state, which is very similar to clinical depression or anxiety. So when I think about our mental health crisis today and why it is that so many more people are struggling with depression and anxiety, I do think it can be partially explained by this kind of dopamine overload or reward overload, pleasure seeking, and the ways in which, our ancient wiring really was not involved for this kind of environment.

DEFINING ADDICTION

Mighty Pursuit: It's interesting, if you parallel the chart of the mental health crisis and suicide rates and all this stuff, if you parallel it with basically everything you're talking about with the age of social media, it's like a straight up chart in the advent of social media. And so how would you define addiction? Dr. Anna Lembke: So addiction is the continued compulsive use of a substance or a behavior despite harm to self and or others, and that sometimes harm that we see and sometimes harm that we don't see, that others see before we see. Mighty Pursuit: I think the keyword in the definition and then the follow up that you're talking about, the keyword is harm. And so there's obviously varying levels of harm, right? Would you say that it's accurate that most people are unaware that they're harming themselves? Dr. Anna Lembke:So I think the harm can be very subtle. And most of us are not aware of those subtle initial harms. But I also think it's important for people to realize that the harms can be life-threatening. So we know patients who are suicidal, because of their inability to control their consumption of the internet, technology and digital media. So it really spans the full range. But yes, most of us, we're on the sort of mild end of things. And the harms are extremely subtle, and often we don't recognize those harms until we get some distance and we stop -- Mighty Pursuit: From the substance or drug? Dr. Anna Lembke:From the drug, from the device. If we're talking about digital drugs or whether we're talking about drugs that we put in our mouths or smoke or drink or whatever. It usually takes a period of time away for us to really see sort of true cause and effect. Mighty Pursuit: It makes me think about just even very real-time for myself. So having some stomach issues, I was diagnosed with SIBO, which is like Small Intestinal Bacterial Overgrowth. So the reason why I'm bringing this up is because I had this whole routine, like every day I would get up in the morning and I would have a coffee. And then at some point later in the day, I would just have a piece of toast with peanut butter and a little jelly on it. And these are all good ingredients or organic ingredients. And then at some point in the day, I would also have some kombucha and I developed this rhythm of doing this every day. And I would kind of notice, I guess, that I would feel good when I do these things. But when I developed [the SIBO], I needed to kind of fast from almost all of those things. The crankiness and the irritability and then almost I feel like you subconsciously look forward to those moments in the day. Like, oh, I'm going to get a little high from doing this, or I'm going to get a little piece of comfort. And at a certain point it's like you feel like you're actually becoming a slave to that. And I mentioned this example because when I've talked to other people about it, it's kind of unsuspecting. It's just kind of like oh, peanut butter and coffee. But you had an example in your book of romance novels – Dr. Anna Lembke: Right, yeah. Mighty Pursuit: And so literally you could kind of develop this with anything. I would say, almost. Dr. Anna Lembke: So I mean, I think it's always important that we don't sort of trivialize severe addictions, whether it's to drugs or whether it's to behaviors like sex or gambling or video games. And so, you know, obviously the sort of ways in which we habitually orient ourselves around things like what we drink and eat in a day that certainly can lead to a serious addiction. But I think the point that you're making, and correct me if I'm wrong, but I think the point that you're making is just how much our brains really are little alarm clocks when it comes to these reinforcers. Mighty Pursuit: 100%. Dr. Anna Lembke: That's really, really true. So, for example, when we're working with patients who are trying to get off of benzodiazepines like Xanax, and often people will dose multiple times in a day. Two times in a day. Three times in a day. They've been doing that for weeks, months, years. As we go down, what we generally do is instead of eliminating one of those times in the day, we go down by a little bit on the dose but maintain the same schedule. And the reason that's important is because, again, our brains are like, "oh, it's, you know, 12:00, I need to have my Xanax or I need to have my peanut butter or, you know, whatever it is." We are amazingly sort of like, we have this sort of rhythm around these substances and it's a very powerful drive. So when that time comes, you know, if we don't get to see our drug, the brain really rebels and kind of says, "No, no, you need to do this now. You need to do this now." So the timing of these things is really important. Mighty Pursuit: Is there like a depressive effect that happens if you don't give your brain whatever it is? Dr. Anna Lembke: Well, I mean, yeah, if you think about depression in a way, as a state of craving or akin to a state of craving. I mean, the universal symptoms of withdrawal from any addictive substance or behavior are anxiety, irritability, insomnia, dysphoria, craving. So there is this kind of, you know, the brain saying you need to consume this now. It's a really uncomfortable state. It's a craving state. And it's something that our brain essentially says this is important for your survival. So this is non-trivial, right? And we can have to a very small degree, those kinds of urges around something like our peanut butter sandwich. Now it's not the same thing as something like heroin that we're used to. It's not going to be as powerful and intense. And again, that's the difference between things that are very, very addictive. And things that are not as addictive. But also important to qualify that different people are going to find different things addictive. You know, what’s really reinforcing for you and your brain may not be so much for my brain and vice versa. Mighty Pursuit: I think that's really important. Obviously, like with my example, I think you're speaking to the varying levels of extremity and the harm in which it will do to you. And I think that on the most extreme level, obviously it's severely debilitating. Whereas in my example, which I feel like could be true with a lot of people on social media or whatever, it’s kind of a little cloud that's hovering over you. You're not living life to the full, you kind of feel a little handicapped to the thing that you're just consuming. And then it kind of brings to mind the question of like, well, what would life be like if I just didn't use social media for the next month? And then just having to deal with that reality. So I think the point that you're making is like, so it would appear then that there are certain substances that are more addictive than others. And if I'm understanding the science correctly, it's because the more dopamine that is delivered to the brain's reward pathway, the more addictive the experience. And so would that mean that it's true that like if you're using heroin, there's just like a crazy amount of surge of dopamine that goes to the brain or am I kind of misinterpreting that? Dr. Anna Lembke: No, you're doing a great job. Mighty Pursuit: So, would you say that certain substances create higher highs? Like drugs? Dr. Anna Lembke: So in general, things that we think of as intoxicants, are intoxicants because they release a lot of dopamine all at once in the reward pathway. So for example, something like heroin is going to release a lot more dopamine than something like broccoli. In fact, if you don't like broccoli like me, then it probably won't release any dopamine at all. On the other hand, if I hadn't eaten for 2 or 3 days and I was really hungry, and you gave me a piece of broccoli, that would most certainly elicit some dopamine, right? Because it's going to now try to bring me sort of back out of that hunger state. And also, it is important to keep in mind the drug of choice. So for some people, opioids in fact may not be reinforcing. They may cause so much nausea or other discomfort without enough of the euphoria or relaxant effects that they may not be interested in using opioids again. And so it is important to remember this drug of choice concept that generally what's intoxicating for most humans is the things that release a lot of dopamine all at once. But it's not every single human. So our brains are different enough. Mighty Pursuit: So there's an individual effect to it? Dr. Anna Lembke: Yes.

FULL LIST OF MODERN ADDICTIONS

Mighty Pursuit: I think it was on the Andrew Huberman Podcast. But I heard you say that.. so is it true that social media is on the same level as some drugs in terms of its addictive potential? Dr. Anna Lembke: What we know about social media is that it does light up the brain's reward pathway. So the same reward pathway is drugs and alcohol. And, you know, the medium itself is reinforcing the fact that it's a way to make connections to other humans, which we know is something that releases dopamine mediated by oxytocin, the love hormone, which is reinforcing. So it's both the human connection and the medium through which that connection is made. Social media has essentially distilled human connection down to its most reinforcing elements. Plus we have this sort of immediate control over it. And that also adds to the addictive potential, the fact that I can use this substance or behavior to immediately change the way I feel, and that I have control over it at the moment. That's a big part of the addictive process. But what we don't actually have, as of yet, we don't have measurements for how much dopamine is released or how it compares to other types of reinforcers. Mighty Pursuit: To make things super practical, obviously there are a lot of things that you can get addicted to, or even develop like a dependance on. And so just to kind of go over like the high dopamine stimuli that surrounds us. There's things that would be relatively obvious to people. And I feel like throughout history it's like, oh yeah, that would be an addiction. So you know, drugs, like heroin or cocaine. Alcohol. You mentioned gambling was another thing. And I think those are more of the commonly accepted things. I think there's a lot of confusion around weed in our society. I can't tell you how many conversations I've had with people where it's like weed has no addictive qualities. Which could be true for some people. They could just get off it. So, what is the deal with weed? Dr. Anna Lembke: Yeah, so this is a really unfortunate misconception out there in the world that cannabis, weed, marijuana, whatever term you want to use, is not addictive. And this is just simply not true. I think that this originates from this idea -- which is a false idea -- that says that in order for something to be addictive, you have to have kind of a life-threatening withdrawal from it. So on that same note, people will say this about psychedelics. Oh, psychedelics aren't addictive because you don't have a come down or a life-threatening withdrawal. Alcohol is addictive because there's a potential for a life-threatening withdrawal. But if I drink a lot and I don't have a withdrawal beyond a mild hangover, I'm not addicted to alcohol. And that is simply not true. Because the criteria for addiction are related to the signs and symptoms of physiologic withdrawal. But you don't need to be physically dependent or have physiologic withdrawal in order for something to be addictive. Again, addiction is the continued compulsive use despite harm. And when we talk about the behavioral aspects, we talk about it's kind of the three C's. Dr. Anna Lembke: So control. So out of control use, repeatedly planning to use a certain amount. And repeatedly using more than intended. We talk about compulsions. That's a whole lot of mental real estate occupied with thinking about the drug. Planning on using it, how to overcome it or hide use. A level of automaticity around use. Like I reach for my phone without even realizing I was doing it. And then of course, the third C is the continued use despite consequences. So none of those, none of those three C's -- control, compulsions or cravings -- has anything to do with physiologic dependance or withdrawal. Now, most people or many people who use substances like alcohol, cannabis, opioids will also develop a physiologic dependance. Which is manifested not just by a life-threatening withdrawal, but by the subtler symptoms of withdrawal, as well as in anxiety, irritability, insomnia, dysphoria and craving. And I have yet to meet a person who uses cannabis daily who, when they stop, doesn't experience some degree of anxiety, irritability, insomnia, dysphoria and craving. That's withdrawal right? Also tolerance is another marker of physiologic dependance needing more of a drug over time to get the same effect. Finding that your drug at the same dose isn't working as well as it used to. We see that all the time. Mighty Pursuit: So you need more of it? Dr. Anna Lembke:We see that all the time with cannabis. So in other words, let me just kind of backup and clarify. Cannabis is addictive. The data show that something like 15% of people who use cannabis will go on to develop a cannabis use disorder or a cannabis addiction. The manifestations of a cannabis addiction are continued compulsive use despite harm to yourself and or others. That harm can be very subtle, as in not motivated, not doing things or experiencing more anxiety, irritability, insomnia, dysphoria. It doesn't need to involve physiologic dependance, but it often does in the form of tolerance, needing more over time to get the same effect and withdrawal when we stop. Not life- threatening withdrawal because cannabis usually doesn't have a life-threatening withdrawal. But the more subtle universal symptoms of withdrawal, which are frankly psychiatric and again, anxiety, irritability, insomnia, dysphoria, craving, as well as in cannabis, a kind of hyperemesis syndrome. So people will sometimes use cannabis to help with nausea. But in fact, as with all drugs, over time the brain adapts, it stops working, and then it can turn on us and do the opposite of what we want it. And that happens with cannabis when it comes to nausea and vomiting. It can actually make people, over time, start to have a vomiting condition called the hyperemesis syndrome, or especially when people try to stop initially their vomiting gets worse. And it's not till they have a sustained period of abstinence that they finally get that that problem improves. So, I mean, we see so many people in our clinic addicted to cannabis. You know, lives really diminished by the use. And we're especially concerned about daily use, and especially since cannabis has gotten to be such a potent drug. I mean, now you're talking dabbing, 90% THC, very different drug than it was 30, 40 years ago. Mighty Pursuit: Yeah, I think I think it's interesting because of the public perception around some of these ideas. And you mentioned psychedelics as well. So we're talking about it's kind of like, oh, well, it comes from the ground. It's like a plant or whatever. To the average person who knows nothing about addiction medicine or neuroscience or whatever, it's like, wow, that's pretty convincing. It does come from the ground. You know there's a plant there. It must mean that it's natural. And so then that means, it's totally fine and good to use this or it's not addictive. And so can you speak to the idea of --- because the digital addictions, literally are kind of being engineered – but when you think about something being natural, can you speak to that aspect a little bit? Dr. Anna Lembke: Well, I mean, there's natural and then there's what we do with nature. So I think if you look at the history of opioids, for example, they're a great example of sort of something that's natural. So originally we got our opioids from the poppy plant in the form of opium. But, in the early 1800s, scientists discovered that they could make a more potent form of opium with certain manipulations in the laboratory. And they came up with morphine, and morphine is about ten times more potent than opium. And then if you follow the trajectory or the history of opioids through time, what you see is ever more potent versions. So heroin was invented in the late 1800s. It's the addition of two acetyl groups to morphine. Acetylated morphine, that was supposed to be the non-addictive form of morphine that led to, heroin epidemic of the early 1900s called narco-mania. And then over the 1900s, what you see is progressively more, more and more potent forms of opioids. Now we have fentanyl. Fentanyl is 50 to 100 times more potent than morphine, and it's responsible for two-thirds of the opioid related overdose deaths that we're seeing in the country today. As part of the ongoing opioid epidemic that started in the late 1990s. And by the way, fentanyl doesn't require any plant precursors. So we went from needing to grow poppies, harvest them, and then process them to fentanyl where you don't need the plant precursor at all. So that's just sort of one example of the way that technology has contributed to this progression of ever more potent forms of drugs that occur naturally in nature. Mighty Pursuit: So it's manipulating nature, essentially? Dr. Anna Lembke:Right. In a way that's predictable. Like making it more and more potent and that's also affecting and accelerating our progression toward addictive use of those substances. Same thing with cannabis, right? We now have all kinds of ways to process cannabis to make it much more potent than previously. It's also true if you look at something like pornography. So pornography has existed for millennia. In various forms. But we now have ever more potent forms, now you can get it on the internet, and it's like live human beings. Mighty Pursuit:Yeah, it's not the same thing as a magazine. Dr. Anna Lembke: No, no, the magazine that you had to go steal from your friend's older brother by finding it underneath the mattress or whatever. Mighty Pursuit: And that's just a picture. Dr. Anna Lembke: Yeah, now any kid with an iPad who puts in a certain query can have access to -- Mighty Pursuit: Which speaks to the access thing again. Dr. Anna Lembke: And we're talking moving images, right? And people actually connecting themselves up with electrodes to the internet and having other people manipulate them. So this progression from sort of intoxicants or stimulants or reinforcers that have become ever more potent over time, you can track that again for almost everything that we consume. Mighty Pursuit: That gets kind of into the next segment or category of addictions, which I feel like has been less obvious to people, but now it's becoming more awareness around this. You know, you have social media, smartphones. You just mentioned porn. Netflix, on-demand TV. It's interesting, even when you think about the progression of episodes with on-demand TV and the way that they just drop off and then there's these little elements of like how you have the little time thing going on in the bottom right corner. And that's encouraging more and more use. More and more compulsive use. One area that I wanted to ask you about, is it possible to get addicted to people? In the sense of, I'm thinking about the honeymoon phase in a relationship. And so it literally feels like a drug at some point. And so it's on your mind all day long. Especially if there's a physical component to the relationship when you first meet somebody. And so what's going on there with that whole thing? In terms of people. Dr. Anna Lembke: So anything that's reinforcing for the human brain has the potential for addiction. And definitely making intimate human connections releases dopamine. We know that oxytocin, our love hormone, binds to dopamine releasing neurons in the nucleus accumbens and the reward pathway. And that's why falling in love feels really good. And of course, it makes sense from an evolutionary perspective that our brains would want that to feel good because we need to fall in love in order to make the connections that allow us to procreate and propagate the species. So all of this is very logical and makes sense. And unfortunately, that also means that there is the potential to get addicted to other people. And it's a well-recognized sort of the broad category of sex addiction is love addiction. For some people it's more about the sex, but for others it's really more about the conquest. Dr. Anna Lembke:Or if you look at the whole area of codependency, which is this idea that really originated with the founding of Alcoholics Anonymous, founded by a group of individuals who themselves were alcoholic and came together to help each other. And then typically these were men. This was the 1930s and their wives started their own group because they recognized that in a kind of maladaptive way, they were enabling their loved ones' addiction. So although it seemed, on the face of it, that they were doing things to try to help, really their behaviors were ultimately making things worse. But I think, more importantly, the key about codependency is the way that, for the codependent individual, they actually get addicted to the person, and that person then becomes a means by which they modulate or regulate their own emotions. And so let me just qualify this by saying, integral to any relationship is mutual need. Like, if we didn't need each other, there would be kind of no reason to be connected, you know. So being emotionally present, caring about each other and being affected by the other person's behaviors, that's all natural and good and part of being in a relationship. But what happens when we get addicted to a person is that we essentially use that person, often unconsciously, as a way to sort of manage our own emotions. And independent of what's actually good for them and what's good for us. Mighty Pursuit: I think where it becomes problematic and I'm speaking just from firsthand experience here. So I've been in this boat probably three times when you feel like something's wrong. So you have this, I guess like maybe a 12 to 18 month period of just being head over heels, like on the moon, just such feel-good emotions. And then I feel like some people end relationships and feel like it's not good for them because all of a sudden that feeling isn't there. And we're gonna talk about this later, but the whole idea of happiness in our society and the idea of, if something's not making me feel good, then it's bad. Or like relationships bad for me. Or this shouldn't be the way that it is. And a lot of people use terms like chemistry or whatnot. That's not really a good definition of what love is. Love is far more of an action than it is a feeling. Although feelings can accompany that. But if I don't want to take out the garbage or do some sort of act of service, the fact that I go and actually do that is indicative of me making a self-sacrificial act to show the love rather than the idea of being addicted to a feeling from someone is kind of like what they can do for you. And so what do you think about that whole kind of equation? Dr. Anna Lembke: Yeah, you described that really well. You know, I mean, romantic love is like a drug. And so like any drug, you know, with repeated use, it eventually stops working. So that means that for a relationship to last through time, for many years or decades, we can't expect that it will ride exclusively on those early feelings of sort of overwhelming, intoxicating, romantic love. That's what gets us to sort of make the leap to want to commit to this person for the long haul. But absolutely that kind of infatuation eventually dissipates. And then, what you're left with is a different phase of the loving relationship, which is more founded on things like mutual respect. And mutual investment and you know, giving and generosity and all those things. And it takes work. I mean, initially this work just feels effortless because you're just in this state. Mighty Pursuit: Yeah, because it's doing something for you chemically. Dr. Anna Lembke: Yes, right. Because you're essentially high and you're completely obsessed with that person and infatuated. But as that dissipates, in order to maintain that intimacy and that love, it requires an ongoing investment. Including doing things that you don't always feel like doing. So if we're just invested in maintaining that intoxicated state, I mean, we're not really going to be able to be in a relationship with that person continuously. And so this is what happens with sex and love addiction is exactly that, that after that romantic love goes away, people lose interest and then they look for a new love object to generate those feelings again. And so, you know, insight and awareness for people who have that pattern is that they are essentially using people to change the way they feel. They're not really investing in a relationship with another human being, because investing in that relationship means continuing to cultivate intimacy, which requires behaving in certain ways that don't always feel good. Mighty Pursuit: I think what you're speaking to is the maturation of a relationship in a sense. And I don't want the audience to get confused and say that you won't experience feelings of intense love or attraction or I don't know, eroticism or whatever, but the idea that is just going to be like the constant, where it's kind of like a curve. It's like an up and down, you may feel those things at any given point or you may not. And so I think that's really interesting -- I don't know if you're familiar with Dr. John Gottman in Seattle. He's probably the top relationship scientist / expert. He's been studying relationships for 40 plus years. And so he runs this thing called the Love Lab in Seattle, and he famously can predict divorce with a 94% accuracy. So he'll have couples come in there, and then can track their relationship over time. And so I just think when we're talking about science and what you're talking about. It's literally the same exact thing of what he's saying, of the different phases of relationships and the failure is in people that can't advance past that first phase because they were so addicted to the feeling, and now they just can't mature into the next phase of what it actually means to have a lasting relationship. And so I thought that was really interesting. Dr. Anna Lembke: I mean what's coming to mind now for me is, in my work with patients with severe sex addiction who are in recovery and often this is men, older men who are married and want to figure out how to recapture intimacy, and sexual relationships with their spouse, with their wives, typically, without really engaging in the kind of behaviors that were part of their sex addiction. And it's really hard to do because a big part of sex addiction is also fantasy. You know, that's sort of part of it. And also the precursor. And of course, when you're dealing with those kinds of potent sexual experiences, then kind of run of the mill intercourse with your spouse of 30 years or 20 years or 10 years or a dozen years, whatever it is, it's hard. Right? And it's such a struggle because, you know, even the urge to have fantasies about someone else while being with the partner. Feels like part of the problem, right? That they're not fully present for the partner. And I remember one of the individuals I was talking to who told me that a trick that he had learned that really helped him was that he kept his eyes open during intercourse. Which I just thought was kind of powerful and interesting. It was like his way of just being fully present with his spouse. Right? Dr. Anna Lembke:And it just speaks to like all of the different images and experiences that pass through our brains. And kind of the potency of sex and then how to kind of preserve intercourse with our spouse 10, 20, 30 years into the marriage and still have it be a beautiful thing. And it's just, people need to recognize it just changes. The shape of it changes. And that's sort of the intensity of that erotic love from early on just becomes something more akin to the love that comes from deep loyalty and deep trust. And, you know, all of the exchanges, all the memories, but experienced in the mind and the body then just in a very different way. And I think there just needs to be more discussion and also room in our culture for this sort of evolution through time with our partner. Mighty Pursuit: This wasn't in my notes, but what you're talking about really came to mind was like dating apps. Dr. Anna Lembke: Very addictive, let me just say. Mighty Pursuit: So we already talked about the fact that there's companies that are engineering these products to make them addictive. And then we just talked about the brain on love. And now you have this kind of third component when it comes to dating apps, which is especially something like Tinder. So you're swipe, swipe, swipe, swipe, swipe. And it's like, are they attractive? Not attractive? Attractive? Not attractive? And so with your expertise, what would you say about just like dating apps in general, the addictive potential, what that does for like relationships and setting up relationships and whatnot? Dr. Anna Lembke: So we talked a little bit about how part of that early erotic love is the pursuit, right? And the uncertainty, you know, do they like each other and then sort of the culminating in the physical intimacy. And what dating apps have essentially done is they've drug-ified that whole pursuit phase of it so that the reward that people get from the searching and then being chosen or choosing someone else becomes a big part of the reinforcing aspect of it, because it's just so fast and there are so many images, and you can go through that process again and again. When you think about sort of how humans used to have to find partners. I mean, you had to leave your house. Yeah. And then you had to go talk to people, or maybe you even had to find people, right? Like there weren't that many people. You had to go find the people, and maybe you had to walk really far to find them, and then you had to talk to them. And maybe there were moments of anxiety or frustration, or maybe they really weren't that good looking or interesting, but sort of, that's what you got. And that's what you presented as well. Now, gosh, I mean, it's just, you go on these apps and all of the infinite people and they're beautiful or whatever, interesting, rich, smart. We see so many people who are really exhibiting serious addictive behaviors with dating apps. And then, of course, it ultimately then over time leads to hookups and casual sex. And then on to the next person. Mighty Pursuit: So you have people coming in with that? Dr. Anna Lembke: Oh yeah, absolutely. And then meeting strangers and having sex and then having to come down from that and then swearing they'll never do it again. And then the next weekend going on there again. And so it's hard. But at the same time it is the way people meet each other now. So you can't throw the baby out with the bathwater like that's -- Mighty Pursuit: It's just these large societal changes. Dr. Anna Lembke: It's how people meet other people. It's how people signal to other people that they're interested in a relationship, that they're available. You know, it's hard to know if you meet somebody in a bar, at a restaurant, at a party, like are they single or are they not single? Are they interested in me? So it's become a way to kind of mechanize that whole courting ritual. But you know people can get addicted to the courting ritual part. Mighty Pursuit: Just to finish off the list with the high dopamine stimuli, obviously we're talking about people, we talked about food a little bit. And then by extension, I guess caffeine fits into that. Then there are these kinds of celebrated addictions. And the first thing that comes to mind really is work. Mighty Pursuit: I mean you live in Silicon Valley. So many tech companies. I think it was Marissa Mayer, who was the Yahoo CEO for a while. She had this famous quote about how she could work 130 hours in a week, and she had a baby. But then like, she was like in between like the baby and so it's like -- Dr. Anna Lembke: The nanny would go to work with her. Mighty Pursuit: And then you think about Elon Musk talking about a 100 hour work week or whatnot. And so it's almost like a desirable pathway and trait that means something about my identity and who I am and my self-worth that I am putting in all of these hours. And so can you talk about what is actually happening behind the scenes in terms of a work addiction? You know we talked about relationships, but how is it that we get addicted to our work? Dr. Anna Lembke:Well, you know, again, I think always keeping in mind the definition of addiction, the continued compulsive use despite harm to self and or others, and recognizing that some of that harm can be in the form of opportunity costs. So other things that I didn't do, because I was spending all my time doing this, and when we see work addiction, if we're going to call it that, it's people coming in just expressing a lot of regret about the many years they spent working and overworking instead of spending time with family, spending time with friends, cultivating hobbies, traveling, pursuing a spiritual pathway, as well as some of the immoral behavior that they may have engaged in, in pursuit of these work accolades or work related rewards, professional accolades. Dr. Anna Lembke:So I think that's the way that it usually manifests in clinical care. When we talk about sort of the drug-ification of modern life. Work has also been drug-ified. We talked about this a little bit. But, you know, again, it's more accessible, it's more potent, especially for white collar work or more prestige like finance jobs. People can earn a lot of money because then you've got like, power and fame wrapped up with material gain. So whereas people who don't have those kinds of jobs are, again, opting out of the workforce. So, yeah, it's really a tricky one because as you say, our culture really celebrates workaholics, you know, people who do nothing but work. I mean, young people now, who do they look up to? Yeah, it's people like Mark Zuckerberg and Elon Musk, but I think what many people know who have lived that life is that it's not necessarily ultimately, the most rewarding kind of existence is. Mighty Pursuit: So, I mean, there's an alcoholic, but you used the word workaholic. Is that actually a scientific thing or is that more of a cultural term that we use? Dr. Anna Lembke:Again, I mean, the DSM. So we diagnose addiction. We don't have a blood test. We don't have a brain scan. It's a complex biopsychosocial disease, and it is partially based on cultural norms. For example, why on Earth, alcohol and nicotine are legal drugs, but other drugs that are potentially maybe less harmful are not legal drugs. So there's a lot of interaction between the drugs we use and sort of cultural norms around use. So yes, because working and working hard is a cultural norm and celebrated. We don't generally recognize that as an addiction, but anybody who lives with somebody who is a workaholic, can tell you some of the costs, usually it's relationship costs. And then again, we do see in clinical care, we do sometimes see people coming in who want to specifically work on that aspect of their lives. Mighty Pursuit: Yeah, that's really interesting. I think going back to the definition of addiction and that keyword of like harm. So can you speak to like you're talking about opportunity cost, the different ways that you've seen harm? And then there's obviously like severe life-threatening withdrawal from a drug. And so can you speak to the different forms of harm that you see arise from addiction? Dr. Anna Lembke: From work addiction? Mighty Pursuit: Addiction in general. Like it doesn't matter what kind of thing you're addicted to. Dr. Anna Lembke: So I mean, the categories of harms are very broad to physical harms. You know, people end up with organ damage, including organ damage to the brain. People end up with interpersonal harms, damage to their most important relationships, damage in their work life, damage in their school roles if they're students. There are spiritual harms, you know, the moral injury when people get deep in their addiction, they can often lose their moral compass and engage in behaviors that they otherwise wouldn't engage in. What I find, perpetually fascinating, in the clinical care of people with addiction is how personality disordered they look when they're in their addiction and how when they get into recovery, they really don't manifest those kind of pervasive character defects that we associate with personality disorder. They can be very grounded, humble, kind, and generous. It's really like a personality change. Mighty Pursuit: It's interesting because when I think about harm and addiction, where my mind runs to immediately. Even friends or family members that were drug addicts and then trying to get off the drug. And there's this crazy withdrawal process physically that's happening where they get very sick. And so, we've covered digital stuff. We've covered food, work, whatever people. So is it true that you can actually experience withdrawal from the full breadth of all these things? For example, like withdrawal from, "okay, I'm working 80 hours, now I'm cutting back to 30." Is someone actually experiencing a form of withdrawal there? Dr. Anna Lembke: We do see a form of withdrawal again, as I always like to say, the universal symptoms of withdrawal from any addictive substance or behavior are actually psychiatric or psychological symptoms. So anxiety, irritability, restlessness, depressed mood, craving in the form of intrusive thoughts. So people who, stop I mean, I think a lot of people can relate to this just going on vacation right? In the first 2 to 3 days, I think there's a comedown for a lot of people where they're sort of having to shift gears from work and adjust to doing less. Adjust to being less stimulated by their devices. I mean, those are all sort of subtle forms of withdrawal. It's also true that we see actual physical symptoms of withdrawal in people who, for example, stop compulsive masturbation. So, people who are trying to get into recovery from a sex addiction, we recommend no orgasms with themselves or others for 30 days to start. And some of those folks will talk about headaches, nausea, vomiting, stomach ache. Same thing with gaming disorders. So people who stop video games for 30 days, which is, again, our early first pass intervention, will have sweating nausea. So people can have physical withdrawal, including from other things that aren't substances that they ingest. Mighty Pursuit: Could you share with the audience the example that you had in your book about the fantasy novels? Because you talked about there being like a withdrawal process from that. Dr. Anna Lembke: Yes. Absolutely. So yeah. So in my early 40s, I started reading romance novels for whatever reason. I've been a reader all my life, but that wasn't a genre that I had read in my youth. And it started with The Twilight Saga, which is a vampire romance novel, and it was just very transportive for me. It just took me into this very engaging fantasy life that was beguiling and bewitching. And I read all four of the books within a month or something. And then I went back and read them again and read them again. And, you know, then I started to think “God, are there more vampire romance novels?” And turns out there was a whole universe of vampire romance novels. And so I went and read those, and then I got a Kindle so that I wouldn't have to go to the library. I could just download one book right after the other. And I developed over time, over the course of about a year, I developed what you could classify as a mild addiction to romance novels and to sort of fantasy escape fiction in general, to the point where, we would go to family gatherings and I would bring romance novels and just sort of go off by myself and read, instead of participating in family life. Dr. Anna Lembke: And I would read late into the night every night, even though I said, tonight I'm going to go to bed early. Now it'd be two, three in the morning, and then I'd have to get up four hours later and go to work exhausted. And I began to think that I actually might have a problem when I took a romance novel to work and found myself reading in the ten minutes between patients, because that had not been something that would have ever occurred to me. And it was sort of like also, contrary to my values, I would have thought that would have been a time to sort of reflect or take notes. But I was just so caught up in this kind of fantasy life and as that happened, I found that I was less and less interested in my real life. Dr. Anna Lembke: So, all of a sudden, I found fault with my husband or I was not really wanting to participate in my kids lives the way that I had been such a priority for me before. I was sort of slightly more depressed, a little bit more anxious. And then importantly, other things that used to give me joy were no longer joyful. The only thing I wanted to do was to be left alone so that I could read my romance novels. And then, of course, there was tolerance, needing more and more potent forms over time to get the same effect. So that was, went from Twilight to 50 Shades of Grey and then needed very explicit sex scenes and then was actually, wouldn't even finish books. So as soon as I got to that sex scene, that was it. I didn't care what else happened in the book. I went on to the next one. You know, which is very similar to my patients who talked about, saying, "oh, you know, I'll never use black tar. I'll never inject black tar heroin. Like, I'll never do that. You know, I'll smoke a little opium. I'll never inject black tar heroin." And then there they were, injecting black tar heroin. So that's sort of what it felt like looking back, I didn't see it quite as it was happening. Dr. Anna Lembke: But when I did realize that there was a problem, which I realized because I communicated that, had a discussion about it with someone else, which is really also very interesting how we don't see these things happening, but then when we describe our behavior to another human being, it sort of becomes real to us in a new way. And that's what happened to me. I decided to do the same early intervention that we recommend for patients, which was to abstain for 30 days. So I did that and I was really, really surprised at number one, how difficult it was. And number two, how much physical restlessness I had and insomnia especially, as were talking about our brains as little alarm clocks, especially at that time of day when I would normally read romance novels, which was typically at the end of the day, when it was time to go to sleep, I would take one into the bed and read it as a kind of a way to put myself to sleep. Dr. Anna Lembke:And without doing that, I was just like, oh my gosh, I'm not able to sleep. I cannot. And I was up most of the night, just like, I can't believe I can't fall asleep. It was really amazing. And that lasted about two weeks, which is again, exactly the time frame for acute withdrawal. And then it started to get better by week three and by week four I was sort of sleeping, you know, able to initiate sleep, as I had done in my younger years in my earlier life. So it was really an eye opener. It was really surprising. And then I said to myself, well, I think I'm good to go. I'm going to go back to reading romance novels. And then that weekend after four weeks of not reading them, I binged all weekend long. And then we see that too. We call that the abstinence violation effect, where most people want to go back to using in moderation and some can, but many will actually binge on their drug of choice and then find themselves sort of caught up in the cycle again. So, after that I decided to give up romance novels for good. Mighty Pursuit: Wow. Did your husband and kids notice that you were doing this at the time or not? Or was it like a hidden thing? Dr. Anna Lembke: A little of both. So I would actually like, if I was reading a romance novel and you could see from the cover that it was a romance novel, I would sometimes hide it behind another magazine. Or just sort of just try to hide the cover. Or sometimes if it was a paperback, I would rip the cover off so that you couldn't see that it was like a bodice ripper or whatever on the front. And then of course, once I got the Kindle and this is part of what the technology affords, then it was anonymous, right? Like nobody could see what you're reading. Like, you can be reading anything you want. No one can see. And the anonymity of the internet is also, you know, kind of fuels this because when we're anonymous in our behaviors, we don't really have to hold ourselves accountable in the same way because other people can't see what we're doing. So it kind of becomes this sort of shameful secret place. Or just a secret place. Maybe not even initially shameful. But I think that eventually comes. Mighty Pursuit: I mean, you had a whole chapter about shame, which we'll talk about a little later, but the idea of shame coming into the pictures is a big thing. So, you know, as you reflect on that, and for someone that's watching, how do you tell when something is becoming a problem? Dr. Anna Lembke: It's really hard because it's insidious. I remember about a year ago, one of my kids came up to me and she said, "mom, you're always watching YouTube now." And I was like, "I'm not always watching YouTube. I hardly watch any YouTube videos compared to everybody else who watches so much YouTube." So, you know, this immediate kind of defensive reaction. And she said, okay, well, "it just seems like you're always watching YouTube now." And then she walked away. And then I thought to myself, okay, well, let's see. Let me think about it. Okay. Tonight, I guess I've been on YouTube. Woah, I guess it's been about two hours. Okay. And yesterday it was probably the same. And the day before that it was -- So I guess I am on YouTube a lot now. So then there was a decision. So, okay, I'm going to not watch YouTube for a while. Dr. Anna Lembke:And this process. Oh I'm doing this. Oh I need to cut back. I'm doing it. I mean, we're all dealing with it, right? It's so hard. And it just really, I think it requires sort of a recognition of what the process looks like, a validation of the effort to cut back that it's really worth it. And then I feel better when I do because I've done the experiment and I see that. It's the importance of living or interacting with other people who will, in a gentle and compassionate way, hold us accountable. And I also think just like the open discussion between humans now that we're all struggling with this and that it is hard, between parents and kids. So for example, I really encourage parents when they're talking with their kids about consumption of digital media and their phones and digital drugs to just openly acknowledge how hard it is for them as parents, also to moderate and manage their consumption, whether it's work related or recreationally. Like "hey, this is a really pressing and hard modern problem that we're all struggling with." Mighty Pursuit: Yeah, it makes me think of, there's kind of this chicken or the egg dynamic with addictive behaviors and substances. So some people would say, is addiction the problem? Is it the cause? Or is there something else happening that is influencing now of like, “oh, I'm depressed”. So now I'm running to this, versus it just being a baseline. And can you speak to that a little bit? Dr. Anna Lembke: Sure. So we do know that people with psychiatric disorders are more likely to develop addictive disorders than people who don't have psychiatric disorders. But what actually the relationship between the two is very complex and not all that well understood. It used to be thought, and this is based on a hypothesis that originated in the early 1900s by Sandor Rado, who was an acolyte of Freud's. He was a psychoanalyst. He came up with something called the self-medication hypothesis, this idea that all people who are addicted are actually self-medicating an underlying psychiatric condition. And if we could just treat their underlying psychiatric condition or emotional distress, they would stop these behaviors. Dr. Anna Lembke:But what we've found, both through clinical experience and also through a body of scientific research, is that, number one, like, self-medication doesn't work. It's not medicinal. People with psychiatric disorders who use substances as a way to try to manage those disorders actually have worse psychiatric outcomes, more hospitalizations, more medications, you know, more complexity. So it's not medicinal. If you combine intoxicants and a psychiatric disorder, you get worsened psychiatric outcomes and conditions. But it's also not necessarily true that the psychiatric condition leads to substance use. And very often people in their own explanatory models, looking back, will see it that way. But if you do prospective studies and actually follow people and look at the onset of addiction and the onset of psychiatric disorders, what you find is something that looks a lot different than that. And often what happens is that the substance use starts first and then the psychiatric symptoms manifest. And of course, we know that substance use is the great mimic. People can look manic when they're using addictive drugs. They can look depressed when they're and anxious when they're in withdrawal. They can look psychotic when they're under the influence of certain drugs. So it's very hard to diagnose, like what we call form fruit psychiatric disorder when somebody is using substances. Because we know that when we take those substances away for at least four weeks, very often those psychiatric symptoms entirely go away without us having to do anything else. One of the prevailing narratives right now in mental health more broadly, is this idea of trauma being the -- Mighty Pursuit: The origin of everything. Well, maybe everything is overstating it. Dr. Anna Lembke: Well of mental illness. And essentially the kernel of that idea dates back to Freud. Freud's great contribution was that things that happen to us in childhood contribute and have a huge impact on our emotional well-being in adulthood and that we can even have things in our childhood that happen to us, that happen outside of conscious awareness and that remain unconscious, that impact adult psychopathology. But I don't think that Freud ever intended by that theory, this idea that every form of psychopathology or maladaptive behavior must be traceable back to some kind of early childhood experience or trauma. And so one of the things that I think is not good that that can happen now in mental health treatment is that somebody comes in, they're anxious, they're depressed, they're addicted. And then, the mental health care provider goes looking for the traumatic event, when in fact there may not be a traumatic event that explains that or not a traumatic event of significant enough severity to really justify this person's symptoms.

THE NEUROSCIENCE OF ADDICTION

Dr. Anna Lembke:And furthermore, now that we're living in a world which is so addicted-genic, you don't really need trauma or even co-occurring mental illness to get addicted. You can have the best life, the best childhood, no psychiatric disorder and you can get really addicted because stuff is addictive now. It's been engineered to be that way. And then as a result of your engagement with these addictive substances and behaviors, you can end up with a psychiatric disorder depression, anxiety, psychosis, insomnia and attention. You know, we often have people coming into our clinic who are not looking for help with addiction. They're looking for help with depression and anxiety. 20 years ago, the first thing I would have done for those folks was prescribe an antidepressant. Now, the first thing that I prescribe for them is a 30 day dopamine fast from their drug of choice to see whether or not just simply stopping their drug of choice. It actually alleviates those symptoms. And in the majority of cases, when people are willing and able to do that, they feel much better from a psychiatric perspective. After 30 days of not using their drug of choice, which to me is just really powerful. Mighty Pursuit: So I think that's a good segway. Because it ties in directly to probably the most groundbreaking scientific discovery in the field of addiction with neuroscience and stuff. And you talk about this heavily in your book, but the idea of there being a pain / pleasure balance in your brain. And I think to understand on a very practical level what you're saying, that a normal, healthy person could just automatically get addicted, you kind of have to understand the pain / pleasure balance, no? So, what is that? Dr. Anna Lembke:Okay so what neuroscience has shown is that, broadly speaking, pleasure and pain are co-located in the brain. So the same parts of the brain that process pleasure also process pain. And they work like opposite sides of a balance. So this is an extended metaphor to understand the process of homeostasis. So imagine that, you know in our brains there's a seesaw or a teeter totter like in a kid's playground. And that represents how we process pleasure and pain when we experience pleasure it tips one way. And when we experience pain, it tips the other. And there are certain rules governing this balance. And the first and most important rule is that the balance wants to remain level, or what neuroscientists call homeostasis, such that with any deviation from neutrality, our brains are going to work very hard to restore level balance. And the way that our brains restore that level-balance is very important for understanding how we become addicted. So essentially, let's say, I read a romance novel that releases dopamine in my brain's reward pathway. My balance tilts to the side of pleasure. But no sooner has that happened than my brain will adapt to that increased dopamine by down regulating dopamine transmission not just to baseline levels, but actually below baseline into a dopamine deficit state. That's called neuro-adaptation. Dr. Anna Lembke:And I like to imagine that as these little neuro adaptation gremlins hopping on the pain side of the balance to bring it level again. But they like it on the balance so they don't get off as soon as it's level. They stay on until it's tilted in equal and opposite amount to the side of pain. That's the come down, the hangover, the after effect, the Blue Monday, or just simply that state of wanting to read one more chapter in my romance novel. Right? That state of craving. Now, if I put the book away and I don't read another chapter, those gremlins get the message that their job is done. They hop off and homeostasis is restored. But if I continue to read romance novels or ingest my drug of choice, whatever it is, over days to weeks to months to years, those gremlins start to multiply and pretty soon they're camped out on the pain side of the balance. And now I've entered “addicted brain” where I've changed my hedonic or joy setpoint such that I need more and more pleasure in more potent forms. Not to get high and feel good, but just to level that balance and feel normal. And when I'm not using, I'm walking around with a balance tilted to the side of pain. Experiencing that kind of constant state of craving, as well as those psychiatric symptoms that are characteristic of withdrawal, which are, again, anxiety, irritability, insomnia, depression. And that's why people who are struggling with anxiety and depression and also using substances and behaviors in an addictive way, will feel like they're self-medicating a psychiatric disorder because when they use it temporarily levels the balance and they feel better. But what they don't appreciate is that it causes those gremlins to get bigger and stronger and multiply even more, so that ultimately what initially was maybe a solution or a source of relief from psychiatric symptoms is now actually contributing to and/or exacerbating those problems. Mighty Pursuit: It makes me think about how you wrote in your book that we want to recreate feel good emotions and things of that nature. And so when we're pressing on the pleasure thing, it's like we want to feel good. One of my biggest questions when it comes to pain-pleasure balance is there's this idea that you can actually just completely fry your brain at a certain point, and then that balance just gets thrown out of equilibrium. And so how does that happen? And is it actually possible like this ties back into the stimuli because like if some substances are more addictive than others in the sense that it delivers a bigger dopamine blast to the brain. So can you actually fry that balance off of social media or work or whatever? Or is there only certain substances that create a physical kind of aspect that will cause that? So how does that work? Dr. Anna Lembke: Well, the answer is that we don't really know. What we see phenomenologically, for example, in opioid addiction, is that some people with severe opioid addiction, it looks like even with longer periods of abstinence, they still experience that constant state of craving as well as dysphoria, depression. And that's where opioid agonist treatment comes in. This is things like methadone maintenance or buprenorphine where we actually give them opioids to treat opioid use disorder. They don't get high off those opioids. But what we think it's doing is essentially restoring homeostasis or a level-balance so that they can re-engage in the rest of their lives. And so that's really because opioid agonist therapy works for those individuals. We speculate or we infer, from that, that essentially, they have lost the neuroplasticity to be able to restore a level-balance even with sustained periods of abstinence. Dr. Anna Lembke:Now, whether or not that can happen in other addictions, we just really don't know. It depends on probably a lot of different factors. For example, it probably depends on the age of the person. Young people have much more neuroplasticity or malleability than older people. So the ability of the brain to kind of heal and recover, and develop new neural circuits is very strong when we're young, and it's not as strong when we get older. It probably depends on the level or intensity of the addictive behaviors. In my clinical work, I do feel like sex addiction is a real tough one because as one of my patients said, the bar is in your brain. So it's the fantasy life, which is such a big part of it. And it's hard to kind of escape your own fantasies. You know, not fantasizing, people can do it, but you don't even have to go look for a bar, in order to be exposed to your drug of choice. You can just think about it in a moment. Yeah, you can just be thinking about it. And I think that is really hard. But again, I do in my clinical work with effort, a lot of effort over long periods of time, people can unwind those neural circuits and develop new neural circuits that kind of -- Mighty Pursuit: Which is the plasticity. Dr. Anna Lembke: Yeah, which is the plasticity which becomes dominant. So I mean, it speaks to the aspect of this that is learned behavior. And what do we mean by learned behavior? It means we've just developed a robust neural circuit that probably never entirely goes away, but can go dormant or quiet as we kind of activate other neural circuits, but also can be reignited. If we're, triggered again in some way. Mighty Pursuit: It makes me think of a tragic case of Philip Seymour Hoffman. He was a brilliant, brilliant actor. I remember watching a lot of his movies. And from what I could pull from his story. He had a heroin addiction. But he was off heroin for 20 years. And then all of a sudden, I think in 2013 and 2014, he just tragically died. And it was from a mixture of those drugs. And so it makes me think of what you're talking about in the sense of like, how is it that he could be off of this for 20 years and then whatever had happened to his brain from the initial use, was so powerful that like, snap right back into it 20 years later. Dr. Anna Lembke: Yeah and we see this all the time, you know, in clinical care that despite decades of abstinence, when people are re-exposed to their drug of choice or re-exposed to a similar drug, it can plunge them immediately into the depths of their addiction, like overnight. There's not that long a ramp up period that it initially took to get them to that level of behavioral pathology. And it also, you know, all of this really speaks to the challenges of modern life, where these stimuli are everywhere and they're so easy to get. Right? And they're chasing us down. Even if we want to insulate ourselves, from these stimuli, it's so hard to. There are ads and billboards and images and emails and texts and it's just really tough.

THE PROBLEM WITH AVOIDING PAIN

Mighty Pursuit: It makes me think of, we talked about the idea of that we keep going back to these substances or devices, whatever, because we want to feel good and it's kind of contributed to a culture that has an inability to deal with any sort of pain. You obviously wrote a book before Dopamine Nation about the opioid crisis. The whole show on Hulu, Dopesick, was just so interesting because the message coming from the pharmaceutical companies was basically we can cure you of your pain. And I feel like that message is just like our society now. We're not used to even having a dull or even what you were talking about in the Andrew Huberman podcast, just a boring moment. And yeah, we don't like boredom. We don't like not being stimulated at any point. Dr. Anna Lembke: I think it's even gone further than we don't like it. It's that we've pathologized it. Right? We have this idea that if you're not happy all the time and there must be something wrong with your brain, you need to go see a doctor and maybe get prescribed medication. I think people really don't recognize the extent to which, like life really is hard and that to experience, some degree of depression, anxiety is sort of part of the human experience, but also even more than that, that we live in a world that is not conducive to good health. Right? It sort of conspires against us. You know, there is this notion in mental health and in psychiatry that if people are struggling, there must be a problem in their brain. But really, it's a problem in the world. And it's a problem between the mismatch between how we evolved and the world that we live in now. I mean, the simple fact that we're so sedentary that we hardly move our bodies, the simple fact that we're more and more isolated. People not getting together. We're such social creatures. We need each other. So there are a lot of ways in which the environment is really the culprit, rather than the culprit being some kind of brain disease. Mighty Pursuit:Well it's the accessibility thing that you're talking about as well. Just on the subway down here, like we were sitting on the train. There's ten people in our periphery, right? And I'm like, just look at each of these people. Eight of them were on their devices. And so it's interesting because we're living in a moment where every dull moment, like you could be on that line for coffee. It's just like that dull moment, there's like an urge. And that's where you really see the addiction. It's like, I need to pull out my phone right now and look at something. Dr. Anna Lembke: Yes, distract myself. Mighty Pursuit: Or I'm on the elevator with someone in my apartment building, and I need to pull up my phone because I just feel awkward standing next to them. Or I'm at a social gathering, like, it's just like this urge. And so you mentioned the whole idea of happiness. And I think how much of the problem with this crisis is the overarching narrative of happiness? Because it's not just that there's access. It's not just like that we're getting addicted, but then it's also like what people are hearing, what they're being told, which is that something is wrong if you're essentially not in a dopamine-rich state, right? Dr. Anna Lembke: Yeah and this is sort of not wanting to look at or deal with or tolerate uncomfortable feelings, when in fact, the truth is that the more we work to try to run away or avoid those feelings, the faster they chase us down. And that contentment or thriving really comes when we stop running and we sort of examine those thoughts and feelings. We sort of sit with them for a while. That's really where we begin to then experience some comfort and peace. Instead, we're continually trying to distract ourselves from those experiences. And there are lots of ever more ways to do that, in this sort of virtual space. But I think, the result of that is really that we do feel more anxious and depressed, and we're seeing that, borne out in terms of the number of people who are now endorsing struggling with these problems. Mighty Pursuit: Why do you think it's so hard to just sit with our own thoughts? Dr. Anna Lembke: Well, I mean, it makes sense that we would want to avoid pain. Over millions of years of evolution, we have evolved to reflexively approach pleasure and avoid pain. Really, all of our sort of human effort goes toward naturally, trying to avoid pain, right? But the problem is that, we've now created this ecosystem where we're so insulated from pain, have so much access to pleasure that we've essentially established, kind of our own mental health crisis. So I think we have to use our perception of what is happening to recognize that, "oh, wow. I really need to intentionally insulate myself from all of these pleasures, and I need to actually seek out and do things that are difficult and hard in order to bring my brain back into some kind of health." Mighty Pursuit: You had this really powerful quote in Dopamine Nation, you said, "the question is why in a time of unprecedented wealth, freedom, technological progress and medical advancement, do we appear to be unhappier and in more pain than ever? The reason we're all so miserable may be because we're working so hard to avoid being miserable." Dr. Anna Lembke: Yeah and I really believe that. I think that we are actually evolved for pain. We need that kind of friction in order to thrive and be happy. And yet, our lives are ever more rewarding, pleasurable and convenient. So I think in order to be healthy again and experience contentment, we need to intentionally go out of our way to make things less convenient, less pleasurable, and even intentionally seek out things that are painful. Mighty Pursuit: I mean, on a practical level, there's this line which I feel like everyone's been told, "if it just if it feels good, do it." Do you feel like that's terrible advice? Dr. Anna Lembke: Yes, I think that's terrible advice. Mighty Pursuit: I feel like the idea of the happiness thing. Like it's just so woven into the language of our culture. And so when I think about the areas that affect the things that I could write down is, we talked about relationships already. Like, if they're not making me happy, then like, something is wrong. Or even the idea of, we just want our kids to be happy or whatever makes them happy. Or you wrote about in your book, like, even the idea of altruism or doing good for someone else, it's about making yourself feel good and happy. And so like there's just like all these areas where we're hearing these narratives. And so then when it comes to sitting alone in a moment with our thoughts and in our pain, it just feels so deeply unsettling and wrong. Dr. Anna Lembke: Yeah and again, you know, I think we can have a lot of compassion for ourselves because in a world of scarcity and ever present danger, reflexively seeking pleasure and avoiding pain is the way you survive. But recognizing that we don't live in that world now, and therefore we have to sort of, you know, have that cognitive load that comes with doing the thing that's not reflexive and not easy. But actually trying to, you know, again, create more positive friction in our lives. I think it's really important. Mighty Pursuit: Along the lines of the theme of debunking myths or examining cultural narratives, I wanted to take a second to circle back on porn because, I think it does tie into the cultural narratives, because I think very few people would argue that heroin is healthy. I think most people can understand, like, yes, I probably shouldn't do heroin, but there are actually a lot of people that would claim that porn can be good for you. And this obviously could be a loaded conversation because there's so many dynamics. There's like spiritual dynamics. There's, I've referenced John Gottman before, there's stuff that he said about relationships and then there's a whole kind of justice oriented thing about there being rape material on porn sites or whatnot. And then there's sex work, and then there's like the right to be able to do sex work. And so, what would you say on the topic of porn, specifically in cutting through weeds, like, is porn addictive and/or is it good for you? Dr. Anna Lembke: So, I mean, number one, porn is clearly addictive for some people, not all people. And I don't judge people who use porn one way or another. What I do is I treat people who come to me and say, porn is ruining my life, and I want to stop, and I can't do it. In the early aughts, the early signals for people getting addicted to different types of digital media, it really started with middle aged men coming in with pornography addiction. And these were men who admitted to using pornography or prostitutes or what have you, compulsive masturbation, through their lives. But basically being able to manage it, it wasn't out of control, right? It wasn't causing huge harm. But with the advent of the internet and then in particular our smartphones in the early 2000s, those individuals reported that it just completely exploded their lives. They had no more no more control. They were now marshaling all of their time, energy, money, creativity, to engaging in this activity and really unable to stop, even despite significant consequences. And again, when you think about sort of the heart of addiction, it's really continued compulsive use despite consequences. And with severe addiction, we're talking about very severe consequences. So I think that's a really important distinction, right, that when people have identified that it is a pathological behavior in their lives and they want to stop, then that's what, you know, what we try to help them do. It's just sort of like, is it working well for you? Is it getting you where you want to go? Is it creating the life you want to lead? And I think that's really important. Dr. Anna Lembke:You know, since publishing Dopamine Nation, I've received a few letters from folks, one very condemning, saying that, he patient that I describe in the book who has a sex and masturbation addiction, who gets into recovery that I actually harmed him because really I should have just validated his sexual preferences and let him experience that. And my response to that was just, I don't judge somebody's sexual preferences. He came to me. He was struggling. His marriage was falling apart. He was unhappy. He was suicidal. He wanted to stop the behavior. And it was contributing to many problems in his life. So that's kind of how I don't think about that. Mighty Pursuit: I found this sex researcher, Dr. Gloria Bloome, she said that an orgasm is actually the biggest non-drug blast of dopamine available. Is that true? Dr. Anna Lembke: Well, again, we don't really have in humans, sort of specific measures. So it's really hard to say that, but it's very clear that that orgasm causes a flooding of a whole bunch of different neurotransmitters in the brain, including dopamine. I mean, it's obviously reinforcing. Mighty Pursuit: I mean, there's also a Harvard study that was done on porn specifically and talking about kind of the mechanism. Well, it was I think they had used rats and had done a study on this. You had referenced earlier the idea of needing more of that drug of choice. And so a lot of the things we're talking about, I think experientially people are like, yes, that's my life in the sense of I was watching this type of pornographic content, but now I'm watching this type and now I'm watching this type. And like, you need more and more. Is that kind of an established phenomenon in some of the patients that you see? Dr. Anna Lembke: So the natural history of any addiction is that people start out using it for a number of different reasons to have fun or to solve a problem like depression, anxiety, boredom, insomnia. And if that substance or behavior effectively does for them what they were hoping it would do, they will return to using it. And over time, with repeated use, as the brain changes and adapts to that flooding of dopamine, they will find that they need more of the drug in more potent forms to get the same effect. And with something like a pornography addiction that looks usually like more deviant, deviant forms of pornography, and then often advancing to not just pornography, but sex workers or hookups with live people or whatever. You know, with gaming disorders, it's usually more advanced games, more levels. You know, there are all kinds of ways to make any drug sort of more potent over time. And then they find that they're using all of their creativity, energy, money, you name it, getting the drug, consuming the drug, hiding drug use, and then ultimately leading to consequences. And yet, despite those consequences, they struggle to stop. And that's kind of the arc or the natural history of any addictive disorder, whether it's a substance or it's a behavior. Mighty Pursuit: I think the dangerous part, if you will, of that progression as it relates specifically to porn. I think there was, in April of 2021, Pornhub had released a transparency report which had found that 653,000 videos contains either minors, nonconsensual content, hate speech, animal harm, incest, bodily fluids like blood and feces and or violent content. And so to tie into this conversation, it's like if there's a ramp up in the type of content we're seeking, then like, what does it say that like we would actually be getting addicted to, like even content like that? Dr. Anna Lembke: To me that's just really sad and scary. And it also continually pushes the boundaries of deviance. Of like, what sort of people do in a civilized society, what kind of behaviors are acceptable and what kind of behaviors aren't acceptable? And so it's scary to think about, you know, those boundaries of deviance getting further and further out. Mighty Pursuit: And then, the other one that you had mentioned earlier, that's pretty relevant to this topic is the opportunity cost. And so there research from Gottman, this is specifically in the context of a relationship, so the use of porn by one partner leads a couple to have far less sex and ultimately reduces relationship satisfaction. And then the other thing is like when one person becomes accustomed to masturbating to porn, so they're actually turning away from intimate interaction. And so obviously there's like self-harm that's being done there. There's harm being done to the relationship. Because if the purpose of sex is, pleasure and intimacy and obviously procreation, but between two people and then you actually can then manipulate that experience in your own brain because it's like you're controlling everything. And so then when you have two people in the equation, there's like two people that need to be accounted for and their preferences and your preferences and how those two things unite. And so, you know, I think the idea of an opportunity cost is another thing. Mighty Pursuit: So, I think that just generally with anything we get addicted to, I had done a lot of research on Walter Mischel's work on self-control, which you had you had referenced in your book. And he talked a lot about this disconnect between the present and future self and the idea of not seeing them on a continuum, of this behavior that I'm doing right now actually has no implication on who I'm becoming in the future. And almost this illusion of, if I have a harmful or destructive behavior right now, I could just on a whim, just stop it, and then become someone different in the future. And so do you have any thoughts there in terms of that? Dr. Anna Lembke: So one of the techniques that we use in clinical work, when we're working with patients who are resistant to, stopping their addictive behaviors, you know, most commonly, let's say something like smoking cannabis or, drinking alcohol in excess. I'll often invite them into an exercise where I ask them to project themselves into the future by saying something like, "okay, well, I hear you that you're not interested in quitting smoking now, but do you see yourself smoking like those ten years from now?" And they'll stop and almost universally, it's so interesting to me. If you use a decade time frame, they'll say, "oh, no, I'm not. I'm not going to be smoking in ten years." And I say, okay, "how about five years from now?" And then it's like, "no, I'm not going to be smoking in five years." Then I say, "how about two years from now? "And then still they'll say, "no I'm not going to be smoking two years from now." It's like, "a year from now? Six months from now?" And so by doing that, you get to kind of like, okay, if it's definitely not going to be the behavior that you're going to have ten years from now, when are you going to change it? At what point? And so by doing so by inviting them to consider sort of the longer arc of their life, you are asking them to enter into time in a little different way and see the connections between their present selves and their future selves. And that can then very often lead to motivation to change the behavior now.

HOW TO DEFEAT ADDICTION

Mighty Pursuit: That's really good. I think when it comes to that kind of spectrum and, you know, I do want to obviously touch on like the hope of this conversation and the hope of the path forward and kind of in some ways escaping the cycle of addictive behaviors and the high dopamine stimuli. And so you have talked a big thing about it, I guess the first step would be to reframe the way that we see pain, like if we want to be a better person in the future and a healthier person in the future. And like that kind of starts in the present moment with the way we see pain. Would you say that's right? Dr. Anna Lembke: I think that that's both at the individual level and the cultural level. I'd like to see this shift there. I mean, let me just say it's not easy to do this. Because again, it's reflexive to try to avoid pain. But, I think it is important if we can get to that space where we realize, oh, gosh, all of these things I'm doing and all this effort I'm making is because I'm trying to run away from this feeling. And if I would just stop and just turn and face that feeling. You have to really do it to believe it, but something really miraculous can happen in that moment. We get some sense of peace that we don't get when we're running away. Mighty Pursuit: When it comes to pressing into the pain side, what I thought was interesting about your mind and perspective on this is what you wrote in Dopamine Nation. How do I say this word? Pharmacotherapy. Dr. Anna Lembke: Pharmacotherapy. Mighty Pursuit: "Pharmacotherapy alone without insight, understanding and the will to change is unlikely to be successful." And so you see this dynamic especially when it comes to overeating or the obesity crisis. If someone goes and then they have a surgery, they're not necessarily like addressing the underlying psychological component for that. And so I thought that was just interesting, in a sense of how your psychological framework about all this stuff deeply matters for you to kind of get to the other side. Dr. Anna Lembke: Yeah, I mean just looking at all of the ways that we use medical interventions, typically medication. But in the case of obesity, also surgeries, to try to intervene really speaks to kind of the level of desperation too, that we're feeling. Where, even despite our best efforts, we're struggling with appetitive control. And I would say that's that's pretty universal. So I think, I guess I always just come back to wanting to really acknowledge the ways in which it just really has become very difficult to manage our appetites, and so kind of being open to this idea that, we have to really reflect on what we're doing. Mighty Pursuit: You're speaking to the difficulty of it. How would you say one gets the courage to press on the inside? Dr. Anna Lembke: Honestly, it's often born of desperation. A kind of a sense of like, I've tried everything else and it's not working, but I think, you know, it doesn't have to be just sort of a moment of crisis. I think psychotherapy, good psychotherapy can really help with this. You know, a spiritual community or spiritual practices can really help us. Spiritual practices almost universally reframe pain as an important opportunity for growth. Which is really countercultural to how we think of pain sort of in our modern capitalist systems. So, those can be important opportunities or ways to sort of get courage within a community to do those things and just kind of experimenting. I mean, that's why I do recommend that people engage in these fasts, as a way to just sort of experiment with their lives and see how you feel. Mighty Pursuit: Engaging in the fasts, obviously there's expectations of what's to come. And you mentioned the 14 day period for yourself, even with the fantasy novels. So that kind of gives a baseline of like okay, things might be off equilibrium, at least for that long. But I think you had a couple examples in the book, where you wrote about one individual, "after quitting the substance, he was flooded with all the negative emotions he'd been masking with drugs when he wasn't feeling sad or angry or shame, he was feeling nothing at all, which was possibly worse." And then the idea that pursuing pain obviously is harder than pursuing pleasure. And so the courage or the willpower to get through that, is particularly really relevant in the first couple weeks, right? Dr. Anna Lembke: Oh, yeah. I mean, it has to be, like a project that you plan. And, you know, anticipate that you kind of let people know you're going to be doing it. Create structures in your life. So to optimize your success, when we think about that quit date, you know, we plan for it, right? We try to marshal all the resources, and we acknowledge that it's going to be really, really hard. We don't pretend like it's going to be easy. And I think that that's helpful. Just kind of knowing that it's going to be hard. Feeling like you have support to do it, feeling like it's a project worth doing. Because, of course, part of what happens with craving is that our heads generate stories almost instantaneously. To rationalize why we should go back to using or why this period of absence isn't warranted or isn't isn't useful or isn't necessary. So, yeah, I think, it takes a lot of kind of girding yourself for what's to come, but also knowing that it's time limited. And that you know that you really will feel better. Often with addiction, people think they only have two choices. Use drugs and be miserable, or stop using drugs and be miserable. So it's really important that we hold out for this third option. Know there is a way forward where you're not using drugs or not using drugs in quite that way, and where you can really feel better. Mighty Pursuit: So in terms of strategies, let's talk about the practicals there. Can you explain kind of like how willpower works, like is willpower itself just like a finite resource? Dr. Anna Lembke: So for the most part, willpower is greatest when we first wake up, and then wanes through the course of the day. And we only have so much willpower, it takes a lot of mental and emotional energy to resist doing the thing that we reflexively and impulsively want to do. So we can't rely on willpower alone. In order to be able to take on this project of abstinence or changing these deeply automatic, kind of compulsive behaviors, which is why we always emphasize self binding, that is, putting both literal and metacognitive barriers between ourselves. Mighty Pursuit: So distance. Dr. Anna Lembke: Yeah, distance. Putting some actual literal physical distance. Or there are other forms of self binding. And we have to do it in advance of intense desire. Right. If we wait until that moment and we have the drug right there, it's extremely difficult to resist. But if we anticipate it and sort of create barriers, get it out of the house. There are other types of self-binding strategies, like medication can be a self-binding strategy, ways that we have medications that affect appetites. You know, doing it together with other people can be a form of self-binding, a way to do it communally or have it be to hold ourselves and others accountable. We can use time as a form of binding, like the dopamine fast, it's like, okay for 30 days. I'm not going to use this drug of choice. And it's important to have that all in advance so that we don't rely on willpower alone. Mighty Pursuit: When I was reading the idea of self-binding, in your book, it immediately made me feel like the concept of self binding itself kind of has ancient roots. Especially from a spiritual perspective. And so 2000 years ago, even Jesus kind of spoke about going to kind of extreme measures to, I guess putting guardrails in place, where he specifically spoke to kind of more something that fell in line of like addictive sexual behaviors. And then one of his disciples kind of used the word “fleeing” when it came to that stuff. Dr. Anna Lembke: Fleeing? Mighty Pursuit: I think the Greek and, you know, someone's probably gonna write a column about this. I think it's phuego, I think is the Greek word, but that literally means to seek safety by running away, kind of in a metaphorical sense. And so that is almost in perfect alignment with what you're saying about the idea of like putting distance. And so when I think about the coffee dynamic, like I was just talking about earlier, I found like in the month where I was off coffee, it was extremely trigger- some for me to be in a coffee shop. Dr. Anna Lembke: Yeah. Mighty Pursuit: And I had to have a different routine that month because my routine would be like, I go to the coffee shop in the morning and I have a coffee and I work, but it felt really trigger-some to like, go to the coffee shop and then have a tea, you know? And again, you know, there's levels to it if you call it addiction or not. But that's just an example of like the triggersome nature. And then I think even when it comes to social media, I think, you know, having the apps readily on your phone or the idea of like deleting them, putting some sort of time barrier on your phone. You also talked about the idea of like, having someone else who's holding you accountable as well. So can you speak to that, like a little bit like? Do you feel like some of the technology that's been developed like that, I don't know, helps people like not watch porn or stuff? Like, do you think those are actually effective techniques or not? Dr. Anna Lembke: I think they can be when the person is really invested in the project of abstaining. So there are content blockers now that are helpful to some of my patients where they can block all content not related to just the bare minimum of using that device. Or they can let in only certain content. There are all kinds of time measuring apps now that will alert you how long you've been on. So I think with a really motivated person, those can definitely be helpful and have been helpful to patients and other people that I know. Ways to make the device just less potent, going grayscale, so that you're not being bombarded by these intense visual images. That's a form of self-binding. What I also, recommending more and more is not just different ways of using the device, but actually separating physically from the device entirely, like going out of the house without your smartphone. Which can feel really anxiety provoking. Mighty Pursuit: That's been effective for me just like not having on me at all. Dr. Anna Lembke:Yeah, right. And a lot of people that's very scary and, and and in a way, I would ask when people feel that if they don't have any other life experience with addiction, that's how people with drug addiction feel when they're not sure when they're going to get access to be able to score some more drug. It's that exact same type of feeling. But I really think, you know, physically distancing ourselves from the device or if the device, if you have to have it on, actually completely power down. There's something cognitively that to me is very interesting that happens when the device is turned off and hence not transmitting or receiving anything. It's almost like our mental attention for it goes down when we know it's not functioning and connected to the internet. So I like that one too. So it's again, just really urging people to spend some time separated from their device and just kind of walk through the world in a slightly different way and just notice how it feels. I'm really encouraged by young people like you who I feel like are experimenting more and more with not having their devices with them. I mean, yes, it's true, you walk through any airport or any transportation, everyone's on their devices, little kids on their devices. It's always a little bit sad. But, more and more, I'm seeing people out and about who aren't pulling out their phones or don't even appear to have their phones on them. And I think that's great. Super encouraging. Mighty Pursuit: I've gotten out of this rhythm, but there was a period where like, like Saturday was like my day off. And so I would actually like to put the phone in a drawer. And then leave. But there actually needs to be a planning process that's involved, like a pre-planning process because, when you think about larger culture, how everything's wired of getting around and whatnot. So if I'm going to like go on a car ride somewhere or go downtown on the subway, I need to account for the fact that I'm not going to have -- Dr. Anna Lembke: You're not going to be accessible. Mighty Pursuit: And I'm not going to have the GPS or this or whatnot. But to your point, I felt like those for a period were like some of the most peaceful days that I had creating that separation. Dr. Anna Lembke: It's a really good point. I mean, I think it's good for people to occasionally get out the paper map, you know, and like, it's a really different experience. You know, you're like, remember, I mean, every New York street corner you would see a tourist sort of like looking at the map. You don't see that anymore. But we still get out the paper maps. Because you never know when sort of the technology might not work. So it's good to have a paper map just in case. We try to do tech free vacations with our family. And, I remember our most recent one, we went to Kauai and nobody had a phone. And you know, we had long conversations that we never would have had if people could have gone off on their phones and chatted on the internet. But once we went to Chile and I had my wallet stolen and nobody had a phone, and that was actually really challenging because I had to call and figure out how to. Mighty Pursuit: You're using payphones or something? Dr. Anna Lembke: Well, that's sort of like vaccines. It's like as long as everybody is vaccinated, you're fine. We actually borrowed somebody's phone. We borrowed a flight attendant's phone. Not the flight attendant, the administrative person at the gate let us make the call to the credit card company and stuff. Mighty Pursuit: You had this this extremely powerful quote, about about the idea of self-binding and the importance of it, because you said, "if we wait until we feel compulsion to use the reflexive pull of seeking pleasure and or avoiding pain is nearly impossible to resist in the throes of desire, there's no deciding. But by creating tangible barriers between ourselves and our drug of choice, we press the pause button between desire and action." And so you described self-binding as like a modern necessity because of how high dopamine it is, you're going to do it unless you put the distance. Dr. Anna Lembke: Yes, I really think so. We have to kind of create a world within a world where we're insulated from all these pleasures so that we're not constantly being triggered. Mighty Pursuit: So there's a couple of things I want to touch on as we close. One of them, which you could use a phrase, maybe a little bit of like silent killers in terms of emotions that can be destructive in terms of the healing process. And so the first one that you talked about extensively in your book, obviously, is just like not being honest about the struggle, both with ourselves and others. Can you speak to that? Dr. Anna Lembke: So you mean like radical honesty? Mighty Pursuit: Yeah, about like radical honesty. Dr. Anna Lembke: So, yeah, I mean, it's something that I learn from patients in recovery, almost universally, no matter how they got into recovery, they said that they can't lie. And it's not just that they couldn't lie about their use. They can't lie about anything at all. They can't lie about why they were five minutes late for a meeting. And I just thought that was really fascinating and, and sort of began to research why it is that telling the truth or radical truth telling about things large and small would have such a powerful impact on recovery. And I think it works at many different levels. I mean, one of the ways it works is I think it promotes intimacy. So we often talk about the importance of intimate human relationships, but we don't necessarily talk about how to get there. And I think what wedges people apart is little lies. And what brings them closer together is this kind of radical transparency, especially about things that, when we're attempting to cover up our own selfishness, our own mistakes, as when we're open with our partner about that. Dr. Anna Lembke: It has a very powerful impact on intimacy. It's really hard to do. I think we resist being vulnerable in that way. But it's super important and it has to be reciprocal and mutual. Radical truth telling also probably stimulates the prefrontal cortex, which is that gray matter area right behind our foreheads, which is so important for delayed gratification and appreciating future consequences. So I think it works probably on a neurophysiologic level. And there's some evidence to support that. It also really impacts the stories that we tell about our lives, our autobiographical narratives, which are not just a way to organize past experience, but also provide a roadmap for the future. If we're being radically honest, then we are telling stories that are richer and more true to life, that involve our own complicity or contribution to the problem, which is really important, not just seeing ourselves as victims of other people's actions. And then when we talk about our lives in that radically honest way, a kind of retrospective radical honesty, I think we have access to better information to make good decisions going forward. Mighty Pursuit:Yeah, that's really good. And the other emotion you talked about is shame. And so I think the science behind shame is pretty extensive in the sense that aspects of it can be very destructive. And so can you talk to me about the difference between destructive shame and pro-social shame? Dr. Anna Lembke: So I mean, as you said, we talk a lot now, in mental health about the harm that shame can bring. And it's certainly true, including the way that self-loathing and shame can perpetuate destructive, addictive, consumptive behaviors. But it's also true that if we didn't feel some degree of shame about these behaviors, we wouldn't be motivated to change them. Right? So shame can also be a very useful and what I call prosocial emotion because essentially feeling shame about transgressing certain, let's say norms or engaging in behaviors is exactly the emotion that will motivate us to change those behaviors. But in order for shame to be prosocial and not destructive or malignant, we need to be in a social context where we won't be shunned for telling the truth. And where we will be given a path for changing that behavior as well as making amends for the harm that we've caused. Mighty Pursuit: So when it comes to that, where does accountability come into the process? The idea of quote unquote speaking truth in love to people, because you wrote, "we as mental healthcare providers have become so caught up in the practice of empathy that we've lost sight of the fact that empathy without accountability is a shortsighted attempt to relieve suffering." So you said, "the key to accountability is accountability with compassion." And so how do we hold someone accountable without shaming them in a destructive way? Dr. Anna Lembke: I think it's important to acknowledge when people have done something to harm other people. You know and just like to allow ourselves to sit with that. While also acknowledging that there could be some loss of agency for that person who did harm because of a mental illness. Because of their addiction, because of their depression or their psychosis or whatever it is. So kind of hold those two things simultaneously. Mighty Pursuit: That's good. Dr. Anna Lembke: But then importantly, after that talk about here is a path toward not repeating that kind of harm. Mighty Pursuit: Yeah. That's good. Well, I mean, in the healing process, I kind of just wanted to land and circle back on dopamine because, I don't want people to walk away from the conversation with kind of an extreme view that dopamine itself is a bad thing. Because dopamine is built into our neurochemistry. And so do you have kind of any final words about how we should view dopamine in general? Dr. Anna Lembke: Dopamine is vital for our lives. It's the neurotransmitter that tells us, hey, this is really important for your survival. Sit up and pay attention. But as you say, dopamine isn't inherently bad or good, right? It's a signal for the brain. When we talk about dopamine fasting, we are not literally talking about not ingesting dopamine because we don't ingest dopamine. If we took a spoonful of dopamine, it would have no effect at all because it doesn't cross the blood brain barrier. What we're talking about is trying to avoid the kinds of intoxicants that release a lot of dopamine that is made in our brain, releasing it all at once in that particular reward circuitry. And why do we want to avoid that? Again, because our brain will adapt by down regulating our dopamine production and transmission, not just a baseline, but below baseline. So, it's about dopamine fluctuations. It's about our tonic baseline level of dopamine firing in relation to going up or going down given what we're doing, what we're ingesting. So we can learn a lot from understanding those dopamine fluctuations. But it's not that dopamine itself is good or bad. Mighty Pursuit: And I mean, there's like plenty of natural things that are built into the human experience. I'm thinking about exercise or going walking in the mountains or nature or here in New York City, like Central Park. I mean, food has been manipulated, but just the sense of food in general. Food as nourishment. You're not getting these crazy spikes of dopamine, but it's a good thing. Dr. Anna Lembke: It's a really important point. And it's a good point to clarify at the end that our brain really evolved for these very tiny spikes of dopamine. And typically in response to a period of deprivation. So our pleasure-pain balance is actually going to the pain side. Then we get some reward for our effort. And then we actually go back to homeostasis as opposed to what we have now is these highly potent reinforcers that slam our pleasure pain-balance to the pleasure side. And then because of that, the brain has to then do this massive sort of countervailing effect in order to ultimately try to bring things level again. So when we're talking about healthy sources of dopamine, we're talking about meeting with friends, walking in nature. Mighty Pursuit:Human connection. Dr. Anna Lembke: Human connection. But not the drug-ified version of that. We're talking about. I mean, we know that meditation, increases dopamine firing. You know, prayer increases dopamine. The brain learning increases dopamine in the brain. So it's about engaging in these sort of health forms of dopamine that don't make us feel suddenly euphoric, but rather through effortful engagement over time give us these gentle feelings of wellness or well-being. And then it's also about, intentionally doing things that are difficult, pressing on that pain side so that the gremlins hop on the pleasure side so we get some of that dopamine indirectly, which is much less vulnerable to this problem of compulsive overconsumption. Mighty Pursuit: That's so good. I couldn't think of a better quote to kind of leave off on, and especially for someone who is kind of engaging in maybe more unhealthy behaviors and wants to get free from them. You wrote, "if we wait long enough, our brains usually adapt to the absence of the drug, and we re-establish our baseline homeostasis, a level balance." And so, yeah, I just wanted to leave that as like an encouragement for people, pressing on the side of pain and kind of achieving level balance. Like what is the reality today of what you're struggling with, doesn't have to be the reality tomorrow. And so I think that provides a lot of hope. Dr. Anna Lembke: Yeah. Oh, absolutely. Lots of room for hope.

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