The Joe Rogan Experience - Joe Rogan Experience #1708 - Anne Lembke

00:00:03.000 The Joe Rogan Experience.

00:00:06.000 Train by day.

00:00:07.000 Joe Rogan Podcast by night.

00:00:09.000 All day.

00:00:12.000 Hello.

00:00:13.000 Hi.

00:00:14.000 Thanks for doing this.

00:00:14.000 Appreciate it.

00:00:15.000 I'm happy to be here.

00:00:16.000 I'm very excited to talk to you about this.

00:00:18.000 This is a very interesting subject.

00:00:20.000 I have had problems with addiction my whole life.

00:00:23.000 Particularly, like I had a really bad video game addiction at one point in time.

00:00:27.000 And I had a quick cold turkey.

00:00:29.000 It was like an eight hour a day addiction.

00:00:32.000 And when was that?

00:00:35.000 20 years ago.

00:00:37.000 Somewhere around then.

00:00:37.000 Okay.

00:00:38.000 Yeah.

00:00:38.000 A little more than 20 years ago.

00:00:40.000 Okay.

00:00:40.000 So you were in your 30s?

00:00:42.000 Yeah.

00:00:43.000 And how did you realize that you were addicted?

00:00:46.000 Oh, I knew.

00:00:48.000 You knew from the very beginning?

00:00:51.000 Well, it was very fun.

00:00:52.000 I was playing this online video game called Quake.

00:00:55.000 And what it is, is you play online and you are in this 3D environment.

00:01:04.000 And you hear, like, sounds in 3D, and the graphics are amazing, and you're running around shooting at people, and they're shooting at you, and it's really exciting.

00:01:14.000 It's very thrilling, but it's not real life, and it'll eat your whole life away.

00:01:19.000 Yeah.

00:01:19.000 So, I'm curious, how did you, I mean, did you know from the very beginning that you were addicted?

00:01:24.000 No!

00:01:25.000 So, at what point, like, how long into it did you say, gee, this is a problem, I should change this behavior?

00:01:31.000 Well, I would go to bed in the morning.

00:01:38.000 Because I would come home from a comedy show and I would literally play all night long.

00:01:42.000 Okay.

00:01:42.000 And then I would realize it was like 8 o'clock in the morning and the sun was up and I was just going to bed.

00:01:48.000 I was like, this is terrible for you.

00:01:49.000 Like, what am I doing?

00:01:50.000 I'm basically working a night shift.

00:01:53.000 And I was also realizing that I was tired a lot because I was just really wrecking my system by doing that.

00:02:04.000 And also, the game is so exciting.

00:02:07.000 You're like...

00:02:09.000 You're redlining, and then you get out of there, and you feel cracked out.

00:02:15.000 Yeah.

00:02:15.000 So usually, as we become addicted to something, we don't see it until there's some sort of threshold where maybe we have a bad consequence, or someone else makes a comment, or just something happens so that we start to look at our behavior in a different way.

00:02:33.000 So I guess I'm wondering with your video game addiction, What was it for you?

00:02:37.000 Do you remember what the tipping point was where you said, I have to stop doing this?

00:02:41.000 I do a lot of self-auditing.

00:02:43.000 I think I was pretty aware that I was screwing up.

00:02:46.000 I wasn't focusing enough on my career, like my stand-up.

00:02:54.000 I wasn't focusing enough on other aspects of my life.

00:02:57.000 I was just way too into it.

00:03:00.000 And I was realizing also the reward.

00:03:07.000 I have a problem.

00:03:08.000 I'm an obsessive person.

00:03:10.000 I get into things.

00:03:12.000 The things that I like, I just think about them all the time.

00:03:16.000 It's not balanced.

00:03:17.000 Because I have this obsession with getting really good.

00:03:22.000 Whatever I get into, it becomes too much of my life.

00:03:27.000 I was watching this documentary recently about my late friend Anthony Bourdain and in the documentary they were talking about how he used to be addicted to heroin and then later on it actually became a healthy thing.

00:03:45.000 It became jujitsu.

00:03:46.000 But it was like this addiction where he talked about it constantly and all the people that were working with him were laughing about how he never stopped talking about it.

00:03:55.000 He was just addicted to it.

00:03:56.000 And so he was getting good at it.

00:03:58.000 It was healthy.

00:03:59.000 His body was getting very healthy.

00:04:01.000 But it was the same sort of function in the mind.

00:04:07.000 That's what I want to talk to you about.

00:04:09.000 What is that?

00:04:10.000 Yeah, yeah, yeah.

00:04:11.000 So, I mean, it's a great question.

00:04:14.000 It's something that people used to call the addictive personality.

00:04:18.000 We don't really call it that anymore.

00:04:20.000 We just use the idea of the disease model.

00:04:23.000 So we say that somebody has the disease of addiction.

00:04:28.000 It's a chronic relapsing and remitting problem.

00:04:32.000 People come to it with different degrees of vulnerability, and the risk for it can essentially be summarized as nature, nurture, and neighborhood.

00:04:41.000 And just to briefly describe that, If you have a biological parent or grandparent with addiction, you are at increased risk compared to the general population of getting addicted yourself.

00:04:52.000 If you have a co-occurring mental illness, you are at increased risk of getting addicted.

00:04:57.000 If you have certain character traits, like you're more impulsive, you have a hard time putting a break between the idea to do something and actually doing it.

00:05:06.000 You're at increased risk for addiction.

00:05:09.000 So that's kind of all in the sort of nature risk category.

00:05:13.000 There's also the nurture piece of it.

00:05:15.000 So if you grow up in an environment where you experience a whole lot of trauma, you are at increased risk for becoming addicted.

00:05:23.000 If you grew up in an environment where your caretakers model using drugs and alcohol or other addictive substances or behaviors as a coping strategy, you are at increased risk of becoming addicted or even if they just implicitly condone it.

00:05:38.000 And then that brings us to the whole neighborhood idea.

00:05:42.000 And this, I think, is a really under-recognized aspect of our risk for addiction, which is just simple access.

00:05:49.000 So if you live in an environment where you have more access to highly reinforcing drugs and behaviors, you're more likely to try them.

00:05:57.000 And just simply in being exposed...

00:06:00.000 Especially with the increasing potency, variety, and novelty of drugs today, you're at increased risk of becoming addicted.

00:06:07.000 So if you go see a doctor who's more free with their prescription pad, you're exposed to opioids or benzos, you're more likely to get addicted.

00:06:14.000 If you grow up in a culture where people are playing a lot of video games, you're more likely to try them, more likely to get addicted.

00:06:21.000 And neighborhood are the risk factors.

00:06:24.000 But again, people bring different degrees of vulnerability to this problem of addiction.

00:06:29.000 And some people are more vulnerable than others.

00:06:32.000 And you may indeed be in that category where you're just somebody who, you know, once you find something that's reinforcing for you, you just go and you just want to do it again and again and again.

00:06:44.000 When you say reinforcing, what do you mean by that?

00:06:47.000 I mean that it's rewarding in some way.

00:06:50.000 Rewarding, right.

00:06:51.000 So it's pleasurable at first.

00:06:55.000 Now the thing about addiction and the way that it changes our brains is that that thing that initially is pleasurable and has us engaging in approach behaviors If we continue to consume that substance or engage in that behavior,

00:07:11.000 it ultimately actually puts us in a dopamine deficit state such that we want to continue to do that behavior, not to feel good, but just to stop feeling bad.

00:07:22.000 And that's kind of one of the fundamental things about the disease of addiction.

00:07:27.000 It's innate vulnerability to start.

00:07:30.000 Added to the changes that occur in the brain as a result of ongoing consumption of our drug.

00:07:38.000 And those brain changes are what drive continued compulsive use.

00:07:42.000 So that's the difference between being enthusiastic about something that you enjoy versus something that consumes your life.

00:07:50.000 So you're kind of chasing the dragon.

00:07:54.000 That's what they talk about it with heroin addiction, right?

00:07:56.000 Don't they say chasing the dragon?

00:07:57.000 The initial rush that you get from the first uses of it, you're always chasing that, but really what you're doing later on in life is just trying to not be sick.

00:08:08.000 Not having it in your body makes you feel terrible.

00:08:11.000 Right.

00:08:12.000 So interesting, that term, chasing the dragon, it comes in part from, as you describe, like the elusiveness of trying to recreate that initial high, which with continued use becomes harder and harder.

00:08:24.000 But it also literally comes from when heroin is inhaled.

00:08:29.000 So if you put it on a piece of tin foil and you light it underneath, you get this kind of smoke.

00:08:33.000 Then that plume looks like a dragon's tail.

00:08:36.000 So it's got a couple of different meanings.

00:08:38.000 But yes, I mean, what you're saying is exactly right.

00:08:41.000 And the way that I describe this to patients and describe it to medical students is imagine that in your brain there's a balance, kind of like a teeter-totter in a kid's playground.

00:08:52.000 And one of the most interesting findings in neuroscience in the past 75 years is that pleasure and pain are co-located.

00:08:59.000 Which means the same parts of our brain that process pleasure also process pain and they work like opposite sides of a balance.

00:09:06.000 So when we do something that's rewarding or reinforcing or pleasurable, our balance tips slightly to the side of pleasure.

00:09:14.000 We get a little release of dopamine, the pleasure neurotransmitter in that part of our brain, our reward pathway, and we feel good.

00:09:20.000 But the thing about that balance is that it wants to remain level, and the brain will work very hard to restore a level balance, or what's called homeostasis.

00:09:31.000 And it does that by tipping the brain an equal and opposite amount to the side of pain.

00:09:36.000 So again, the way the balance restores homeostasis is to tip to the opposite side.

00:09:42.000 That's the come down after using that moment of wanting to do it again, the hangover.

00:09:47.000 If we wait long enough, that feeling passes and balance is restored.

00:09:51.000 But if we don't wait and we continue to use our drug again and again, We end up with a balance that's essentially weighted to the side of pain.

00:10:01.000 And I imagine that like these little neuroadaptation gremlins hopping on the pain side of the balance.

00:10:06.000 Not very scientific, I know.

00:10:08.000 But the point is that with repeated use, we get enough gremlins on the pain side of the balance to fill this whole room.

00:10:14.000 And then we're essentially working from a dopamine deficit state.

00:10:18.000 We've down-regulated our own dopamine levels.

00:10:20.000 We've downregulated our own dopamine transmission, and those gremlins like it on the balance, so they don't get off after the hangover is over or the acute withdrawal.

00:10:29.000 They can persist there for weeks to months to years, which is why people with addiction...

00:10:35.000 Even when their lives have become so much better, we'll relapse because they're not walking around with a level pleasure pain balance.

00:10:43.000 They're walking around with a balance tipped to the side of pain.

00:10:48.000 They're experiencing the universal symptoms of withdrawal from any addictive substance or behavior, anxiety, irritability, insomnia, dysphoria, and intrusive thoughts of wanting to use their drug again.

00:11:01.000 Now, with enough time elapsed, and again, in people with severe addiction, it can take months to years, those neuroadaptation gremlins will hop off.

00:11:10.000 We will regenerate our own dopamine and our own dopamine receptors, and our level balance or homeostasis will be restored.

00:11:17.000 Is it scientific to call them gremlins?

00:11:19.000 Super scientific.

00:11:22.000 Because I mean, I'm hearing it's like, well, that's a great way to put it.

00:11:26.000 Because like people that are, like Jamie can attest to this, we had a relapse of our video game addiction.

00:11:33.000 We, at the old studio, had a bunch of computers set up and we started playing again.

00:11:39.000 And then we wind up playing like hours and hours every day and I had to stop again.

00:11:44.000 I go, oh, I see what's happening here.

00:11:46.000 I'm right back into this.

00:11:48.000 But this was like decades later.

00:11:49.000 Yes.

00:11:50.000 Well, I mean, and there's a couple interesting points about that.

00:11:53.000 So one is that in creating easy access at your other studio, the temptation was, you're not able to withstand it.

00:12:02.000 And that's...

00:12:03.000 Oh, no, there was no, it wasn't temptation.

00:12:05.000 It was a plan.

00:12:06.000 Like we planned to set this up.

00:12:08.000 I thought it would be fun to have.

00:12:09.000 But then once I knew there was no temptation, like we never went, maybe one time again, One time we did it, we went back and played again after like a year of not playing.

00:12:20.000 We played a couple times when the Doom guys came.

00:12:23.000 But never went back to it again.

00:12:25.000 I was like, oh, I know what that is.

00:12:26.000 And so the room just sat there with these computers and we never used it.

00:12:30.000 But the way of looking at it like gremlins is a very interesting...

00:12:34.000 Is that your thought process?

00:12:36.000 Yes.

00:12:37.000 You look at it like gremlins.

00:12:39.000 Yes, that's how I... So I, for me...

00:12:41.000 Just a nice way to think of the neuroscience and a nice way to teach it is to imagine this balance that gets tipped to one side or the other and the little gremlins which represent neuroadaptation hop on one side or the other as the opponent process mechanism to try to restore homeostasis.

00:12:59.000 What are those things?

00:13:00.000 What are the actual gremlins?

00:13:03.000 Don't call them gremlins.

00:13:04.000 Okay, so the gremlins represent neuroadaptation.

00:13:09.000 It's the way that our brain, it's our innate re-regulating mechanism to restore a level balance.

00:13:16.000 So if we ingest a substance or engage in a behavior that causes a very large release of dopamine in the brain's reward pathway, Our brains will immediately respond to that by down-regulating our own dopamine production and our own dopamine transmission.

00:13:35.000 They will put us into a dopamine deficit state.

00:13:38.000 So it's not that we just go back to a level balance or homeostasis.

00:13:42.000 We go below baseline dopamine levels.

00:13:45.000 Okay, so if you think about dopamine firing, we're always firing at a tonic level, a baseline rate of dopamine.

00:13:51.000 And dopamine goes up or down depending upon what we're doing.

00:13:57.000 And it is what really governs our approach and avoidance behavior.

00:14:01.000 But every time we have a big surge of dopamine upwards, there's a price to pay for that.

00:14:08.000 And it is that dopamine levels then go below baseline to compensate for that before bringing dopamine back to our baseline tonic levels.

00:14:18.000 And if you repeat that behavior again and again, the initial response to the stimulus gets weaker and shorter, and the after response, the dopamine deficit state, gets stronger and longer until you've essentially put yourself in a chronic dopamine deficit state.

00:14:36.000 Where you're always chasing the dragon.

00:14:38.000 That's right.

00:14:39.000 And when you're not doing that behavior or ingesting that substance, you are in basically something akin to a clinical depression.

00:14:47.000 You're in a dopamine deficit state, so you feel lousy.

00:14:51.000 What if you have multiple addictions and you use those to balance out your dopamine release?

00:14:55.000 Yes.

00:14:56.000 Would that be a good strategy?

00:14:57.000 No.

00:15:00.000 But a lot of people do, right?

00:15:02.000 Yes, right.

00:15:03.000 So this comes up a lot in clinical care.

00:15:06.000 So, for example, I'll ask a patient, you know, how many times a week do you drink alcohol?

00:15:10.000 They say, oh, just once.

00:15:11.000 It's not a big deal.

00:15:12.000 Okay.

00:15:13.000 How many times a week do you use cocaine?

00:15:15.000 Oh, just once.

00:15:16.000 No problem.

00:15:17.000 Okay.

00:15:18.000 That's Tuesday.

00:15:19.000 Yeah, right.

00:15:19.000 It's Tuesday.

00:15:20.000 So what you end up discovering, and this is increasingly common, is like daily polypharmacy, right?

00:15:27.000 Where in their minds, they're not addicted to anything because they're only doing it once a week.

00:15:32.000 But if you add it all up, they're doing something that's addictive every single day.

00:15:36.000 Wow.

00:15:37.000 And all of those substances end up basically working on the same common dopamine pathway, having a compounding effect.

00:15:45.000 Wow.

00:15:45.000 What is the evolutionary biology reason for this?

00:15:51.000 Yeah, yeah, I love that.

00:15:53.000 So, I mean, you know, these evolutionary stories are sort of just-so stories, but I think we can speculate and tell them.

00:16:00.000 I mean, we evolved over millions of years to approach pleasure and avoid pain, and it is what has kept us alive in a world of scarcity and ever-present danger, right?

00:16:10.000 I mean, if we, so when, like, we travel across the desert and we find some water, woohoo, you know, dopamine, that's good.

00:16:17.000 But if we stayed in that, you know, euphoric celebratory state, we really wouldn't be aware of the fact that night's coming or there's a predator that's going to get us.

00:16:26.000 So our brains have evolved to very quickly bring us back down to baseline, again by going below baseline, and that keeps us sort of ever vigilant, ever seeking new and greater rewards, which is exactly what we need in order to survive in a dangerous world and in a world where we don't have the kind of abundance that we're talking about now.

00:16:49.000 And, you know, one of the things that I think has happened is that humanity has reached this really unprecedented state in which our primitive brains are completely mismatched for our modern ecosystem, which is an ecosystem of incredible overabundance and quantity,

00:17:07.000 potency, and variety of these novel drugs.

00:17:10.000 So we're designed for essentially like a hunter-gatherer life.

00:17:15.000 That's how the human body is designed.

00:17:18.000 And I'm sure a lot of those obsessive and dopamine reward system, the release comes from this idea of finding food.

00:17:28.000 The idea of figuring out how to survive and feed the family.

00:17:33.000 When you're successful on a fishing trip and you come back with food, everybody's happy.

00:17:38.000 Like that kind of thing makes people strive to be obsessed with success in that particular area in hunting.

00:17:47.000 Yeah, yeah, yeah.

00:17:48.000 We're always looking for the next thing, never satisfied with what we have.

00:17:52.000 Because we can't be because we have to get more food tomorrow.

00:17:55.000 That's right, that's right.

00:17:56.000 So it's sort of like a built-in human reward system.

00:17:59.000 It absolutely is.

00:18:00.000 And one of the things that I think about people with addiction in our modern times is that, you know, First of all, addiction is endemic in the population.

00:18:11.000 Since the beginning of human history, you can find accounts of people getting addicted to intoxicants.

00:18:16.000 It's not a new phenomenon.

00:18:18.000 What is new today is the increasing numbers of people with minor addictions and just the increasing numbers of people with addictions all across the board.

00:18:26.000 But one of the ways that I think about people with addiction is that There are people who thousands of years ago probably would have been highly adapted to the environment because they would have been our seekers.

00:18:41.000 They would have been the people who were always pushing the envelope.

00:18:45.000 But in the modern world, it can really be a curse to have that kind of temperament and that kind of physiology.

00:18:54.000 Because, you know, modern life is everything sort of, you know, we've got everything we need.

00:18:59.000 We don't have to do anything to survive.

00:19:01.000 We don't even have to really do anything to, you know, we don't have to get off the couch even just to eat.

00:19:06.000 So it can be very challenging to have that chemical makeup in this modern environment.

00:19:12.000 Now, what's the best method for recognizing whether or not you have an addiction or whether you're just an enthusiast?

00:19:24.000 Like, if you're, whatever, if it's a sport or, you know, whatever, it's maybe a gambling thing.

00:19:31.000 Like, how does one know when it's a real problem?

00:19:35.000 And how much recreation can you have without it being addictive?

00:19:42.000 So great question, and I think the answer is going to be different for every person.

00:19:47.000 There's not like a one-size-fits-all.

00:19:50.000 In general, when we are diagnosing addiction in clinical care, it's not based on quantity or frequency per se, although daily users tend to be people that we are concerned about.

00:20:04.000 But the diagnosis of addiction is really based on behaviors and can be briefly summarized as the four C's.

00:20:11.000 Control, compulsion, craving, and consequences, especially continued use despite consequences.

00:20:19.000 So, like, what if you're, like, I have friends that are addicted to golf and they just can't wait to go play golf.

00:20:25.000 What's the consequences?

00:20:26.000 Well, it might be that their spouse says, gee whiz, why are you playing golf all the time?

00:20:31.000 Maybe they just need a new spouse. 1.00

00:20:33.000 Well, okay.

00:20:34.000 Okay, so this actually comes up a lot in clinical care.

00:20:39.000 Like, to what extent is it my problem, and to what extent do I have to change my life?

00:20:44.000 And I always say to patients, you know, that is a great question, and not one that I can answer for you, but maybe together we can find the answer.

00:20:53.000 Because the truth is, sometimes it is a question of needing to change your life, right?

00:20:58.000 And I wouldn't presume to necessarily know, especially with cases on the border.

00:21:04.000 On the border of like...

00:21:06.000 Consequence.

00:21:08.000 Pathological, yeah.

00:21:08.000 I mean, there are some cases where like, okay, you don't need to be a psychiatrist to diagnose that this person has addiction.

00:21:14.000 It seems open to interpretation in the world of what you would call extreme winners, like the Michael Jordans of the world, the people that are just absolutely, completely obsessed with winning.

00:21:24.000 That seems like you could kind of call that an addiction, but then they are the most celebrated people in all of the world.

00:21:32.000 Right.

00:21:32.000 So you're tapping into something that is really important to talk about, which is that our society rewards certain types of addictions and not others.

00:21:42.000 We certainly reward professional athletes who have become obsessively focused.

00:21:48.000 I think we're good to go.

00:22:05.000 That's not what it's about.

00:22:07.000 But what I think is important is to recognize that the same mental machinery that approach and avoid behavior mediated by dopamine that is at play when we become addicted to something can be at play really in all different aspects of our lives,

00:22:24.000 not just drugs and alcohol.

00:22:25.000 So you're essentially looking at this very objectively.

00:22:28.000 You're not making a judgment call.

00:22:30.000 You're just saying the same mechanism is in place, whether it is extremely beneficial, like you are, Michael Jordan, or whether extremely detrimental, like you're a person who's addicted to crack, or you're a gambling addict who keeps blowing all their family's money.

00:22:47.000 You're on the same human neurological pathway.

00:22:51.000 That's exactly right.

00:22:52.000 It's the same mental machinery that's, you know, being applied.

00:22:57.000 And again, there are certain types of addictive behaviors that our society rewards.

00:23:02.000 But even in those cases, I think it's important for people to really closely evaluate potential hidden consequences.

00:23:12.000 And I feel like that's happening.

00:23:14.000 I mean, just using the example, again, of athletes, I feel like there are more and more there are athletes who are in different ways kind of questioning their lifestyle or the things that they have to do.

00:23:28.000 Which I think is good.

00:23:29.000 I think it's always good to look at the pros and cons.

00:23:31.000 Basically, there's never the light without the dark.

00:23:35.000 It's really that dialectic that comes into play really in all aspects of our lives, which I think we need to talk about and think about.

00:23:45.000 We celebrate the people that are extreme winners.

00:23:49.000 We celebrate the people that are absolutely completely obsessed with performance, and they have everything dialed in, including their calories, their macronutrients, the amount of sleep they have, the amount of recovery that they seek out, how they do it.

00:24:08.000 But they have a massive reward for that, right?

00:24:10.000 The massive reward is the glory of being a Michael Jordan or being a Mike Tyson or being a Sugar Ray Leonard or whoever it is at the peak of their performance when they're on top of the world.

00:24:22.000 There's a great deal of benefit to having what many would just call extreme discipline.

00:24:31.000 So what's wrong with that?

00:24:34.000 Well, what we hear very little about is when that road comes to an end and that escalating glory and reward dries up and what those people's lives are like after that.

00:24:46.000 And my sense is that unless they've worked very hard to cultivate other aspects of their personality, when that dopamine trail dries up because...

00:24:56.000 They get injured or they just age.

00:25:00.000 Then they have to contend with the come down, the dopamine deficit state, not to mention all of the other aspects related to loss of identity.

00:25:11.000 Who am I if I'm not this person who's winning?

00:25:13.000 Of course, that's an old trope.

00:25:15.000 We know that, but we don't hear about those athletes after that.

00:25:19.000 The other thing I would say that you point out in that description, which I think is also key to the process of becoming addicted, is the ways in which addiction is also about controlling and changing the way we feel in the moment rather than tolerating the feelings or the uncertainty of what's next and just letting it wash over us.

00:25:43.000 So a really key important aspect of what you call discipline, which I think in some contexts might be addiction, is wanting to control what we're feeling when we feel it.

00:25:57.000 And I think this is also deeply embedded into modern life and modern culture.

00:26:01.000 Explain that, wanting to control what we're feeling and when we feel it, and that's what separates discipline from addiction?

00:26:08.000 No, I think there's overlap there, so let me go back.

00:26:11.000 So, part of what drives the phenomenon of addiction is that people control what they feel when they feel it.

00:26:23.000 So, for example, In this moment, let's say I'm struggling, right?

00:26:30.000 But I feel like, oh, I can get through this because when this is over...

00:26:34.000 I'm not saying I'm struggling, but I mean if I were...

00:26:37.000 I know what you're saying.

00:26:37.000 Yeah.

00:26:37.000 Because when this is over, I'm going to reward myself with X, Y, and Z. So like if you go running and then afterwards you can have a slice of pizza.

00:26:44.000 That's right.

00:26:45.000 Exactly.

00:26:45.000 So it's the way that we bracket our endeavors with rewards.

00:26:50.000 And this is just like deeply embedded into our culture.

00:26:54.000 And the control aspect is a big part of the addictive aspect, because I'm now going to control the way I feel when I feel it, which is a very different way of living if you were to eliminate...

00:27:08.000 Rewards as a way to shape time.

00:27:11.000 If you were to think, I'm not going to do anything to reward myself today.

00:27:16.000 I'm just going to get through the day.

00:27:20.000 It totally changes the arc of our experience in the moment.

00:27:26.000 But is there a bad thing with rewarding yourself for doing something that's difficult but that's ultimately beneficial, like getting a run-in?

00:27:35.000 Like, say if you're going to run five miles.

00:27:38.000 It's not easy to run five miles.

00:27:40.000 If you decide, okay, I'm going to run five miles and when I get back I'm going to reward myself with some ice cream.

00:27:43.000 Is that negative?

00:28:05.000 I don't think it's Modern life is completely revolving around this process of rewarding ourselves.

00:28:13.000 And it's just really the way that we shape time.

00:28:16.000 And I do think that it's also a way in which we are not present in the moment.

00:28:22.000 Because actually to be present in the moment is mostly unsatisfactory and unpleasant.

00:28:28.000 Is that good?

00:28:30.000 To be unsatisfactory and unpleasant?

00:28:32.000 You're painting a very gray world.

00:28:34.000 I'm getting sad.

00:28:37.000 You know, I know.

00:28:39.000 My message is...

00:28:41.000 Stay grayed in the moment.

00:28:43.000 Right.

00:28:44.000 It's not a dark message.

00:28:46.000 It's really not, although it's a hard sell.

00:28:52.000 Let me see how I can put this differently.

00:28:56.000 For a long time, I think this idea of using rewards to kind of shape your day can work.

00:29:05.000 But eventually, you know, it tends to stop working.

00:29:09.000 Because whatever we do that's rewarding, we develop tolerance to.

00:29:13.000 We need more and more of it, a more potent effect.

00:29:15.000 Couldn't you just shift the reward?

00:29:17.000 Sure.

00:29:18.000 And people do it all the time.

00:29:19.000 But there's cross addiction.

00:29:21.000 So ultimately, that new reward will only work for so long or we'll get addicted to the new reward.

00:29:28.000 So I think that...

00:29:31.000 There's a better, harder solution that is about not using rewards as a way to shape time, but instead letting our experience unfold with uncertainty and embracing that uncertainty.

00:29:51.000 I don't know if I'm communicating this, but you can let me know if it makes no sense.

00:29:56.000 I kind of see what you're getting at.

00:29:59.000 And what you're getting at is that there's a benefit in living in the moment instead of seeking out these constant rewards.

00:30:10.000 So difficult things, obsessive things, and then the reward for that obsessive thing.

00:30:16.000 What is the benefit of living in the moment?

00:30:19.000 Mm-hmm.

00:30:20.000 Well, first of all, let me just say that for a long time, when I would hear people say, you know, be in the moment, and I would try to do that, I thought I was doing it wrong because I thought if I could just be in the moment, I would experience some sort of bliss, and I never did.

00:30:37.000 But what I eventually realized is that being in the moment means tolerating the distress of just fully being in the moment.

00:30:50.000 And that's all the harder to tolerate because we have all these rewards that are waiting for us and we'd rather go there.

00:30:57.000 So being in the moment is tolerating the distress of being in the moment?

00:31:03.000 What's the benefit of being in the moment?

00:31:08.000 The benefit of being in the moment, for me, once I acknowledge that I'm not necessarily going to feel good, is that I can really be present and then open to positive experiences that are not of my own making.

00:31:25.000 Like what?

00:31:27.000 Really unexpected.

00:31:29.000 Really unexpected and not that frequent.

00:31:32.000 But when they do come along, they're lovely.

00:31:36.000 What are these experiences, though?

00:31:41.000 They're unpredictable, and they're incredibly fleeting, but it's just- Are these miracles?

00:31:46.000 Are you talking about miracles?

00:31:46.000 No.

00:31:47.000 No, I'm not talking about- Maybe I am talking about miracles, but I don't think of them as miracles.

00:31:53.000 I mean, let me ask you this.

00:31:57.000 What are some of the happiest moments that you've had in your life?

00:32:02.000 Or just think of one of the- Where were you and what were you doing?

00:32:06.000 Oh, well, that's very difficult.

00:32:07.000 I've had a very happy life.

00:32:09.000 I've been very lucky.

00:32:10.000 I've had a lot of very fun experiences.

00:32:13.000 Okay, okay.

00:32:14.000 So, you know, you could be baseline temperament just a happier person than I am, which is perfectly possible, because I do think we come into life with sort of different degrees of happiness, and I'm probably a little bit on the unhappiness side of things.

00:32:31.000 This is my position though.

00:32:32.000 My happiness has often come from very hard work.

00:32:35.000 And then a reward.

00:32:38.000 My happiness has often come from accomplishments.

00:32:41.000 Accomplishments that were very difficult to achieve.

00:32:44.000 Other than love, family, that kind of happiness.

00:32:49.000 It's a different kind of happiness.

00:32:51.000 So let me ask you this.

00:32:56.000 No.

00:33:02.000 Never.

00:33:03.000 Not really, no.

00:33:05.000 I seek out very, very difficult things to do, and in getting better at those very difficult things, I believe that you're challenging your human potential, and that you're trying to figure out how to master your emotions,

00:33:23.000 your discipline, your focus, and I think there's great reward in that.

00:33:28.000 I think there's great reward in discipline.

00:33:31.000 There's great reward in sticking to a difficult schedule, particularly physically, that's hard to stick to, like a physical workout schedule or a meditation schedule,

00:33:46.000 yoga, things along those lines.

00:33:48.000 If you can do that on a daily basis, I believe it alleviates a considerable amount of anxiety.

00:33:55.000 And it fills the mind up with challenges that I believe the mind requires.

00:34:02.000 I think your mind requires a certain, at least my mind I should say, my mind requires a certain amount of challenges.

00:34:09.000 It requires difficult puzzles to solve.

00:34:12.000 I think that's why I got addicted to games.

00:34:15.000 I used to be addicted to pool.

00:34:18.000 I've been addicted to martial arts.

00:34:19.000 I've been addicted to a lot of difficult challenges.

00:34:23.000 I think for sure I've been addicted to stand-up comedy, which is also a difficult mental challenge.

00:34:28.000 But I find great reward in seeking out these challenges and trying to do my best to solve them.

00:34:41.000 Yeah.

00:34:42.000 So, I mean, what you're describing is something that I actually recommend to patients who are trying to get into recovery from addiction to things like drugs, alcohol, or other highly reinforcing things like games or pornography.

00:34:57.000 If we think about the pleasure-pain balance again, what I actually recommend they do, in addition to abstaining from their drug of choice, is to actually intentionally press So how does one step intentionally onto the pain side?

00:35:24.000 By doing the very kinds of things that you talk about, effortful engagement in daily practices that are not easy.

00:35:32.000 So you've really figured it out in terms of you need a certain amount of friction in your life.

00:35:42.000 100%.

00:35:42.000 Right, and you need maybe more friction than average.

00:35:44.000 And you've determined that the best way for you to get that friction is to do things that are hard.

00:35:52.000 And that is what I've learned from my patients and what I now prescribe to them.

00:35:56.000 One of my patients said to me, if there's one thing I've learned about recovery, it's that the hard way is usually the right way.

00:36:03.000 So your reward comes from this effortful engagement and probably results in you having dopamine release, right?

00:36:10.000 Not as an immediate factor, but as the opponent process or the after effect.

00:36:16.000 So that's all very good.

00:36:19.000 But I guess where my mind goes, thinking about you and your experience...

00:36:26.000 I mean, certainly we can get addicted to pain, right?

00:36:29.000 And we can push too hard on that side of it and take that too far.

00:36:34.000 I mean, it sounds like what you do is you do that for a while with one activity on the pain side, and then you switch to another one, so there's just that little bit of novelty to stretch yourself again.

00:36:44.000 But I guess I wonder, is there a point at which you kind of get burned out on all of that?

00:36:51.000 No.

00:36:52.000 Okay.

00:36:53.000 Well, stand-up comedy, for sure, no.

00:36:55.000 I've been doing that for more than 30 years.

00:36:58.000 Martial arts, for sure, no.

00:36:59.000 I've been doing that more than that.

00:37:01.000 I've been doing that for almost 40 years.

00:37:08.000 No.

00:37:09.000 Okay, so this is still working for you.

00:37:11.000 I just find things that are difficult.

00:37:14.000 My problem, I do have issues with obsessive things, like games.

00:37:21.000 I still play pool, which I find, I think there's a mental reward and there's benefit to the focus that I get from The geometry of pool and the calculations of the maneuvers and how to move the ball around,

00:37:41.000 all those different things.

00:37:42.000 I think it's a mental exercise that I think is actually very good for me.

00:37:45.000 But I want to play it eight hours a day.

00:37:47.000 Right.

00:37:47.000 You know, so I have to force myself.

00:37:50.000 I gotta go, okay, it's...

00:37:52.000 X amount of time, and then that's it, and then it's over, and then I gotta go home.

00:37:56.000 I just know my brain, and I know that if I did fall into the addiction side of it, and I started playing 10, which I did used to do.

00:38:05.000 When I lived in New York, I used to play eight hours a day.

00:38:08.000 When I fall into that, then I don't feel good.

00:38:11.000 Then I feel like wrecked and I feel like I'm wasting my life.

00:38:15.000 It doesn't feel like recreation.

00:38:17.000 It feels like a negative obsession.

00:38:20.000 For me, it's about finding this balance.

00:38:23.000 The things that I find that I get obsessed with that turn out to be beneficial are usually the things that enhance my life.

00:38:33.000 We were talking before the show started about comedy.

00:38:36.000 And there's a great reward to putting a set together and then the audience has a great time.

00:38:43.000 And you feel great because these people came out to see you.

00:38:46.000 They schedule their evening around this.

00:38:49.000 They have a great time.

00:38:50.000 And everybody walks out of there and they feel good.

00:38:52.000 That's an amazing feeling that's worth all the effort and reward.

00:38:57.000 It's this complicated puzzle that the mind has to solve.

00:39:04.000 I don't know how other people feel, but I think a lot of people, myself included, need difficult things to solve.

00:39:16.000 They need a challenging But yet rewarding occupation.

00:39:21.000 They need something that stimulates their mind.

00:39:25.000 Do you remember when going postal was a thing?

00:39:29.000 Where post office workers, for some reason, were just shooting a bunch of people.

00:39:33.000 And I remember having a conversation with my friend about it.

00:39:36.000 I'm like, imagine the monotony.

00:39:37.000 Of, like, just sorting things out by zip codes or just whatever it is that forced...

00:39:43.000 I mean, what is it that you was for...

00:39:46.000 And it stopped somehow or another with the post office paid people more money.

00:39:50.000 I don't know what happened.

00:39:50.000 But they stopped shooting people.

00:39:53.000 But it was a thing where, like, multiple post office workers were, like, going on rampages to the point where there's games called Going Postal, like a video game.

00:40:03.000 And I was always wondering, like, is that because that's not challenging?

00:40:07.000 It's not rewarding?

00:40:08.000 Like, what is it?

00:40:09.000 What is it about it that makes people so frustrated or that builds up this angst or this anger or, you know...

00:40:19.000 But then some people love a job like that where they just show up and they talk to their friends at work and they have a coffee break and they have a great time and they feel completely satisfied by that.

00:40:32.000 Maybe they go home and they watch a little TV or they watch a game.

00:40:35.000 Maybe they'll play little video games before they go to sleep and they can have a happy life like that, at least allegedly.

00:40:44.000 So, is it that you have to find the balance for your own personality, your own personal biological makeup, your own life experiences, and all the levels of neurotransmitters you have in your brain as opposed to other people?

00:41:02.000 Is that what it is?

00:41:03.000 It's like finding your own personal balance?

00:41:05.000 Yeah, I mean, you know, addiction is called a biopsychosocial disease.

00:41:11.000 And it's a really great construct because it speaks to the fact that there's a biological component, you know, your sort of innate biochemistry.

00:41:22.000 There's a psychological component, the way that you problem solve or, you know, have insight or not into your behaviors.

00:41:30.000 And then there's the social component.

00:41:32.000 What's your life?

00:41:33.000 What are your opportunities?

00:41:36.000 I mean, you seem like somebody who...

00:41:40.000 Has had opportunities and also has made the most of those opportunities, but there are lots of people who probably don't have those types of choices and opportunities, so then they need to figure out, you know, people who, I mean, I don't know what it's like to work in a post office,

00:41:56.000 but, I mean, it might be very interesting.

00:41:58.000 It might be very boring.

00:42:00.000 I do think that there are ways you can make it interesting by, again, trying to be more present and focus on it.

00:42:07.000 But what can happen in a lot of jobs that, like, lack the same level of fascination is that people kind of get through that and then reward themselves at the end of that day.

00:42:20.000 Right, exactly, right.

00:42:22.000 Yeah.

00:42:22.000 So, you know, again, speaking to kind of the difficulty of modern life for many people, I mean, you have what appears to be a really interesting job, and you've made—I mean, I gather you're a self-made person,

00:42:38.000 right?

00:42:38.000 So you've made these opportunities for yourself, which is a testament to your own discipline, but also there's an element of luck there.

00:42:46.000 Would you agree?

00:42:47.000 Yes.

00:42:48.000 Yeah.

00:42:51.000 But gosh, not everybody has that.

00:42:54.000 And so how do they make a life worth living even within that context?

00:42:59.000 Also, I just want to emphasize again that you've tapped into something that I think I think it's really, really important in that you realize that the best way to get your dopamine is through the opponent process mechanism.

00:43:11.000 So instead of getting it by ingesting something that immediately releases dopamine in your brain's reward pathway, you do hard things by pressing on the pain side of the balance.

00:43:23.000 Which then triggers your own endogenous opponent process or reregulating mechanism to create dopamine in response to that, which is potentially a more enduring source of dopamine, less likely to lead to tolerance and addiction.

00:43:38.000 I don't necessarily know that I would agree that it's a pain side of things, though.

00:43:43.000 Because I think a lot of it is the way you approach things.

00:43:48.000 Yeah.

00:43:50.000 Well, again, I use that term pain very broadly.

00:43:53.000 That would include doing things that are effortful in any way, doing things that are creative.

00:44:00.000 Maybe pain's not the right.

00:44:02.000 For me, it's the pleasure-pain balance.

00:44:04.000 That's a metaphor that I use.

00:44:06.000 But you're absolutely right.

00:44:07.000 This is, broadly speaking, not just physical pain.

00:44:09.000 We're talking about emotional effort, creativity, cognitive complexity, things that take effort on a daily basis where the reward is delayed.

00:44:20.000 It's also really true that the pleasure-pain balance is an oversimplification and that we can experience pain and pleasure simultaneously, for example, when we're eating spicy food.

00:44:33.000 It's also true that the meaning that we give to our suffering can absolutely change that experience.

00:44:38.000 So there's a Very famous experiment done by Dr. Beecher, who interviewed World War II soldiers right after they had, you know, on the battle lines, right after they had received these grotesque injuries,

00:44:55.000 guts spilling out, amputated limbs.

00:44:57.000 And he found that approximately two-thirds of them had no pain in the immediate aftermath of their injury.

00:45:03.000 And through his research, he concluded that the reason for that was, number one, they realized they were still alive and happy to be so.

00:45:09.000 And number two, they realized they were probably going home.

00:45:12.000 And so the meaning for them of the injury was going home.

00:45:16.000 So our prefrontal cortex You know, that area right behind our forehead communicates with our lower brainstem, lizard brain reward pathway, and incredibly, you know, modifies and modulates that experience to sort of describe,

00:45:34.000 you know, a corollary example.

00:45:37.000 There was a case report of a young man, a construction worker, who jumped on a giant nail that went right through his boot, through his foot.

00:45:44.000 He showed up in the emergency room, intense pain.

00:45:47.000 They gave him opioids.

00:45:47.000 It wasn't enough.

00:45:48.000 Still screaming in pain.

00:45:49.000 They gave him more opioids.

00:45:50.000 It wasn't enough.

00:45:51.000 Still screaming in pain.

00:45:52.000 They finally had to give him so many opioids that he became unconscious.

00:45:55.000 They slowly removed the nail.

00:45:57.000 They slowly removed the boot.

00:45:58.000 And it turns out the nail had gone right between his toes.

00:46:02.000 So he, in fact, had no tissue injury, but his mind saw the boot, the nail sticking up to the boot, and he experienced real pain.

00:46:12.000 So that pain was real for him.

00:46:14.000 It wasn't made up, but his brain had elaborated that pain.

00:46:18.000 A less charitable person would not look at that man that way, especially people who've actually been injured.

00:46:25.000 Well, you know, I tell you, the ways in which our brains can manufacture pain...

00:46:32.000 But is that really our brain?

00:46:34.000 Or is it...

00:46:35.000 Well, I guess it is, right?

00:46:37.000 Because it's all happening inside the mind.

00:46:39.000 Yes.

00:46:40.000 But that seems like a baby, a big grown man baby, right?

00:46:45.000 I'm not saying, look, obviously terrible that the man was injured, sort of, not really injured much.

00:46:51.000 But that's kind of—that's like the caricature of men when they get sick, right?

00:46:57.000 No.

00:46:58.000 Isn't it?

00:46:58.000 No, no, no.

00:46:59.000 Where their mom has to take care of them or their wife has to take care of them and they act like a big baby? 0.95

00:47:05.000 No, no, no.

00:47:05.000 No?

00:47:05.000 No, to me—I mean, it's an extreme example, but to me it shows how— Our interpretation of what has happened to our body has a huge impact on how we experience that injury or that stimulus.

00:47:23.000 And it's real.

00:47:25.000 Right, but is that interpretation because the person has not experienced actual real injuries before and it's just massive anxiety because they've lived a sheltered life?

00:47:35.000 Well, okay.

00:47:35.000 So anxiety exacerbates pain.

00:47:38.000 So for example, people with chronic pain, we know that when they have anxiety, it opens up the gates to the experience of pain and their pain gets worse when they have stress.

00:47:48.000 But pain is very subjective, right?

00:47:49.000 Yes, it is.

00:47:49.000 We don't know what a person's feeling.

00:47:51.000 That's right. 0.99

00:47:51.000 Like people have told me that some things are painful and then I experience them like, what the fuck are you talking about? 0.99

00:47:56.000 This is nothing. 0.96

00:47:57.000 Yeah.

00:47:57.000 You know, like tattoos.

00:47:58.000 I remember before I got tattooed, people were telling me, oh my God, it's the most painful thing ever.

00:48:02.000 And I was getting tattoos like, this is hilarious.

00:48:05.000 This is the most painful thing ever.

00:48:07.000 Obviously, there's parts of your body that are far more sensitive, and I found that out the hard way.

00:48:11.000 But even those parts, like your elbow and like towards your upper shoulder...

00:48:17.000 I guess your chest and your ribcage is supposed to be very painful.

00:48:20.000 It's not that bad.

00:48:21.000 It's not like childbirth.

00:48:23.000 I've been there when my wife was giving birth.

00:48:25.000 It's painful.

00:48:26.000 I've had broken bones.

00:48:28.000 I've had surgeries and torn ligaments and torn meniscus, things that are very painful.

00:48:34.000 It's not that.

00:48:35.000 Okay, so people have different innate pain thresholds.

00:48:39.000 Is it innate or is it learned to tolerate?

00:48:42.000 Part of it is innate.

00:48:43.000 Do we know this for sure?

00:48:45.000 Well...

00:48:46.000 We do.

00:48:47.000 How do we know that?

00:48:48.000 Well, I know because as a mother, I saw that in my own kids.

00:48:52.000 Right, but don't one of your kids complain more than the other one?

00:48:56.000 Isn't one kid more likely to just deal with stuff?

00:49:00.000 That's right.

00:49:00.000 That's the innate.

00:49:01.000 But is that or is that a way of interfacing with reality?

00:49:05.000 Is it a way of seeing things and just dealing with Or is it a registered number, right?

00:49:14.000 So you say that guy was experiencing pain.

00:49:17.000 What was his number?

00:49:19.000 If he had 1 to 10, 10 is you're about to die, 1 is you got a mosquito bite.

00:49:25.000 What is that pain?

00:49:27.000 Some people hit 4 and they cried like a little baby.

00:49:31.000 And some people, they can get all the way up to nine and they won't budge.

00:49:35.000 Okay, so I agree with you.

00:49:38.000 There's no pain-o-meter.

00:49:41.000 There's no way to measure somebody's subjective experience of pain.

00:49:44.000 But it is true that people are born with different pain tolerance.

00:49:51.000 For example, some people are born insensitive to experiencing any pain at all.

00:49:55.000 But isn't that rare?

00:49:56.000 And it's very different.

00:49:57.000 But it's very different, right?

00:49:59.000 It's rare.

00:50:00.000 But let's acknowledge that people are different in all kinds of parameters.

00:50:04.000 You can accept that maybe people are born with different innate pain thresholds.

00:50:10.000 Now, you add to that...

00:50:13.000 Exposure to pain, regular, graded, and then people develop tolerance to pain, right?

00:50:19.000 Where they can tolerate...

00:50:20.000 Acceptance.

00:50:21.000 Well, and it's not just, though, a cognitive acceptance.

00:50:24.000 It's actually this pleasure-pain balance at work.

00:50:27.000 It's real neuroadaptation.

00:50:29.000 But the neuroadaptation, is it measurable?

00:50:31.000 Well, it's not measurable.

00:50:32.000 So how do we know that it's real?

00:50:34.000 How do we know that this tolerance is not just acceptance?

00:50:39.000 Like, if you injure yourself, some people will freak out and they'll have massive anxiety.

00:50:45.000 I've seen it from martial arts in particular.

00:50:48.000 And then other people go...

00:50:50.000 Okay, looks like I'm hurt.

00:50:51.000 Like the soldiers coming back from the battlefield, like this concept.

00:50:56.000 Some people can just handle it.

00:50:58.000 Clearly, there's a psychological element that you highlighted earlier when you were talking about these soldiers.

00:51:04.000 They could be disemboweled, losing limbs, but yet they weren't experiencing pain.

00:51:09.000 Because of the psychological element of the fact that they were coming home, The fact that they were alive, so they had put this injury into a different place than the average person would, say, if you were in a car accident and experienced the same injury.

00:51:23.000 This is a psychological thing.

00:51:25.000 This is not an innate tolerance.

00:51:29.000 So I guess I would agree with you that there's a huge psychological and learned component.

00:51:36.000 And with graded exposure, we can develop tolerance to pain.

00:51:41.000 That is absolutely true.

00:51:43.000 But I also think that there are innate differences there between individuals.

00:51:50.000 Just like there's an innate psychological and personality differences.

00:51:54.000 Yes, yes.

00:51:54.000 And maybe those are the same thing.

00:51:56.000 I mean, there are experiments, for example, showing that if you apply a pain to different parts of the body at the same time, the stronger pain will lessen the experience of the lesser pain.

00:52:11.000 So there's something biological that happens, again, as our brains adapt and process those dual signals.

00:52:21.000 So, I mean, you know, psychological differences are also brain differences, right?

00:52:27.000 Those are innate differences.

00:52:29.000 And a lot of them are based on life experience, though.

00:52:32.000 Yeah, right, right.

00:52:33.000 Yeah, so resilience is based on graded exposure.

00:52:37.000 So, for example, people with anxiety disorders or specific phobias, a treatment for that is actually to expose them in measured ways to the thing that they're afraid of.

00:52:47.000 Like spiders?

00:52:47.000 Like spiders, like driving over bridges, like going on airplanes, like talking to people, which more and more young people have social phobia.

00:52:56.000 Exposing them to other difficult things, does that make them more resilient in other ways?

00:53:01.000 Like one of the things I've gotten into recently is cold plunges.

00:53:05.000 Have you ever done one of those?

00:53:08.000 Yes.

00:53:08.000 Did you enjoy it?

00:53:09.000 No.

00:53:11.000 Not at all.

00:53:12.000 What did you do?

00:53:13.000 Explain.

00:53:14.000 We were in Iceland.

00:53:16.000 Oh, the real deal.

00:53:17.000 Yeah, right.

00:53:17.000 And they have the very hot one and the very cold one.

00:53:19.000 And I really could.

00:53:21.000 I had a very difficult time with the cold water.

00:53:23.000 That's something I really cannot do for any measurable amount of time.

00:53:28.000 But I bet you could.

00:53:30.000 Yes, if I practiced it, yes, I could.

00:53:33.000 Particularly if you learn some breathing exercises?

00:53:36.000 Yes.

00:53:38.000 Although I've heard about the breathing exercises and I've tried them and I can't get it to work.

00:53:43.000 With cold?

00:53:44.000 Yeah.

00:53:45.000 How many times have you done this?

00:53:47.000 Oh, well, I tried it quite a lot when we were in Iceland.

00:53:49.000 Did you?

00:53:50.000 How many times did you try it?

00:53:51.000 Like, I don't know, every day for a week.

00:53:53.000 It didn't get any better.

00:53:54.000 Do you know what I mean?

00:53:55.000 Yeah.

00:53:57.000 Was it the kind where you were in a frozen lake and they cut a hole in it and you climbed right in?

00:54:01.000 No, it was like in a spa with a bunch of old Icelandic people who all had no problem with it. 0.53

00:54:07.000 Well, they're just so used to it, right?

00:54:09.000 Yeah, right.

00:54:11.000 It's not comfortable.

00:54:13.000 But my question was, I wonder if exposure to difficult environments like that builds resilience in other aspects of your life.

00:54:24.000 I wonder if you can regularly expose yourself to extreme cold or maybe the sauna, extreme heat, and that can actually build resilience.

00:54:35.000 If resilience is almost like a psychological aspect that can be nurtured.

00:54:43.000 Is that possible?

00:54:45.000 Oh, absolutely.

00:54:46.000 I mean, that's so much of the work that, you know, that I do with patients is trying to get them to do things that are hard, that builds up their actual biological, psychological resilience to hard things, but also importantly,

00:55:03.000 gives them a touchstone for For confidence and competence and self-efficacy.

00:55:09.000 That they can get through that.

00:55:10.000 That's right.

00:55:10.000 I did that so I can do this other thing.

00:55:13.000 And that is so key in life, like knowing I endured that thing.

00:55:18.000 And it's like you get to steal from that and apply it to the next thing.

00:55:23.000 But it doesn't always cross over.

00:55:24.000 So there's a great anecdote about Alex Honnold, El Capitan.

00:55:29.000 He's been on a couple times on the podcast.

00:55:31.000 Oh, neat.

00:55:31.000 Okay, great.

00:55:32.000 I love that guy.

00:55:32.000 Yeah.

00:55:33.000 And they studied his brain to see if his amygdala was different because how could he do it?

00:55:40.000 And they came up with this theory that his amygdala was different and he was born with a different amygdala.

00:55:44.000 But he basically refuted that and said, I think it's just graded exposure from all of the climbing that I've done.

00:55:51.000 You know, I've built up this kind of, you know, mental calluses to be able to climb.

00:55:56.000 But apparently when they were putting him in the MRI machine to study his brain, he had almost had a panic attack.

00:56:03.000 I mean, this is hearsay.

00:56:04.000 I, you know, I don't, I don't, I'm not friends with that.

00:56:06.000 Let me ask him.

00:56:07.000 Let me ask him.

00:56:08.000 Yeah, you ask him if that's true because I read that.

00:56:10.000 I read that.

00:56:11.000 He's pretty mellow.

00:56:12.000 But I mean, the point is that there's not always cross-tolerance for these things.

00:56:17.000 I think in many ways there can be cross-tolerance.

00:56:19.000 And you can, again, in that self-efficacy, you can use it.

00:56:22.000 But it doesn't necessarily mean you can do everything.

00:56:25.000 But the thing about the climbing to him is it's not painful in that it's not scary.

00:56:32.000 He's so good at it and he's done it for so long.

00:56:35.000 The way he described it very specifically, he's like, it's pretty chill.

00:56:40.000 He goes, until it's not.

00:56:42.000 And then if it's not, there's a real problem.

00:56:44.000 But he just stays calm and just climbs.

00:56:47.000 He just gets his hand there and pulls himself up.

00:56:50.000 He gets here and pulls himself up.

00:56:52.000 It's a mellow thing.

00:56:53.000 It's not a frantic thing.

00:56:55.000 Like for you or I, they would look down.

00:56:58.000 My hands are sweating right now thinking about him climbing.

00:57:02.000 I freak out.

00:57:04.000 My friend Kelly sends me these videos all the time because he knows I freak out. 0.99

00:57:09.000 Of like people riding their bike on the ridge of a cliff or that kind of stuff, or people who are jumping from like ledge to ledge, like that kind of shit. 0.95

00:57:17.000 My hands start sweating like crazy. 0.88

00:57:20.000 No, I'm terribly afraid of heights too.

00:57:24.000 It drives me nuts.

00:57:25.000 But it's not just that.

00:57:27.000 It's like willfully putting yourself in these positions that could be avoided.

00:57:31.000 Yes.

00:57:31.000 There's something about it's not just the fact this guy wants to ride a dirt bike around the rim of a cliff.

00:57:39.000 It's that he's doing it and he doesn't have to.

00:57:44.000 Right.

00:57:44.000 They're like, don't do that.

00:57:46.000 Right.

00:57:46.000 You know, like my brain says, don't get down, Alex.

00:57:49.000 You don't have to climb up there.

00:57:50.000 Yeah.

00:57:51.000 But for him, that's what he loves.

00:57:55.000 And I wonder what's going on with him.

00:57:58.000 When he gets to that top, I wonder if you could measure, if you had an fMRI, you could just plug him to it right away.

00:58:05.000 Plug him in in the beginning, plug him in at the end.

00:58:08.000 What's the activity?

00:58:12.000 What do you think is happening?

00:58:14.000 Well, you know, I think...

00:58:16.000 My hands are so sweaty.

00:58:17.000 Feel my hands.

00:58:17.000 Okay.

00:58:18.000 Oh, yeah, they are.

00:58:20.000 Soaked, right?

00:58:20.000 Sorry.

00:58:21.000 Sorry I made you do that, but that's what that's from.

00:58:23.000 I wanted you to know I'm telling the truth.

00:58:24.000 I really freak out.

00:58:26.000 Yeah.

00:58:29.000 You know, I mean, I could only speculate what's going on in Alex Honnold's mind, but...

00:58:34.000 I suspect that it is this, like he must have early in his career found climbing incredibly reinforcing, you know, got a huge dopamine hit in his reward pathway.

00:58:48.000 And then, you know, climbing is sort of naturally a thing where you can always escalate it, you know, harder mountains, no ropes, you know, higher and higher.

00:58:59.000 And so there is a way in which, and I have a patient who's a climber, He's addicted to alcohol.

00:59:05.000 He's in recovery.

00:59:06.000 But he says he has to be very careful that he doesn't apply those same sort of addictive tendencies to climbing because he said it would be very easy to do that.

00:59:14.000 And then get hurt maybe?

00:59:16.000 That's right.

00:59:16.000 He says he knows a lot of people who have died because of that escalating process.

00:59:22.000 He knows a lot of people who have died?

00:59:24.000 Well, okay, he knows some of the people who have died.

00:59:27.000 I mean, a lot, but, you know, I don't know.

00:59:29.000 Imagine, you know, 50 people, 30 of them died climbing.

00:59:32.000 Right, yeah.

00:59:33.000 Well, but see, it's hard to do that, right?

00:59:37.000 Once you've devoted all that time and energy and creativity.

00:59:40.000 And then also, I guess, you know, again, importantly, people then also rely on it for their homeostasis and maintain their dopamine levels, right?

00:59:48.000 So then if you were to stop doing that, naturally, there would be a come down, right?

00:59:53.000 I know a lot of folks who had addiction issues with substances who got into endurance sports.

01:00:00.000 Right.

01:00:01.000 A lot of them like they got into triathlons or Ironman or, you know, marathon running, ultra marathon running, that kind of thing.

01:00:10.000 Yeah.

01:00:11.000 Yeah, and I actually prescribe exercise to my patients who are trying to quit drugs and alcohol and pornography and gambling and whatever it is, because we do know that exercise is a great way to get that opponent processed dopamine, the after-effect dopamine that our own bodies make.

01:00:29.000 And we do know that it helps tolerate the withdrawal from drugs and alcohol.

01:00:33.000 There are good data on that.

01:00:35.000 But there's always a risk then of getting addicted to that behavior.

01:00:39.000 And there's some interesting animal studies showing rats, for example.

01:00:44.000 We used to think that...

01:00:46.000 So, for example, if you put one of those running wheels in a rat's cage, they are less likely to self-administer drugs like cocaine and methamphetamines.

01:00:56.000 So when those studies were first being performed, the running wheel was thought to be a way to just measure baseline activity or as a healthy alternative to self-drug administration.

01:01:12.000 But over time, scientists began to see that the running wheel was in and of itself reinforcing.

01:01:18.000 So a rat or mouse will run longer in a running wheel than they will on a flat treadmill or in the wild.

01:01:27.000 Some mice or rats will run so long in the running wheel that their tails will curve up and remain permanently curved in the shape of the running wheel, and some rats will run on that running wheel until they die.

01:01:41.000 And that was the first indication that that running wheel in and of itself can be a drug, that it has its own reinforcing properties.

01:01:50.000 I'm sure you're aware of the studies that they did with rats with heroin and cocaine and that they did it in cages and they found that these rats would self-administer heroin and cocaine to the point where they would drink the water that had heroin and cocaine in it and avoid the regular water and they'd do it until they died.

01:02:12.000 Until they set up a happy environment for these rats. 0.79

01:02:15.000 And this is what gets me to this whole hunter-gatherer thing again.

01:02:22.000 Mm-hmm.

01:02:38.000 And that the environment itself of these cages with the bright fluorescent lights, these were extremely distressful, and so the rats were essentially self-medicating to avoid the distress that they were being put into.

01:02:53.000 Are we doing that to ourselves?

01:02:55.000 This is the question.

01:02:57.000 Addictive behaviors that exist in human beings today, are they exacerbated by the circumstances of our modern world?

01:03:06.000 Cubicle life, commuter life, being on the subway or whatever you're doing where you're just droning in and out and constantly being around people and constantly being in these Unnatural environments.

01:03:20.000 And then, again, this theme of doing something you don't want to do all day long.

01:03:27.000 Something that's not rewarding and not interesting and then you get home and you medicate.

01:03:31.000 Right, right.

01:03:32.000 Okay, so great.

01:03:34.000 I'm glad that's the famous rat part experiment.

01:03:36.000 I'm really glad you brought it up because I have some thoughts to share about that.

01:03:41.000 Cool.

01:03:42.000 So, yes, you know, absolutely, you know, this idea of our not being in an enriched environment that's conducive to good health can absolutely lead to the problem of addiction.

01:03:58.000 Right.

01:03:58.000 However, I think that a central problem today which is not appreciated is that we have turned rat park into rat amusement park.

01:04:13.000 Even in an ideal environment, people can get addicted because they have access to so many highly reinforcing drugs and behaviors that are mediated through technology, access, potency,

01:04:29.000 novelty.

01:04:29.000 So a couple examples.

01:04:31.000 If you put a running wheel in this enriched rat park environment that you talk about, rats will spend an inordinate amount of time on the running wheel and they won't explore the maze, right?

01:04:45.000 Right.

01:04:45.000 So there's something about- A maze in the rat park?

01:04:49.000 Yeah, they won't explore this wonderful enriched environment.

01:04:52.000 They'll spend a lot of time on the running wheel.

01:04:54.000 So they enjoy the wheel?

01:04:56.000 They really enjoy the wheel.

01:04:58.000 Is it dependent upon the size of the environment?

01:05:01.000 Like if you have a warehouse, you know what I'm saying?

01:05:05.000 Like if you have a rat in a warehouse, fill the trees and natural sunlight and all the things that a rat would experience.

01:05:11.000 Like if you have a warehouse with a glass roof.

01:05:14.000 So Leiden University in the Netherlands, they took running wheels and they put them in the wild.

01:05:24.000 Huh.

01:05:26.000 Huh.

01:05:42.000 And that's what I'm trying to get at, Joe, that technology has changed the world such that we are chronically ingesting and engaging in these highly reinforcing drugs and behaviors which have engendered a dopamine deficit state,

01:06:03.000 making us all more anxious and depressed.

01:06:05.000 And it's not necessarily a matter of Trauma or social inequality or not having an adequate maze.

01:06:14.000 Those can be contributors.

01:06:15.000 But even when everything is ideal, even when you and I live in the best rat park in the world, there are so many running wheels.

01:06:23.000 There are so many levers for cocaine and its equivalent that we've all become more vulnerable to this problem of addiction.

01:06:31.000 It's fascinating that in the wild, rats sought out the running wheel.

01:06:35.000 Yes.

01:06:36.000 And they put it both in an urban area where feral mice voluntarily and obsessively ran in the wheel, and they put it in a more rural environment and dune setting where animals obsessively engaged in this kind of...

01:06:52.000 Wow.

01:06:53.000 Yeah.

01:06:54.000 What does that mean?

01:06:55.000 Like, what is the running wheel to a rat?

01:06:57.000 Like, what is the reward of getting on that thing?

01:07:01.000 Is it just wee?

01:07:02.000 Is it just like a child on a Ferris wheel?

01:07:06.000 Yes, yes, yes.

01:07:07.000 And they discovered, just in general, looking at the reinforcing properties of a running wheel, that mice, for example, prefer a square running wheel.

01:07:16.000 And they prefer a running wheel with little obstacles in it.

01:07:19.000 So there's something about...

01:07:21.000 A square, right?

01:07:22.000 Uh-huh.

01:07:22.000 How so?

01:07:23.000 Well, because it's more complicated, right?

01:07:25.000 What do you mean by a square?

01:07:26.000 Well, it's actually a square, but you have to run on it.

01:07:28.000 Oh, so it flops over?

01:07:30.000 Yeah.

01:07:30.000 And you can see these mice kind of flip themselves right and going over.

01:07:34.000 And they enjoy it.

01:07:35.000 Oh, they love it.

01:07:36.000 They absolutely love it.

01:07:37.000 Yeah.

01:07:38.000 What would be the, again, evolutionary benefits?

01:07:41.000 What would be the evolutionary benefit of a mouse playing in the wild?

01:07:45.000 I mean, they're essentially prey animals.

01:07:47.000 Right.

01:07:48.000 Well, I mean, I think this is the crux of the matter is there is no evolutionary benefit.

01:07:53.000 It's a mismatch now between what was a neural network that was adapted to the world, which is no longer adapted to the world we have created.

01:08:05.000 Right.

01:08:06.000 But with humans, I would imagine that a video game sort of piggybacks on your need to problem solve and you're dealing with like combat scenarios that would sort of highlight parts of the brain that were designed to fight off neighboring warring tribes or something.

01:08:22.000 And the whole treasure hunting, you know, part of our brains wanting to find that next best thing.

01:08:27.000 Sure, those are all innate good things, but, you know, then we've turned it up to 11, right?

01:08:31.000 I mean, or 12 or, you know, 500. I mean, so we've, you know, turbocharged these digital products in a way that our minds really don't have the capacity to manage.

01:08:47.000 And then we're just absolutely sucked in there.

01:08:50.000 Do you think that all of those things, I mean like there's a, for sure there's people that make a living out of playing video games.

01:08:59.000 Yes.

01:09:00.000 Are they addicts too?

01:09:02.000 Okay.

01:09:03.000 When I treat mostly young men with serious video game addiction...

01:09:09.000 How many young men do you treat with that?

01:09:11.000 I don't know.

01:09:12.000 Too many.

01:09:12.000 Yes, increasingly common.

01:09:14.000 And these aren't ambiguous situations.

01:09:17.000 These are young people who are depressed and suicidal primarily because of their video and game addiction.

01:09:21.000 Is it mostly men?

01:09:22.000 Oh, yes.

01:09:23.000 Far and away, mostly young men.

01:09:26.000 And...

01:09:28.000 Almost every single one of them will tell me that the way they rationalized to themselves that the amount that they were playing was okay was because they were going to be that guy, you know, who was like a world famous video.

01:09:43.000 They were all going to be that guy.

01:09:46.000 And so, you know, to me, that's again, that's how our brain, even when we're very far from being that guy, everybody thinks they're going to be that guy.

01:09:55.000 And that's part of that rationalization, the justification or the denial that can happen in this whole process of addiction.

01:10:01.000 But someone is that guy.

01:10:03.000 Yeah, one in a million.

01:10:05.000 I mean, not everybody gets to be Joe Rogan, right?

01:10:08.000 You're that guy.

01:10:09.000 But a lot of people won't.

01:10:11.000 So it's not to say that nobody should try.

01:10:15.000 Well, I don't know if I'm a good example because the things that I'm talking about, like the things that I've been successful about, I don't necessarily think you would call podcasting an addiction unless I'm addicted to conversation.

01:10:27.000 Right.

01:10:27.000 I mean, podcasting is maybe a good addiction because people are hopefully learning.

01:10:33.000 I don't think it's an addiction.

01:10:33.000 Okay.

01:10:34.000 Because when it's over, I'm good.

01:10:36.000 Okay, not for you, but maybe for some of your viewers.

01:10:39.000 I don't know.

01:10:40.000 Your listeners?

01:10:41.000 Well, I think people get entertained and they get stimulated by these conversations.

01:10:48.000 And I for sure think that many people are enriched by guests like yourself that can...

01:10:55.000 Provide all this insight to the way the mind works or whatever subject we're discussing.

01:11:00.000 I think there's a great benefit.

01:11:01.000 It certainly is for me.

01:11:03.000 And I think that's what a lot of people get out of it.

01:11:05.000 They get stimulated.

01:11:06.000 And they get stimulated while they're doing other things like driving in their car or on the train or whatever.

01:11:11.000 But I don't think that's an addiction.

01:11:15.000 But I think that As we said before, I'm very lucky.

01:11:20.000 I'm very, for sure, very, very fortunate.

01:11:22.000 But also, I'm a person that when I find fortune, I buckle down and get going.

01:11:30.000 And I don't take breaks.

01:11:32.000 I don't relax.

01:11:34.000 I don't slack off.

01:11:37.000 You don't rest on your laurels.

01:11:38.000 I'm not into that.

01:11:39.000 I'm into keeping going.

01:11:41.000 And I'm into just pushing it.

01:11:43.000 And then that's where the rewards come.

01:11:45.000 Yeah.

01:11:46.000 Because of success.

01:11:46.000 But I don't know if that's an addiction.

01:11:49.000 This might be the one thing that I do that's not an addiction.

01:11:52.000 Yes.

01:11:52.000 And I'm not saying it is an addiction.

01:11:55.000 Not everything is an addiction.

01:11:56.000 Again, the reward pathway is harnessed in many different endeavors.

01:12:02.000 We get dopamine arborization in the reward pathway when we learn.

01:12:08.000 And that's a good thing.

01:12:09.000 And in other effortful activities.

01:12:11.000 But it's all dopamine.

01:12:12.000 Well, it's not all dopamine.

01:12:13.000 But I mean a lot of what's pushing us.

01:12:16.000 Yeah, that motivation is, at the end of the day, dopamine is probably the most important neurotransmitter when it comes to motivation.

01:12:25.000 In fact, an interesting experiment trying to distinguish between motivation and pleasure.

01:12:31.000 Scientists engineered a rat so it had no dopamine at all.

01:12:36.000 And yeah, so a de-dopaminized rat.

01:12:39.000 What did that poor guy do?

01:12:40.000 I know, poor guy.

01:12:41.000 And when they put food in the rat's mouth, it would eat the food and seem to enjoy it, however much you can determine that, you know, looking at a rat.

01:12:50.000 But the rat ate it and chewed yummy.

01:12:52.000 But when they then placed that food a single body length away from the rat, the rat starved to death.

01:12:58.000 Whoa! 0.71

01:12:59.000 Right?

01:13:00.000 So this distinction between liking and wanting is really interesting.

01:13:06.000 And dopamine probably has a lot more to do with wanting more than liking.

01:13:12.000 So it's that motivation to go get the reward that is so key with dopamine.

01:13:17.000 And by the way, how does our brain...

01:13:20.000 Get us motivated, it puts us in a dopamine deficit state.

01:13:25.000 That's craving, right?

01:13:26.000 We're in a little mini dopamine.

01:13:28.000 So, for example, let's say I'm addicted to alcohol.

01:13:34.000 I go by the bar where I would normally drink.

01:13:38.000 As soon as I see that bar, I have a little mini spike in dopamine above baseline, that kind of euphoric recall, just thinking about it.

01:13:46.000 But no sooner does that spike happen than I get a little mini dopamine deficit state.

01:13:50.000 It doesn't go to baseline.

01:13:51.000 It goes below baseline.

01:13:52.000 Then I'm in craving.

01:13:53.000 And patients will describe really, like, literal physiologic, like, sweats, you know, stomach aches.

01:13:59.000 And then the intrusive thought that the only way to feel better is to go and get the drug.

01:14:04.000 And then we're driven to go get it.

01:14:06.000 And then we get a much bigger spike of dopamine when we actually ingest our drug.

01:14:09.000 It makes so much sense what you're saying about the rat when you talk to people that are depressed because one of the things they say is they don't have the motivation to even get out of bed.

01:14:18.000 It's very hard for them to get out of bed.

01:14:20.000 So when they're at this dopamine deficit state, for them there's just no momentum.

01:14:27.000 There's nothing to get them moving.

01:14:30.000 Right.

01:14:31.000 So when patients come in to see me, and often their chief complaint is depression and anxiety.

01:14:36.000 It's not, can you help me stop drinking alcohol or can you help me stop playing video games?

01:14:41.000 But what I will often recommend as a first pass is a month of abstinence from their drug of choice.

01:14:47.000 And I explain the pleasure-pain balance and the way that there's this opponent process mechanism.

01:14:51.000 The gremlins.

01:14:53.000 Thank you.

01:14:54.000 And they're very skeptical that a month of dopamine fasting is going to reset the reward pathways.

01:15:01.000 But if they're willing to do it, 80% of them will come back after a month and describe that they feel much better.

01:15:07.000 And the reason for that is because they've been in this dopamine deficit state.

01:15:11.000 If they abstain, the gremlins hop off, they start to make their own dopamine again, and then they restore homeostasis, and they're able to take pleasure in more modest rewards.

01:15:21.000 Telling someone to just abstain, to just take time, just, hey, put the video games down, stop gambling for a month, whatever it is, stop drinking for a month.

01:15:30.000 Is that enough?

01:15:31.000 Or do you give them tools that aid them in abstaining?

01:15:37.000 Is there something that you can do?

01:15:39.000 Like, is there a guidebook or a framework that they can follow?

01:15:44.000 Yeah.

01:15:45.000 So, I mean, I've developed this acronym, which you probably don't want me to go through.

01:15:49.000 Sure, please do.

01:15:50.000 We have all the time in the world.

01:15:51.000 Okay, okay.

01:15:52.000 Well, first of all, let me say, you know, this is a spectrum disorder, and people on the very severe end are not going to be able to stop on their own.

01:15:59.000 Those are individuals who have to go into hospital or go into a residential treatment setting.

01:16:03.000 For games?

01:16:04.000 Oh, yes.

01:16:05.000 Really?

01:16:05.000 They go to hospitals?

01:16:06.000 Well, there are residential treatment settings for video game addiction.

01:16:10.000 So they just lock these kids up and no games?

01:16:12.000 Yes.

01:16:12.000 And you isolate them in a building and force them to read actual books made out of papers?

01:16:17.000 Right.

01:16:18.000 Well, you know, hopefully you're not forcing them.

01:16:21.000 I mean, in some countries this does happen by force.

01:16:24.000 Here in the United States, try to make everybody on board with the plan with the hope that, you know, they'll feel better if they abstain for a month.

01:16:31.000 But recognizing that In their current environment, their willpower will not do it.

01:16:36.000 And that's just a matter of the severity of the illness.

01:16:40.000 But for people who have more mild to moderate addictions, this outpatient approach of, you know, the dopamine acronym, which is basically D stands for data, you know, gather specific information about how much you're using, what you're using.

01:16:55.000 The O of dopamine stands for objectives.

01:16:57.000 Why are you using?

01:16:58.000 What does it do for you?

01:16:59.000 It numbs me.

01:17:00.000 It's an escape.

01:17:01.000 It makes me feel better.

01:17:02.000 The P of dopamine stands for problems associated with you.

01:17:05.000 So really thinking aloud about what are the negative and unintended consequences, like you did with video games, realizing, wow, I'm up all night and I'm exhausted.

01:17:12.000 I'm not ready for the day.

01:17:15.000 Just writing that down or expressing those to another human being really makes it alive for patients that it's not necessarily going to be when it's just pinging around in their heads.

01:17:26.000 So you make them write it down.

01:17:27.000 Write it down.

01:17:28.000 I have to stop gambling or whatever it is.

01:17:30.000 How many hours a day are you in gambling?

01:17:33.000 How many hours a day are you spending doing it?

01:17:36.000 How much money are you actually winning or losing?

01:17:40.000 Why do you do it?

01:17:43.000 It's validating that it does something positive or people wouldn't do it, but also having people really talk about what they're actually doing so it can't remain hidden in that dark closet of denial.

01:17:54.000 Is cold turkey the only way to get off of that, or is there a slow drip method?

01:18:02.000 Yeah, yeah, yeah.

01:18:04.000 Great question.

01:18:05.000 So the A of the dopamine acronym stands for abstinence, or this four weeks of abstinence.

01:18:09.000 You know, so, I mean, maybe some people can gradually taper.

01:18:14.000 And obviously, if they're physically dependent on something like alcohol or Klonopin or opioids, they wouldn't want to cold taper.

01:18:20.000 It could be dangerous, so they'd want to do a medically supervised taper.

01:18:24.000 But in my experience, for people who are on the addiction spectrum, if they're able to just stop, it's better than if they try to go down slowly.

01:18:36.000 There's something about abstaining for a single month that people can wrap their head around.

01:18:41.000 It's not a lifetime.

01:18:42.000 It's 30 days in the broad scheme of things.

01:18:45.000 You know, can you do that?

01:18:46.000 And what I warn patients about is that they're going to feel worse before they feel better.

01:18:51.000 Their pleasure-pain balance, once they get rid of that constant reward, will tip to the side of pain.

01:18:57.000 And in those first two weeks, they're going to experience withdrawal.

01:18:59.000 But if they can just wait long enough and get to a month, the gremlins will hop off, homeostasis will be restored.

01:19:05.000 And, you know, again, 80% of folks will come back a month later, those who've been able to do it, and say that they feel a lot better.

01:19:13.000 Now, that other 20% are individuals who probably have a co-occurring psychiatric disorder, anxiety, depression, whatever it is.

01:19:22.000 That's also really useful information, right?

01:19:24.000 Like, okay, we need to treat this co-occurring psychiatric disorder at the same time that we address this compulsive overconsumption problem.

01:19:31.000 And then the rest of the acronym, just really quickly, is dopamine.

01:19:35.000 M stands for mindfulness.

01:19:37.000 This is what I was talking about before.

01:19:39.000 Instead of trying to do something to escape feeling bad, just tolerating it for a period of time.

01:19:45.000 The N, wait, dopamine, can I spell?

01:19:50.000 You forgot your own acronym?

01:19:51.000 I can't spell.

01:19:52.000 The spell is the problem.

01:19:53.000 Dopamine, mindfulness, I stands for insight.

01:19:56.000 So I'll have a lot of patients who will say to me, wow, I didn't really think I was addicted until I tried to stop.

01:20:03.000 And then I realized how much I had become dependent on it.

01:20:06.000 So there's really a lot of insight that's gained.

01:20:08.000 The N stands for next steps.

01:20:10.000 When patients come back after a month of abstaining, we talk about the pros and cons, and then we make a plan for the next month.

01:20:16.000 And then the E of dopamine stands for experiment.

01:20:19.000 With this plan in place, whether it's another month of abstinence, or whether they want to try to go back to using, but using in more moderate amounts, which is what most people want to do.

01:20:28.000 Then we make a plan for that.

01:20:29.000 What kind of self-binding strategies can they put in place so that they can use less?

01:20:34.000 Because most people want to use less.

01:20:36.000 So that month of absence, not only does it reset reward pathways, but it also allows people to look back and see true cause and effect.

01:20:43.000 Because when we're in our addiction, we really can't see the true impact of those behaviors on our lives.

01:20:49.000 Yeah, you just kind of get caught up in the momentum of it all, right?

01:20:54.000 When I was talking about people that are addicted that eventually go into endurance sports, it seems like there's something about endurance sports in particular that is very attractive to people that are former addicts or recovering addicts.

01:21:09.000 In that you're completely at the mercy of this activity while you're doing it.

01:21:19.000 My friend John Joseph, he's the lead singer of the Cro-Mags, this band, but he's also a hardcore triathlete.

01:21:28.000 And he was an addict when he was younger.

01:21:31.000 And he now abstains, lives a very healthy lifestyle, eats very healthy.

01:21:38.000 And all he does is, I mean, he trains constantly.

01:21:43.000 He goes on these massive bike rides, these long swims.

01:21:47.000 And it seems like the difficulty of these endurance sports...

01:21:54.000 Whether it's running or Ironman or any of those things.

01:21:57.000 It's so hard to do that you have to be in the moment.

01:22:02.000 You're thinking about every step you're taking as you're running because you're exhausted.

01:22:06.000 You're thinking about every breath.

01:22:07.000 You're thinking about every stroke of your arms when you're swimming.

01:22:11.000 It's not something you can fake.

01:22:14.000 You have to actually do it.

01:22:16.000 And you have to actually do that work.

01:22:19.000 And there's something about that that's very appealing to a lot of former addicts.

01:22:24.000 There's been quite a few addicts that fight in MMA as well.

01:22:30.000 And one of the things I noticed about them is so many of them are incredibly determined, like unusually determined, like unusual endurance, unusual work ethic, unusual ferocity in competition.

01:22:43.000 And I wonder if that also is like whatever led them to be an addict, to be like obsessed with drugs and just ruining their life.

01:22:54.000 When they turn that around and can focus it on something positive, they have an extraordinary amount of focus.

01:23:04.000 Yes, I agree with you.

01:23:06.000 I mean, I think people with addiction are some of the most tenacious people that you will ever meet.

01:23:11.000 And when they can redirect this tenacity to something that's a more adaptive behavior, and I do think sports can be that, you know, it's a very good thing and they tend to be very successful behaviors.

01:23:33.000 Yes.

01:23:42.000 Let's say painful, and I know you don't love that word, but I think of it as painful, you know, physical activities or endurance sports.

01:23:50.000 They also are a way to escape ourselves because we're so fully in our bodies when we're doing them that we're not, you know, dealing with our constant ruminations.

01:23:59.000 Well, I think with endurance sports, I would call it painful.

01:24:02.000 Yeah.

01:24:02.000 You know, it's particularly like long-term running, long-distance running.

01:24:05.000 They all talk about the ability to drown out the pain.

01:24:07.000 Right.

01:24:08.000 And it also becomes a way to achieve a new set point, a new hedonic set point or a new joy set point.

01:24:17.000 Joy set point.

01:24:18.000 Joy set point, hedonic set point.

01:24:20.000 Because again, they're in these like increments on a regular basis.

01:24:23.000 They're pressing on the pain side.

01:24:25.000 And then the neuroadaptation happens to the site of pleasure.

01:24:27.000 So it's a way that they maintain a kind of baseline positive increase in dopamine levels.

01:24:34.000 It seems to me like to be an extreme winner, though, and I keep coming back to Michael Jordan, to be a person like that, you almost have to be an addict.

01:24:45.000 Yes, you have to have that single-minded pursuit.

01:24:50.000 I mean, I guess maybe we need to better define, like, what is addiction?

01:24:56.000 Right, because if they're very healthy, and they're doing really well, and maybe they've narrowed down their obligations outside of that, so all they do is focus on maybe just their family, and then their work.

01:25:08.000 And that's okay.

01:25:09.000 I mean, addiction broadly defined is the continued compulsive use of a substance or behavior despite harm to self and or others.

01:25:18.000 And if there's not harm to self and or others, then it's probably not an addiction, even if it's a very intense, focused endeavor.

01:25:27.000 The problem is that the person who is in their addiction may not be able to see the harm to self and or others, whereas people around them can see it.

01:25:38.000 And I think there's also a problem in that it's just part of being a human being in America.

01:25:46.000 We value success that's measurable above all others.

01:25:52.000 Like when we think about a person that's successful, say if a guy is a businessman who works 12 to 14 hours a day and he's worth a billion dollars, but his personal life is a shambles.

01:26:16.000 We don't think of that.

01:26:20.000 And the rubble of his life that's laid out other than the financial success.

01:26:29.000 Right.

01:26:29.000 And one of the interesting things as a psychiatrist is that I really get to look under the hood of a lot of different types of people, including a lot of people who on the outside look like they have it all.

01:26:40.000 But on the inside are really, really suffering.

01:26:43.000 Give me an example without revealing the person.

01:26:46.000 Oh my gosh.

01:26:46.000 I mean so many, you know, I work in Silicon Valley.

01:26:50.000 I see incredibly wealthy people, you know, brilliant scientists, really smart people, you know, who on the face of it you would never in a million years imagine that they're struggling in any way, much less with a serious addiction,

01:27:06.000 but they are.

01:27:07.000 What are their addictions?

01:27:08.000 Oh my gosh.

01:27:09.000 Pornography addiction, gambling addiction, drug and alcohol.

01:27:13.000 I believe Adderall is a big one, right?

01:27:16.000 Especially with people that work in tech.

01:27:18.000 Yes, I see that a lot.

01:27:21.000 Journalists too.

01:27:22.000 A lot of journalists get addicted to Adderall.

01:27:24.000 Okay, yeah, that I've never seen.

01:27:26.000 Yeah, I have friends who are journalists who say you'd be amazed.

01:27:29.000 It's like 9 out of 10. Yeah.

01:27:30.000 Because I've not tried it, but apparently it's amazing.

01:27:34.000 Right.

01:27:34.000 Have you tried it?

01:27:35.000 No.

01:27:36.000 Do you avoid everything like that?

01:27:38.000 Yes, I do.

01:27:39.000 Everything.

01:27:40.000 Well, I would imagine that's your business.

01:27:43.000 Yes, except for endurance sports.

01:27:45.000 That's my thing.

01:27:46.000 What do you like?

01:27:48.000 I like biking and hiking and swimming.

01:27:53.000 That's about all I can do.

01:27:53.000 Those are good ones because they're low impact.

01:27:55.000 They don't destroy your body.

01:27:56.000 Exactly.

01:27:57.000 Unless you crash on a bike.

01:27:59.000 Right.

01:27:59.000 There's always that danger.

01:28:01.000 Yeah, but still, the impact is so much better.

01:28:03.000 Yes, yes.

01:28:04.000 Yeah.

01:28:05.000 Yeah, I mean, I have a regular practice of biking up Page Mill Road in our neighborhood, which is a very steep mountain, and I never want to do it before I start out, but I'm always happy afterwards.

01:28:19.000 So you've developed your own mitigation methods for dealing with all these problems that we're talking about.

01:28:26.000 Absolutely, I have.

01:28:27.000 Yes.

01:28:28.000 Yeah.

01:28:28.000 So say if you have a person that is dealing with maybe a pornography addiction or something like that, and you encourage them to abstain from a month, do you also encourage them to engage in some sort of difficult physical activity?

01:28:44.000 Yeah.

01:28:45.000 So, I mean, it depends on the person, right?

01:28:48.000 If, like, sports or exercise is not really their thing, I still encourage it, but I don't expect that that will be the solution for everybody.

01:29:01.000 Absolutely prescribe other effortful activity, difficult cognitive activities.

01:29:07.000 Creative endeavors are great.

01:29:08.000 Like, for example, you know, when you're getting ready for stand-up, right?

01:29:12.000 Like, really engaging and creative, and you get an idea, and, you know, you showed me kind of your notes.

01:29:17.000 And then you're thinking about it and puzzling out how to best present that idea.

01:29:20.000 That's so great because it's this really focused flow.

01:29:24.000 Definitely leads to a good type of dopamine.

01:29:28.000 Prayer, meditation, any spiritual practices, super, super important.

01:29:33.000 I do believe that we have a part of our brain that's, you know, evolutionarily designed for prayer.

01:29:39.000 And so when we can engage that in some ways, that's super helpful.

01:29:42.000 You think there's a part of the brain evolutionary design for prayer?

01:29:46.000 Yeah.

01:29:46.000 That's interesting.

01:29:47.000 Yeah.

01:29:48.000 So is it just thankfulness?

01:29:51.000 Is it a worship?

01:29:53.000 Like, what do you think it is?

01:29:54.000 I think people call it by many different names.

01:29:57.000 I mean, some people call it gratitude, being in gratitude for other people.

01:30:01.000 It's my meditation practice.

01:30:02.000 For other people, it's actual prayer, the way we usually think about that.

01:30:06.000 But there's no doubt in my mind that there's a part of our brain that needs to be active in that regard.

01:30:13.000 And if we neglect it, it's not great for our mental health.

01:30:17.000 And so...

01:30:18.000 If my patient has any kind of pathway to any kind of spiritual practice, I ask them, you know, what kind of spiritual practices are you familiar with?

01:30:27.000 Have you tried?

01:30:28.000 And I recommend that they do that too.

01:30:31.000 The other thing that I also often recommend in that month of abstinence is that they tell no lies, not about anything, not even little white lies about, you know, why they were late for a meeting.

01:30:44.000 And the reason for that is really something that I learned from my patients in recovery, that telling the truth about all things is absolutely key for recovery.

01:30:53.000 And I've explored some of the neuroscience behind why that is, but I actually prescribe that to patients when they're trying to quit a substance or behavior that they've become addicted to.

01:31:05.000 That's interesting.

01:31:06.000 The prayer thing, I'd like to get back to that, though.

01:31:10.000 Where do you draw this from?

01:31:12.000 Why do you think that there's an evolutionary need for prayer?

01:31:17.000 Okay, so I'm still studying the neuroscience of that.

01:31:22.000 I'm thinking about that for maybe a future book that I'm writing.

01:31:25.000 So I'm still sort of at the tip of that.

01:31:27.000 But there have been interesting studies sort of showing the parts of the brain that light up when people are engaging in meditation or Or people who have, you know, very strong meditation practices or prayer practices, how their brains might be the same or different.

01:31:40.000 I'll have to come back another time when I've learned more and tell you about that.

01:31:44.000 But you're pretty confident there's something going on with that.

01:31:46.000 I do.

01:31:47.000 I do, yes.

01:31:48.000 You know, my clinical work, I mean, so many people in recovery have gotten into recovery through a spiritual practice of one sort or another.

01:31:59.000 And I just think it's fundamental.

01:32:00.000 And it's been really important in my own life, you know, having this kind of, like, just for lack of a better word, I'm just going to call it spiritual, sort of a loaded term.

01:32:11.000 But I think, you know, some kind of practice that sort of, you know, relates to transcendence.

01:32:18.000 Hmm.

01:32:19.000 Transcendence.

01:32:22.000 It's interesting because there's a real argument that that's been a part of human beings from the beginning of time, which is fascinating.

01:32:31.000 I've always wondered why.

01:32:33.000 One reason why I think we struggle with this today is light pollution.

01:32:42.000 And I got this out of an experience that I had once in Hawaii, where I went up to the Keck Observatory.

01:32:49.000 I've been there several times, but this is the first time and the only time I really nailed it, in that we got there at a perfect time where there was no moon at all, and you get to see every star.

01:33:01.000 It is spectacular.

01:33:04.000 It's very high up in the mountains, so high up.

01:33:08.000 It's on the Big Island.

01:33:09.000 That when we were driving, we had to drive through the clouds.

01:33:13.000 And I was like, oh no, it's cloudy. 0.92

01:33:15.000 This is going to suck.

01:33:16.000 And then you drive through the clouds, and then all of a sudden you're at the top where the observatory is.

01:33:23.000 I forget how many thousands of feet up it is, but it's very high up.

01:33:26.000 And the image of the galaxy, when you see the Milky Way in front of you, it is so humbling.

01:33:34.000 It's so humbling and majestic and magnificent.

01:33:38.000 And it's so valuable.

01:33:40.000 I remember thinking, how did we ruin this view with streetlights?

01:33:46.000 Because that's what we did.

01:33:48.000 We've eliminated this image.

01:33:51.000 Which I think was with human beings from the beginning of time.

01:33:55.000 And when human beings start to take into consideration their environment and the parameters of their world and where things are, and then you're faced with this impossible vision of size and of scope and of just this epic proportion When you see all the stars and you see how big it is and you can't imagine that those things are literally thousands of light years away.

01:34:25.000 And you're looking at this, you're like, what is all that?

01:34:29.000 This is crazy.

01:34:30.000 And I think there's something about that that instills a very, just a natural sense of awe that we're missing.

01:34:42.000 And I think it's one of the reasons why people are so detached.

01:34:44.000 Yeah.

01:35:01.000 The big theme with so many of them was the gods in the heavens.

01:35:05.000 And I think it had something to do with the epic scape of the sky, when you would look up and you would see.

01:35:12.000 And we don't see that anymore.

01:35:14.000 Yeah, I mean, so awe is a really interesting emotion, which has been defined as that experience of encountering a stimulus that is more than our mind can process.

01:35:29.000 And I think that's an interesting definition because I think there's something to that.

01:35:35.000 It's kind of mind exploding.

01:35:38.000 It's both wonderful and terrorizing at the same time.

01:35:43.000 To me, that's awe and that's that kind of feeling that you get or that I get when looking up at the stars.

01:35:49.000 And I do think you make a really good point about overstimulation.

01:35:54.000 One of the things that I noticed during quarantine, which of course was tragic for people who were ill, for people who had family members die, but I saw for a lot of my patients, it was actually a really positive experience because it was de-stimulating.

01:36:14.000 It was like all of that frantic running around and all of that sort of All of those constant, you know, stimulating, multiple interactions with multiple people a day, it all kind of went away.

01:36:25.000 And for some of my patients, it was like, oh my gosh, this is what, this is how my life needs to be like.

01:36:33.000 That way I was living before was really crazy making.

01:36:36.000 So I think, you know, I think you're absolutely right.

01:36:38.000 I think there's a way in which we're all overstimulated.

01:36:42.000 And that way we really need to dial that back for our mental health.

01:36:46.000 I think we're definitely overstimulated and I think there's definitely an argument that we learn something from the pandemic with a lot of people.

01:36:55.000 They're able to work remotely.

01:36:56.000 They're working from home.

01:36:58.000 I think that's great too.

01:36:59.000 But what I was getting at is just the whole need for prayer and this understanding that we are part of something that's so immense.

01:37:12.000 Any sort of egocentric ideas that you may have are preposterous when you're faced with the Milky Way.

01:37:19.000 Yeah, right.

01:37:20.000 So a central aspect, just bringing it back to addiction and recovery, is humility.

01:37:28.000 And that experience of feeling yourself as very small potatoes.

01:37:34.000 And how healthy and good that is.

01:37:37.000 Even though, you know, oftentimes it comes with a very painful experience or feeling of brokenness or feeling like, you know, you're not good enough.

01:37:46.000 Well, you know, when we can arise from that and sort of hang on to that humility, I think it's really it's a very good and positive thing in our lives.

01:37:55.000 Yeah, I think so too.

01:37:56.000 And the experience of nature.

01:38:00.000 I grew up in the Northeast and the Northeast gets very cold in the winter and you get a lot of snow and it's, you know, I lived in Massachusetts and it gets, it's just part of life.

01:38:10.000 You have to deal with that.

01:38:11.000 There's none of that in California, or Los Angeles at least.

01:38:15.000 And I remember thinking of Los Angeles like, these people don't understand nature.

01:38:19.000 You're only encountering nature occasionally.

01:38:22.000 And I think there's a spoiled child aspect to the people that live there because of that.

01:38:29.000 They have this detachment from their real place in the overall spectrum of life.

01:38:35.000 They feel like it's all revolving around them, which is really the perfect place to set up something like Hollywood, right?

01:38:40.000 Where the goal is to make it all about you.

01:38:43.000 The goal is to get a show or a movie where it's all about you.

01:38:46.000 And so this sort of lack of dealing with the consequences of the world...

01:38:53.000 And the environment itself, like snow and rain and all that.

01:38:57.000 I mean, occasionally you deal with fire.

01:38:59.000 And when you do deal with fire, people get so much more humble.

01:39:02.000 It's so fascinating.

01:39:03.000 They calm down and they realize like, wow, okay, we really are, at least for now, all in this together.

01:39:10.000 Yeah, I'm always amazed at how good I feel when it rains, like just the rain outside, like it calms me down.

01:39:17.000 In California, sure.

01:39:18.000 Well, we do occasionally get rain up north.

01:39:22.000 But I mean, just how that kind of restlessness, in me anyway, kind of quiets with a good thunderstorm.

01:39:28.000 Nature.

01:39:28.000 Yes, but I would argue that this is not just an L.A. problem.

01:39:32.000 I would argue that this is a modern rich nation's problem.

01:39:36.000 We're very detached from nature.

01:39:39.000 I think all the time that people are spending on screens, I mean, some people's only experience of nature is like a Photoshopped version of it.

01:39:47.000 Right.

01:39:47.000 So this is something that I think ideally we would all get back into nature.

01:39:53.000 I remember watching recently one of your episodes because my son was trying to get me prepped for this.

01:39:59.000 And he showed me...

01:40:03.000 An episode where you talked to these folks who had gone out, I think, and were hunting, and they got attacked by a bear or something.

01:40:11.000 Oh yeah, my friend Steve Rinoa.

01:40:12.000 Right, right.

01:40:12.000 But I mean, I think people really crave those types of experiences.

01:40:17.000 Being attacked by bears?

01:40:18.000 Well, you know, something that feels...

01:40:20.000 Humbling?

01:40:21.000 Yeah, and sort of real and like at survival level.

01:40:24.000 I do think we need that.

01:40:27.000 Yeah.

01:40:28.000 No, I think so, too.

01:40:28.000 I think there's something about it, even as terrifying as an encounter with a bear, where it sort of lets you understand you are walking through life with blinders on.

01:40:41.000 Right.

01:40:42.000 Which is why, you know, there's a pretty robust therapeutic intervention for people with severe addiction, which is called wilderness.

01:40:51.000 And of course, you know, there's a lot of criticism of different types of treatments, but that can be really transformative for some young people to be out in nature.

01:40:58.000 My friend Dan Doty does that.

01:41:00.000 It's one of the things he does.

01:41:01.000 He takes folks out, especially young guys that have real behavioral problems.

01:41:09.000 And they camp and they live off the land for weeks and weeks at a time.

01:41:15.000 And it straightens a lot of them out.

01:41:17.000 Yeah, no, it's awesome.

01:41:18.000 It's transcendent in some strange way.

01:41:20.000 That's right.

01:41:22.000 I think, I mean, I don't want to say people are meant to live any way, because I think people are meant to live a bunch of different ways.

01:41:30.000 There's a lot of people that are very happy doing things that wouldn't make me happy, and I think there's obviously a lot of variety with human beings.

01:41:37.000 But I think that The way our bodies are designed is not much different than the way the bodies of people that were designed 10,000 years ago were.

01:41:47.000 Or people that lived 10,000 years ago were rather.

01:41:49.000 And those people, their lives were around community.

01:41:53.000 Their lives were around their whatever crafts and whatever skills that they had to develop in order to survive and contribute to the tribe.

01:42:05.000 Yeah.

01:42:05.000 Hunting and gathering and then it was about raising children and teaching them the rituals of adulthood that were all designed to facilitate your growth and advancement so that you could contribute to this tribe so that everyone could all sustain and stay alive together and feed each other.

01:42:24.000 And that's how human beings lived. 0.99

01:42:26.000 And now we're talking shit on Twitter. 0.99

01:42:30.000 You know what I mean? 0.98

01:42:31.000 And now we're staring at TikTok all day, and now we're doing all sorts of weird things that we're not designed for.

01:42:40.000 And that's one of the things that led me to my video game addiction.

01:42:44.000 I was recognizing that I'm not designed for this.

01:42:48.000 That this was a hijacking of whatever systems that I had that were in place that craved excitement and stimulation.

01:42:59.000 And I was getting this digital version of it, which if you could handle it, it's really fun.

01:43:06.000 But if you can't handle it, and if you're a person like me who obsesses on things, you know, you could say an addiction or you could say, why do you choose to call it, why do you think it's an addiction or a disease rather than an addictive personality disorder?

01:43:27.000 Mm-hmm.

01:43:29.000 So, I mean, that change in language has occurred over approximately the last 20 years or so, moving away from calling it like an addictive personality to calling it the disease of addiction.

01:43:42.000 And the reason for that is, I mean, there are many reasons.

01:43:47.000 One is just the simple neuroscience, the explosion in neuroscience.

01:43:52.000 We're good to go.

01:44:12.000 A disease potentially improves access to treatment because it destigmatizes.

01:44:17.000 So when we call it a disease and we treat it like a disease in the healthcare system like any other, people get better at the same rates that they do from other chronic relapsing and remitting disorders like type 2 diabetes, heart disease, obesity.

01:44:32.000 So I think there are just practical reasons as well for calling it a disease.

01:44:38.000 And again, you know, you and I have used the term loosely to define a broad spectrum of behaviors and a broad spectrum of severity.

01:44:46.000 And when I do that, it's not at all to trivialize severe addiction and the kinds of very serious life consequences that it has for people.

01:44:58.000 But it's rather to explain that the same neural networks that drive compulsive overconsumption of checking our phones is at play in people who become severely addicted to drugs and alcohol.

01:45:17.000 It's really just a matter of severity.

01:45:21.000 The brain itself varies, right?

01:45:26.000 Like human beings, their desires, the things that they seek out, the kind of artistic and creative endeavors that they seek out, the pleasure endeavors that they seek out, all the different things that they seek out.

01:45:39.000 When you're dealing with an individual patient, you call them patients?

01:45:45.000 Yeah.

01:45:45.000 I do, yes, because I'm an MD, so they're patients.

01:45:48.000 If I were a psychologist, typically the nomenclature is that they're clients.

01:45:53.000 When you're dealing with a patient, how long does it take you to sort of sort out what type of personality they are?

01:46:05.000 Like, where they fall into, and maybe what...

01:46:08.000 Is this...

01:46:09.000 Is addiction coming out of abuse when they were young?

01:46:13.000 Is it coming out of maybe...

01:46:17.000 How do you do that?

01:46:18.000 Yeah.

01:46:19.000 So one of the things that I have concluded is that there's no point initially in spending a lot of time trying to figure out, number one, why the person got addicted, or number two, whether or not they'll be able to get better.

01:46:35.000 Number one, it's a waste of time to figure out why initially, because it doesn't matter.

01:46:41.000 Whatever your doorway into addiction was, once you develop addiction, the intervention is the same, and recovery starts with abstinence and requires all of the interventions that we do.

01:46:56.000 Later on, you can spend time kind of trying to unpack, gee, how did we get here?

01:47:01.000 What are some of the early antecedents, including like childhood antecedents or trauma?

01:47:06.000 Although, again, there's a danger there in focusing too much on the why and not enough on, okay, how do I get better?

01:47:13.000 Right.

01:47:14.000 The other thing that I've learned after many years of being a psychiatrist is that I am terrible at predicting who's going to get better and who isn't.

01:47:22.000 I used to think that I could tell when someone walked in, oh, this person, oh, they're going to do great, and this person, there's no hope.

01:47:29.000 Not true.

01:47:29.000 I have had many patients I thought, wow, this is nothing I'm going to be able to do for this person.

01:47:34.000 You know, miraculous recovery.

01:47:36.000 Other people I was certain would, you know, get better in a jiffy, and no matter what I did, I couldn't help them.

01:47:43.000 So I don't predict anymore.

01:47:45.000 I don't try to predict.

01:47:46.000 I just take each person as they come and just try to essentially be a witness to their journey.

01:47:54.000 Interesting.

01:47:55.000 That's so telling, right?

01:47:59.000 This idea that you can't predict.

01:48:01.000 And that some people, you see them, you go, well, this person's successful.

01:48:05.000 They're well-educated.

01:48:07.000 They're clear-minded.

01:48:09.000 They've got a directive.

01:48:10.000 They're going to go.

01:48:10.000 They're going to figure this out.

01:48:11.000 And then, nope, doing heroin again.

01:48:13.000 Yeah, yeah.

01:48:14.000 And one of the tricks, or at least my Achilles heel that I've learned over time, is if I identify with the patient, I'm more likely to think that they're going to get better and more likely to miss some key things.

01:48:28.000 Are there any sort of standard things that you notice about people who do well versus people who don't?

01:48:36.000 Is it a denial thing?

01:48:38.000 Is it people who are more deceptive or can trick other folks into thinking that they're okay?

01:48:45.000 Maybe people who are more charismatic?

01:48:47.000 Yeah.

01:48:49.000 Yeah, it's a great question.

01:48:51.000 I mean, insight is certainly useful.

01:48:53.000 So when people have insight into the fact that they are addicted, that is helpful, but that's not necessarily a guaranteed winner.

01:49:00.000 I have had patients who have incredible insight into their addiction and don't get better.

01:49:05.000 So that's not the key, although it's helpful.

01:49:09.000 One of the things that I've noticed over the years is that if I have a patient who comes in and they tell their story in a way that blames everybody else for their problems, that person is... 1.00

01:49:20.000 They're fucked. 1.00

01:49:25.000 That's the case with everything. 1.00

01:49:27.000 Let me just say it's a slow road.

01:49:29.000 I wouldn't say they're totally, you know, not going to get better because one of the very interesting things that happens in the process of recovery is people start telling their story differently.

01:49:41.000 They start...

01:49:42.000 Interesting.

01:49:42.000 Yeah, and that's, of course, part of the 12 steps of Alcoholics Anonymous is kind of acknowledging our part and our responsibility and where we've contributed to the problem.

01:49:52.000 And when people are in really good recovery, they get really good at that.

01:49:56.000 Because, of course, it's a muscle, too, that you practice.

01:49:58.000 And they, you know, are constantly taking their inventory.

01:50:01.000 Saying, okay, you know, where did I, how did I, I'm feeling uncomfortable.

01:50:04.000 You know, how did I, where did I mess up on this?

01:50:06.000 So that's really interesting.

01:50:10.000 Alcoholics Anonymous is always referred to as Friends of Bill, right?

01:50:14.000 Yes, it can be, right.

01:50:16.000 And that's based on the guy who started Alcoholics Anonymous, who developed this 12-step program.

01:50:21.000 You know, he was into LSD. So I don't know much about that history.

01:50:27.000 Enlighten me.

01:50:28.000 Well, I think it was something that they felt was very controversial to the point where they didn't want to have it a part of the program.

01:50:37.000 But what I've read about him, and Jamie, see if you can pull up the history of Al Cox Anonymous and LSD. Wilson wrote a letter to Heard saying, Most Alcoholics Anonymous people were strongly opposed to his experimenting with a mind-altering substance.

01:51:08.000 And then there's another one from The Guardian, LSD could help alcoholics stop drinking, AA founder believed.

01:51:13.000 You know, this is all in, when was this, what was the year?

01:51:18.000 I want to say it was in the 40s, right?

01:51:20.000 When did he experiment with LSD? This article here says 20 years after setting it up in 1935, so the 50s?

01:51:28.000 Oh, okay, the 50s.

01:51:29.000 Well, when did Hoffman synthesize LSD? Because it was before there was a stigma attached to it, right?

01:51:36.000 There was a sweeping psychedelics acts of 1970, which essentially made all these things that used to be used for clinical research illegal, including MDMA. Well, MDMA was later, but...

01:51:48.000 43?

01:51:49.000 43. So these people were, there was no stigma attached to using these substances that in many ways, I'm not, and I've experienced LSD, but I'm not an enthusiast.

01:52:04.000 I haven't had enough experiences to really talk about it.

01:52:07.000 But one thing that people who have had multiple like very heavy trips have told me is that they gain an insight into themselves that they don't think is available without it.

01:52:21.000 It removes them from them and allows them to look at themselves in a deeply introspective way.

01:52:29.000 This is also true of Ibogaine, and Ibogaine has had tremendous impact on people with addictions, including my friend Ed, who started up a clinic in Mexico.

01:52:43.000 He got addicted to pills.

01:52:45.000 He had a back injury and got hooked on opiates and was trying to find some way around this and trying to figure out what to do.

01:52:53.000 And in the process, he found out about Ibogaine, had an Ibogaine experience.

01:52:59.000 He did a session and then completely cured himself of that and then wound up opening up his own Ibogaine retreat because it was so beneficial to him and he wanted it to be available to other people.

01:53:10.000 What are your thoughts on those sort of treatments?

01:53:14.000 I am not an expert in that area.

01:53:17.000 I haven't taken the time to really research it.

01:53:22.000 In general, I always have concerns about using a potentially addictive, mind-altering substance.

01:53:30.000 I don't think Ibogaine is addictive.

01:53:31.000 I think it's so brutal that nobody wants to do it again.

01:53:35.000 If you do want to do it again, you want to wait a long time.

01:53:37.000 I don't think it's addictive.

01:53:40.000 So it may not be addictive for the vast majority of people, but for my patients who are vulnerable to addiction, it definitely can be.

01:53:51.000 Because anything that leads to a mind-altering experience of that kind of potency and intensity will be a draw for them.

01:53:59.000 You know it's like a 24-hour thing.

01:54:01.000 Uh-huh.

01:54:02.000 It's a 24-hour trip.

01:54:03.000 Right.

01:54:04.000 Have you ever experienced it?

01:54:05.000 No.

01:54:05.000 I haven't either.

01:54:06.000 Yeah.

01:54:07.000 I mean, again, for my patients, the longer the better, you know.

01:54:12.000 I am open to the possibility, and I do understand what you're talking about.

01:54:19.000 I do believe that getting a totally new perspective on our lives can be life-changing in a positive way.

01:54:29.000 Here's what I wonder, though.

01:54:31.000 I wonder if there are other better ways to get there than through this kind of microdosing.

01:54:39.000 Well, I don't think this is a microdose.

01:54:42.000 I think the Ibogaine thing is a tremendously powerful and often painful experience for the people that get involved in it.

01:54:49.000 But there's also...

01:54:50.000 Google, what is the mechanism that helps addicts with Ibogaine?

01:54:58.000 In which method does Ibogaine help addicts with addiction?

01:55:04.000 Because there's something that happens where it rewires Certain aspects of the brain, and this has been demonstrated in trials to the point where there's people seriously considering trying to figure out how to get it passed through the FDA and how to get it brought through whatever the regulations are in America.

01:55:28.000 We're good to go.

01:55:53.000 And look at all these addictions that you have for what they are and what their sources are.

01:55:57.000 But then on top of that, also rewires the pathways that cause addiction.

01:56:03.000 Again, I don't know too much about this.

01:56:06.000 So yes, and I will be the first to say that I don't know too much about it either.

01:56:10.000 And I do know though that these are done, that the studies are done under very controlled circumstances.

01:56:18.000 Often involving psychotherapy.

01:56:21.000 So it's like psychedelic mediated psychotherapy.

01:56:26.000 So it's not usually just the drugs by themselves.

01:56:30.000 Right.

01:56:30.000 It says, Ibogaine seems to influence withdrawal in two primary ways.

01:56:34.000 First, it helps regulate levels of dopamine and serotonin in the brain.

01:56:38.000 Ooh, your favorite subject.

01:56:39.000 Both of which are chemicals associated with pleasure and the feelings of well-being.

01:56:43.000 Second, it helps restore damaged areas caused by long-term substance abuse.

01:56:48.000 So then it goes into detail about the regulation of dopamine and serotonin.

01:56:53.000 How does ibogaine work?

01:56:55.000 The control release of the feel-good and reward chemicals in the brain with certain substance or alcohol reach the brain.

01:57:00.000 They can attach to specific receptors like those that stimulate the dopamine command centers.

01:57:04.000 Think of a lock and key mechanism.

01:57:06.000 If the drug, which has a unique chemical shape, finds a corresponding keyhole on the command center, it activates the center and tells it to release its chemicals such as dopamine.

01:57:16.000 Ibogaine is able to work by regulating dopamine surges that occur in addiction because it can inhibit the access to some of these dopamine receptors.

01:57:23.000 In other words, it gets in the way and will not allow the drug like an opioid or an opiate to attach to the receptor and stimulate it.

01:57:30.000 Ibogaine can also block transporter molecules that work to shift dopamine into brain cells.

01:57:37.000 This is interesting stuff right?

01:57:39.000 Yes.

01:57:40.000 What do you think about this?

01:57:41.000 Well, I think it needs more research.

01:57:43.000 Right.

01:57:44.000 Yeah.

01:57:45.000 It'd be nice, though, if that would just blast off on Ibogaine and then go, Doc, I got it.

01:57:50.000 Thank you.

01:57:51.000 Give me a hug.

01:57:52.000 Appreciate you.

01:57:53.000 I'm not doing heroin anymore.

01:57:54.000 Yes, that would be wonderful, except that, you know, history would say that whenever there was going to be a new drug that was going to fix addiction, it usually didn't turn out very well.

01:58:05.000 Yeah, but this isn't new.

01:58:07.000 Yeah.

01:58:07.000 Well, okay, a new old drug.

01:58:09.000 Yeah, I don't know, you know?

01:58:11.000 I wonder.

01:58:12.000 I wonder because of my friend who has a very positive experience.

01:58:16.000 And you know what?

01:58:16.000 That's important, right?

01:58:18.000 But we also need to think about the set and setting as they talk about how it was done.

01:58:25.000 And we need to think about the potential public health consequences of something like this being more readily available.

01:58:32.000 So it's always going to be risk benefits and alternatives when we're thinking about the utility of any medication.

01:58:39.000 What do you think public health issues would be if it was readily available?

01:58:44.000 Misuse and diversion, right?

01:58:46.000 People not using it the way that it was studied to be used.

01:58:51.000 People using it, self-administering it.

01:58:53.000 And again, not with Ibogaine, but with psilocybin, you know, MDMA. I have patients who...

01:59:02.000 Some of whom are in recovery who relapsed because they decided that they wanted to have this kind of spiritual awakening.

01:59:10.000 It was lacking in their lives.

01:59:12.000 So they got, you know, one of these substances on the dark web, self-administered, and were administering, you know, every 10 minutes for a week and ended up in the ICU. So that's the world I'm coming from.

01:59:26.000 I understand your concern.

01:59:27.000 Yeah, Ben.

01:59:28.000 Yeah, that makes sense.

01:59:30.000 I'm all for adults being able to make their own informed decisions, though, and I think that...

01:59:38.000 The way they have these things set up the way I know they have set up in many of these clinics is you're dealing with people that are trained professionals that have had these experiences personally and have had great benefit from it and they're dedicated to guiding people through this addiction process.

01:59:57.000 But then I don't think you have to worry about Ibogaine as a recreational one.

02:00:01.000 As I said I don't think it's fun.

02:00:03.000 Mushrooms I think is a different experience and I think it is fun.

02:00:09.000 Do you think that substances like that can be used responsibly without the threat or the danger of addiction?

02:00:22.000 Yes, yes.

02:00:23.000 I mean, when I talk about self-binding strategies, one of the self-binding strategies that I talk about is categorical self-binding, meaning that we put the substance into a category.

02:00:36.000 And that can be a category that we either will use or we won't use.

02:00:41.000 But one of the categories is actually the category of the sacred.

02:00:45.000 And that would include, in a way, the category of medications administered by modern-day shamans, you know, doctors potentially, right?

02:00:55.000 Because when we regard these molecules as sacred and special, we develop rituals around using them.

02:01:03.000 We use them in discrete ways that have shown to be helpful.

02:01:06.000 We don't use them in other contexts.

02:01:08.000 I absolutely think there's a role for that.

02:01:12.000 I'll never forget, I'm not remembering the details of like what society or village this was, but I remember reading about a quote-unquote primitive village, you know, some many years ago where the entire village would become intoxicated,

02:01:27.000 including children, one day a month.

02:01:31.000 But they all did it together, and it was part of a sacred ritual.

02:01:35.000 So it wasn't like a binge drinking pattern of addiction.

02:01:37.000 It was a sacred substance done in a safe, ritualized way.

02:01:42.000 And I definitely think there's, you know, a role for that, for sure.

02:01:46.000 The problem is when, you know, we sort of ignore set and setting, when we ignore the sacredness so we use more often, when we, you know, don't respect that ritualized environment, which is so necessary to keeping it safe.

02:02:00.000 Right, the difference between a sacred shamanic setting versus the way you feel when you go to the bar to have a few beers.

02:02:07.000 Yes, right.

02:02:09.000 Or just trying to, even if you're telling yourself, I'm doing this because I'm going to have a spiritual awakening, so I'm going to do it with my friend at the top of Kite Hill.

02:02:16.000 Probably not a good idea.

02:02:18.000 Yeah, you could fall down, too.

02:02:20.000 I always wonder about these things like...

02:02:26.000 What would happen if they were made freely available and legal and how much abuse would happen and how much we could mitigate that abuse with education and just time.

02:02:41.000 I mean, there's plenty of abuse of alcohol, right?

02:02:44.000 Right.

02:02:45.000 But we allow alcohol.

02:02:46.000 Well, alcohol is legal.

02:02:48.000 But there's no real benefit other than social lubricant.

02:02:51.000 Occasionally, you know, you come up with some great ideas when you're a little lit.

02:02:55.000 But the benefit of psychedelics is so well established in terms of the way it makes people reframe their life, the way it shifts your perceptions and allows you to think of things in a different way that might not really be possible without them.

02:03:15.000 There's nothing like them.

02:03:18.000 You know, again, I think we need more data.

02:03:21.000 It's not clear to me that the potential benefits outweigh the potential risks.

02:03:26.000 For addicts?

02:03:28.000 Right.

02:03:28.000 For certain individuals.

02:03:30.000 And, you know, how would we screen to make sure that, you know, the right people get it in the right way?

02:03:37.000 I just really think that we need more data.

02:03:40.000 And the good news is that research is very active now, and a lot of You know, young people that I mentor are really excited about this area.

02:03:50.000 So there's a whole generation of people coming up who are excited about this and are working on it and want to work on it.

02:03:56.000 And I think that's great.

02:03:57.000 I just think we need to wait, wait for more data.

02:04:01.000 Well, thank you to MAPS and Rick Doblin and all the great people that have done some incredible work with psychedelics and working with people with PTSD and all sorts of issues and doing it the right way.

02:04:13.000 Doing it with controlled studies and doing it out in the open and completely legal and approved.

02:04:22.000 And they've found great benefit with some of these things, particularly like MDMA with people with PTSD. That's one that they're working on a lot with soldiers and with other people that have experienced trauma.

02:04:33.000 I'm open to the idea.

02:04:34.000 Yeah.

02:04:35.000 Yeah, I'm open to the idea.

02:04:36.000 I'm not convinced.

02:04:37.000 I understand.

02:04:40.000 It's okay.

02:04:41.000 No, I get it.

02:04:44.000 How often do you find people that are actually healthy, like mentally healthy?

02:04:52.000 I don't want to say what percentage, but is it a rare thing to find someone who's truly balanced?

02:04:58.000 Or how many people are kind of like keeping it together, but behind the scenes, barely hanging on?

02:05:06.000 Well, I mean, I think some of the healthiest people that I have ever met and will ever meet are people with addiction in robust recovery.

02:05:14.000 Interesting.

02:05:15.000 Yeah.

02:05:15.000 So, like, there's almost maybe a benefit in recovering from addiction?

02:05:19.000 Absolutely.

02:05:19.000 Really?

02:05:20.000 Oh, yeah.

02:05:21.000 And, you know, I hear that all the time from patients in recovery, that they're actually grateful for their addiction because without their addiction, they would have never found recovery.

02:05:31.000 Wow.

02:05:32.000 So recovery and sort of the structure that it provides has been so beneficial to them in giving them like a clear like a scaffolding or a framework for life that it's better to have gone through it.

02:05:46.000 Yes, a little bit.

02:05:47.000 You know, we were talking earlier about humility and how important, you know, humility is to a life well lived.

02:05:53.000 And there's, boy, nothing that will humble you more than, you know, getting seriously addicted and having to crawl your way out of that.

02:06:00.000 So yeah, these are incredibly courageous, humble, wise people.

02:06:06.000 And I've learned a lot from my patients.

02:06:08.000 Isn't it fascinating that that seems to be a tenet of most religions is this humility, humbling yourself towards God, humbling yourself towards the divine?

02:06:17.000 Yes.

02:06:18.000 Yeah, I think so.

02:06:19.000 You know, I think that self-aggrandizement is really at the core of so much of our suffering.

02:06:24.000 And when we can figure out how to let that go, we're really free and ultimately, you know, live better lives.

02:06:31.000 I think it's also not just the feeding of the ego, but why the ego wants to be fed.

02:06:37.000 What is it about you that wants to proclaim yourself that you're so great?

02:06:42.000 Yeah, I'll never forget when I was pregnant with our daughter and I went around to different nurseries, you know, nursery schools to look for one that would fit her.

02:06:51.000 And I was scanning the room looking around at all these little kids and this one little girl sees me scanning the room and she goes, look at me, look at me!

02:07:01.000 My God, that's my younger self!

02:07:04.000 But there is this, I mean, this has even been described in the psychoanalytic literature as kind of a healthy narcissism.

02:07:11.000 So not all narcissism is unhealthy.

02:07:14.000 We need a certain amount of healthy narcissism.

02:07:17.000 What is healthy narcissism?

02:07:18.000 It's where we're willing to invest our energy, our creativity, our libido into a project, right?

02:07:26.000 Invest ourselves.

02:07:27.000 It's also the area where we're most vulnerable to injury because once we've invested ourselves, if our competence is threatened, then we experience a narcissistic injury and that goes right to our core.

02:07:39.000 It's incredibly painful.

02:07:41.000 The most common reaction to that is narcissistic rage and retaliation.

02:07:45.000 We'll find ourselves...

02:07:45.000 We're like retaliating, like not even maybe to the person who injured us or at another time that has nothing to do with the way that they injured us.

02:07:52.000 But nonetheless, there is this concept of healthy narcissism.

02:07:56.000 It's when narcissism, you know, goes to, like anything, to a pathological degree that it becomes very bad.

02:08:04.000 And unfortunately, our culture really feeds this kind of narcissistic self-preoccupation.

02:08:11.000 Getting back to athletes, you know, I think that's one of the real dangers about being, well, a celebrity of any sort, is that the media kind of wants you to, you know, to be all about you, even when you don't want it to be all about you.

02:08:26.000 And what happens, you know, essentially...

02:08:29.000 Narcissism separates us from our tribe.

02:08:32.000 You know, we stand out from our community.

02:08:36.000 And when we do that, we're really deprived of the good kind of dopamine that we get from those close, intimate attachments.

02:08:44.000 So it's a very dangerous but highly seductive thing because it's sort of the trope of our modern culture.

02:08:53.000 And the opposite is very detrimental too, which is not having any sense of self-worth.

02:09:00.000 That's probably maybe even harder because I think it's easier to dial it back than it would be to become confident or to have feelings of self-worth.

02:09:17.000 If you're a depressed person, Who looks at all these other people and thinks everyone's better than you and you're not valuable and you're worthless.

02:09:25.000 There are people like that out there for whatever reason, whether it's abuse as a child or whatever has caused them to think like that.

02:09:33.000 That may be worse.

02:09:35.000 I guess I wouldn't see one as worse than the other.

02:09:39.000 I mean, I think pathological narcissism is really destructive for the individual.

02:09:43.000 Yeah, I shouldn't say worse, but I would want to say harder to recover from.

02:09:47.000 Well, I mean, gosh, people recovering from narcissism.

02:09:50.000 First of all, they don't show up very often in my office, right?

02:09:53.000 They don't think they have a problem.

02:09:55.000 Yeah, right.

02:09:56.000 It's all the people, the dead bodies around them.

02:10:00.000 Whereas people with, you know, like chronically low self-esteem and lack of confidence, that's in some ways more treatable because they're often more treatment-seeking.

02:10:10.000 And the harm is mostly to themselves, not necessarily to other people.

02:10:15.000 But just to turn it on its head a little bit, there's also a way to be narcissistic about being the worst person.

02:10:23.000 And that sometimes, you know, comes up in clinical care, too.

02:10:26.000 Interesting.

02:10:27.000 Yeah.

02:10:27.000 Where, like, there's a kind of...

02:10:30.000 Self-loathing narcissism?

02:10:31.000 Well, actually, in AA, they call it terminal uniqueness. 1.00

02:10:35.000 This idea that, like, I'm the worst piece of crap that ever was. 0.98

02:10:40.000 I'm so unique. 0.99

02:10:41.000 Nobody can ever help me.

02:10:43.000 You know, that's how messed up I am.

02:10:45.000 So narcissism can manifest in a lot of complicated ways.

02:10:48.000 That's fascinating.

02:10:49.000 I never thought of it that way, but that makes sense.

02:10:51.000 They wallow in their own self-pity.

02:10:53.000 That's right.

02:10:53.000 Yeah.

02:10:55.000 But my perspective was just that from my experience and just people doing things that are difficult to do, that confidence is very important and it's extremely difficult to get someone to develop confidence.

02:11:09.000 Whereas You can get a narcissist or at least someone who's kind of made a mess out of their life to recognize how much of it is their fault and how much of it is the way they interface with people around them and how much of it is these narcissistic tendencies that maybe could be exposed by experiences,

02:11:27.000 whether they're negative experiences or psychedelic experiences or maybe even just some sort of therapy where you're recognizing patterns in your life.

02:11:36.000 Yeah, I mean, you know, for the narcissist, the treatment is, you know, the shattering of the ego and the, you know, engaging in a kind of selflessness and merging with others as opposed to seeking that self-aggrandizement.

02:11:50.000 But I do, in my experience, people who have low self-esteem and lack self-confidence...

02:11:55.000 They can also get better.

02:11:57.000 And again, their project is then engaging in difficult things in small incremental ways and seeing success and then being able to use that as a touchstone.

02:12:06.000 Oh, wow, I was able to do that.

02:12:08.000 I can do the next hard thing and the next hard thing after that.

02:12:12.000 And a little bit that's just getting back to like psychedelics.

02:12:16.000 That's a little bit one of my worries too about that kind of intervention because, you know, there are other ways to get to that top of the mountain.

02:12:25.000 And if you do it through your own hard incremental work over a long period of time, Maybe you get to the same place as the person who used psychedelics, but you did it through your own work.

02:12:35.000 And that means then your new perspective also relies on this touchstone of self-efficacy, which is why I like the idea of psychotherapy better than this kind of one-time medication thing.

02:12:49.000 But those two can be combined, too, potentially.

02:12:52.000 Yeah, I think there's probably a bunch of different ways to get better at pretty much everything, right?

02:12:58.000 But the idea is that you're focusing on getting better.

02:13:01.000 Yeah, right.

02:13:04.000 I've always felt like one of the things that's troubling for people, one of the things that we have a problem with is there's no real guidebook on how to live your life.

02:13:12.000 That's for sure.

02:13:13.000 You know, I mean, I think that's one of the reasons why we develop these bad patterns.

02:13:18.000 And, you know, and oftentimes bad parents...

02:13:33.000 We're good to go.

02:13:42.000 To establish some guidelines of how to live your life and it's one of the things that I think is so beneficial about these sort of tribal rituals that you were talking about is that people have these guidelines and I think holidays and festivals and rituals and the thing about those things that are good is that they sort of establish some sort of structure and for whatever it is about people There's something about having no structure

02:14:13.000 that for a lot of people, it feels very lonely and confusing.

02:14:19.000 Oh, for sure.

02:14:20.000 Yeah.

02:14:21.000 I mean, it's amazing to me how often when I'm working with patients, I have to tell them things that really should be absolute common sense and things that they should have learned growing up.

02:14:34.000 Things like Get up every day and, you know, eat your breakfast and exercise and have a schedule and try to show up and try to show up on time and tell the truth and all these kinds of things that we kind of knew once but we sort of forgot.

02:14:52.000 But you're absolutely right.

02:14:53.000 Structure is really key.

02:14:56.000 You know, the whole wellness movement now really is about trying to create guidelines for people to remember stuff that we seem to have forgotten.

02:15:06.000 I think one of the more interesting things about your work that's very beneficial to people is recognizing what is going on.

02:15:15.000 Like recognizing that there are these chemical pathways, that there's these real things that are happening inside your mind and this is not just some sort of a psychological airy-fairy sort of like an idea.

02:15:30.000 That there's real science behind this.

02:15:33.000 Yeah, and that really clearly resonates for people now.

02:15:36.000 If you give them a neuroscience framework for approaching their lives, that's exciting for people.

02:15:44.000 Whereas if, let's say I were to use a religious framework or a moral framework, people are not going to cotton on to that in quite the same way.

02:15:52.000 At least some people aren't.

02:15:52.000 Yeah, at least some people.

02:15:54.000 That's right.

02:15:54.000 Especially people that really value sort of evidence-based things.

02:15:59.000 Right.

02:15:59.000 They want to know, like, what is causing this?

02:16:01.000 And then you see it, and then maybe you can recognize in your own behavior, oh, I'm leaning into the gremlins.

02:16:09.000 Right, right.

02:16:10.000 I love that term, too.

02:16:11.000 Thank you.

02:16:12.000 Yes, I had somebody contact me and say, you know, I'm trying to quit smoking.

02:16:17.000 I've had a really hard time.

02:16:18.000 But now whenever I crave a cigarette, I just think about the gremlins hopping on the paints in my mouth.

02:16:22.000 And he said, it's really silly, but it's really helpful for me, you know, because I know if I just wait long enough, they'll hop off and homeostasis will be restored and I'll be able to move on.

02:16:32.000 Yeah, it's hard in the moment though, right?

02:16:34.000 It is hard.

02:16:34.000 When you're gripped with addiction, it's hard in the moment.

02:16:38.000 It sure is.

02:16:39.000 Yep.

02:16:39.000 You know, your talk about that little dopamine rush that you would get when you would pass by a bar if you were an alcoholic.

02:16:48.000 Right, right.

02:16:48.000 I used to get that from passing by pool halls.

02:16:51.000 I would see a pool hall.

02:16:52.000 I'd get excited.

02:16:52.000 I'd want to go in there and play.

02:16:54.000 And I would say, well, that's something I enjoy doing, though.

02:16:57.000 What's the big deal?

02:16:58.000 But it was that, but it was also there's some element of escape.

02:17:03.000 Oh, absolutely.

02:17:24.000 And that's where I think the neuroscience comes in and makes it, like, more understandable.

02:17:28.000 It's like, oh, wow.

02:17:29.000 Okay, this is because it's happening in my brain.

02:17:31.000 I've lost some ability to actually choose not to do this.

02:17:35.000 And just that awareness, I think, can help people.

02:17:39.000 All right.

02:17:40.000 Well, that was an awesome conversation.

02:17:42.000 I really enjoyed that.

02:17:43.000 Oh, well, thank you.

02:17:44.000 Me, too.

02:17:45.000 Very enlightening.

02:17:45.000 And please tell people the name of your book and where they can get it.

02:17:49.000 It's available everywhere.

02:17:51.000 Yes, it's called Dopamine Nation, Finding Balance in the Age of Indulgence. 1.00

02:17:56.000 Do you have an audiobook?

02:17:57.000 I do, an audible.

02:17:58.000 Did you read it?

02:17:59.000 I did.

02:18:00.000 Yes!

02:18:01.000 I love that.

02:18:02.000 I hate when some actor person reads anyone's book.

02:18:07.000 Yeah.

02:18:08.000 I was really nervous.

02:18:09.000 Oh, there it is.

02:18:10.000 Yep.

02:18:10.000 I was really nervous to read it myself, but people seem to be okay with it.

02:18:16.000 Great cover, too.

02:18:16.000 What is that supposed to be?

02:18:17.000 That is a Rorschach test because there's a brain in there.

02:18:22.000 And if you don't see it, then join the club because I didn't see it either when I first saw that.

02:18:27.000 My daughter pointed.

02:18:28.000 She said, you know that's a brain. 0.79

02:18:29.000 I was like, oh my gosh, you're right.

02:18:30.000 That is a brain.

02:18:31.000 It seems like a brain with a disease though.

02:18:33.000 Well, it may be a brain with a lot of vibrant colors that maybe went splat. 0.88

02:18:37.000 Ooh.

02:18:38.000 Yeah.

02:18:39.000 Or maybe just putting out all this positive energy.

02:18:43.000 Yes.

02:18:44.000 Let's look at it that way.

02:18:45.000 That's a much better way.

02:18:46.000 Well, thank you very much.

02:18:47.000 Really appreciate it.

02:18:48.000 It was wonderful talking to you.

02:18:49.000 Do you have social media?

02:18:50.000 Do you have anything where people can find you?

02:18:52.000 No.

02:18:52.000 Not really.

02:18:53.000 Good for you.

02:18:54.000 Good for you.

02:18:55.000 That's a good place to be.

02:18:57.000 But thank you.

02:18:58.000 You're welcome.

02:18:58.000 Your book's out right now.

02:19:00.000 It's out.

02:19:01.000 It hit the New York Times bestseller list, and so it's temporarily out of stock.

02:19:05.000 All right.

02:19:05.000 Nice.

02:19:06.000 But hopefully my publisher is working on it, and I know they're working on it.

02:19:10.000 Congratulations on that.

02:19:11.000 That's excellent.

02:19:11.000 Thank you.

02:19:11.000 Yes.

02:19:12.000 It's unexpected and exciting.

02:19:15.000 Go buy it, kids.

02:19:16.000 All right.

02:19:16.000 Thank you very much.

02:19:17.000 Thank you.

The Joe Rogan Experience - September 16, 2021

Joe Rogan Experience #1708 - Anne Lembke

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Transcript