The Path to Enough

The transcript below may be for an earlier version of this episode. Our transcripts are provided by various partners and may contain errors or deviate slightly from the audio.

Shankar Vedantam:

This is Hidden Brain. I'm Shankar Vedantam. It seems like the simplest choice in the world. Given the option between pain and pleasure, we ought to choose pleasure. Is it better to be hungry or full, better to be tired or alert? Better to watch another episode of our favorite TV show or do the dishes. It isn't just our own minds that tell us to choose the path of enjoyment and indulgence. Our friends remind us that life is short. Say no to dessert or another round of drinks, and someone might call you a spoiled sport.

At Stanford University psychiatrist Anna Lembke has heard the same messages, but as a scientist, she's also studied the way our brains balance pain and pleasure. The two sit on opposite ends of a neural seesaw and the brain constantly attempts to bring them into equilibrium or what is known as homeostasis. When we press down hard and often on the pleasure side of the seesaw, triggering bursts of the neurotransmitter dopamine, Anna says, the brain automatically compensates by pressing down on the other side, producing a dopamine deficit. Over time as people press down too much or too often on the pleasure side of the equation, the brain compensates so forcefully that we start to walk around with a chronic dopamine deficit. This can manifest as anxiety, irritability, and depression.

There is complex neurochemistry behind the process of homeostasis, but Anna has come up with a simple way to visualize this. When you press down on one side of the seesaw, imagine a bunch of gremlins inside your head jumping on the other side of the seesaw. We explored how this mechanism works and why it exists in our previous episode. If you missed it, I strongly suggest you listen to it first. Today we continue with the second part of our story about the paradoxical effects of pleasure, and we ask what it means to live a life of balance and harmony, how to work with the brain rather than against it this week on Hidden Brain.

Anna Lembke is a psychiatrist at Stanford University. She has worked with many patients who have addictions not just to drugs like cocaine and heroin, but to everyday activities taken to excess. She has treated patients with a range of out of control indulgences from eating and drinking to online shopping and sports betting. Around the time she turned 40, Anna found herself in the grip of an addiction. She was consumed with romance novels and erotica. At one point, she found herself swept up in the novel Fifty Shades of Grey. The story later made into a movie revolves around a sadomasochistic relationship between a college student and a business tycoon.I asked Anna what drew her to the book.

Anna Lembke:

I'm honestly not even sure I know because it didn't really matter when I was reading it. That is to say the plot and the characters mattered not at all. I was reading it for the sex scenes. Embarrassing to admit that, but it's true. But I remember rationalizing it to myself as a modern day pride and prejudice, but not really.

Shankar Vedantam:

Yeah. You don't think Jane Austen would've written Fifty Shades of Grey?

Anna Lembke:

Don't think so. No. Don't think so.

Shankar Vedantam:

At a certain point, Anna, you started to see that your enjoyment of romance novels and fantasy had tipped over from entertainment to something more potent. When did you have this realization as you were reading Fifty Shades of Grey?

Anna Lembke:

I remember it vividly. It was about three in the morning on a weeknight well past the hour I should have been sleeping so that I could be prepared for the next day to come. And I got to a scene where the characters were using sadomasochistic sex toys, and I just thought to myself, "Well, how did I get here? What am I doing? That's not anything that I'm into or even interested in." It was this sort of like, "Where am I and how did this happen?" And I decided that's it. Something has gone seriously awry here. I need to look at this problem.

Shankar Vedantam:

Anna eventually came to realize that her own engagement with romance novels and erotica had something in common with the addictions she was treating in her patients. When she was reading, she would become so engrossed that it felt like she was in a trance. You can see this among people who have addictions to sports betting or pornography. You can see it among heavy users of YouTube or social media platforms like TikTok. And of course you can see it in the way people disappear into their phones. Anna said she would lose track of time, lose track of herself.

Anna Lembke:

And we want to be in a trance. I mean, I think that's something we have to admit to ourselves. We want to escape ourselves, and I think part of that is a function of this incredibly narcissistic society that we live in where we're so preoccupied with ourselves and our problems and our achievements. We're desperate to get away from ourselves. Plus you have all these amazing drugs that make that possible.

Shankar Vedantam:

A turning point in your life came in 2011 during an encounter you had with a young resident who was training to be a psychiatrist. Tell me what happened and how it came about.

Anna Lembke:

Yeah, so this was a lovely young student of mine, doctor in his residency for psychiatry, and I was teaching a small group of residents how to do something called motivational interviewing, which is a way of harnessing the patient's own motivation to change their behavior. So we got into these pairs so that one could role play the psychiatrist and the other could role play the patient, and the patient could talk about a behavior that they want to change and the psychiatrist could do this motivational interviewing to try to explore how to help them do that. And we had an odd numbers, so that means that I had to pair with the student in order to do the role play. So he said, "Well, I'll be the psychiatrist." I said, "Okay, I'll be the patient." And he said, "Is there a behavior you'd like to change?" And I just sort of said without even thinking about it.

"Yeah, I do some late night reading that I'd like to change," and unusual motivational interviewing style said, "Well, why is it that you want to change that behavior?" Right? You're trying to explore with the patient what their reasons are. And I said, "Well, I just think it's gotten into a bad habit. It's interfering with my sleep. It's interfering with my ability to be present," just sort of vague generalities. I did not tell him what specific genre of book I was struggling with. So then he asked me, "What would you be giving up if you stopped that behavior?" And I said, "I would be giving up the intense pleasure and feeling of escape that I get from reading." But then when I said that, I realized, "But those things are not as important to me as being present for my husband and for my children, for being invested in and good at the work that I do."

Shankar Vedantam:

So I find it so striking and also so revealing, Anna, that it took an actual conversation where someone asked you a simple question and you had to answer aloud for you to see something about yourself. I mean, you are the trained psychiatrist. You're supposed to have insight, and I think it just shows how difficult it is for all of us to see ourselves clearly.

Anna Lembke:

Yeah, isn't that amazing? And it is striking and a bit of a mystery frankly, as to why putting into words what we're doing, especially telling another live human has this remarkable ability to penetrate our lack of awareness and make us aware in a way that also then greatly enables our ability to change that behavior.

Shankar Vedantam:

So did the conversation end there or did the two of you come up with a plan for what you could do to change your behavior?

Anna Lembke:

The conversation as I'm recalling it went on a little bit longer, but not much longer, frankly. So then he asked a very simple question. He said, "Well, what's one thing you could do to take a step toward changing that behavior?" And I thought, "Well, I could get rid of my Kindle because my Kindle gives me such incredible easy access to these downloadable reads including free reads from Amazon," that if I got rid of it would create a barrier between me and the romance novel so that I'd have to do more work to get it. So that's what I decided to do.

Shankar Vedantam:

So how did that go? Did you just quit cold turkey?

Anna Lembke:

Once I had had that conversation with him and I thought about it the next day, I had a moment where I realized, "Oh, wow, I think I've developed a minor addiction to romance novels and erotica." And so then I simply made a decision to do what I recommend my patients do, which is abstain for four weeks, got rid of the Kindle and just made a strong commitment to not reading romance novels and erotica. But what shocked me was that very night, which was the first 24-hour period of my not engaging in romance novel reading as a way to put myself to sleep, I was gripped by anxiety and restlessness and agitation.

And I was surprised because I first of all didn't think there would be a huge physiologic or even psychological response, but I experienced withdrawal the same kind of withdrawal that my patients described.

Shankar Vedantam:

Wow.

Anna Lembke:

I had a very difficult time putting myself to sleep, and so it was extremely difficult. I lay awake for several hours and finally was able to put myself to sleep, and that went on for about 10 to 14 days. So in fact, it was the process of trying to give it up that really brought home to me how addicted I had become.

Shankar Vedantam:

What happened at the end of the month, Anna.

Anna Lembke:

I felt much better and I thought to myself, "I'm good. Now I'm going to go back to reading romance novels," Now and then in a very rational and tempered way, and we're all going to be fine here. And so I went and I got some book and I completely binged. I spent the whole weekend reading all day every day and late into the night on Sunday, went to work bleary-eyed on Monday, and I realized, "Wow, that was a complete mess." And it's clear that whatever those circuits are that have been kindled in my brain, they're still kindled and that a month is not sufficient and I need to recommit to a longer period of abstinence. And that's what I did. I recommitted to a year of abstinence from romance novels, erotica of any sort.

Shankar Vedantam:

One of the things that's hardest about problems involving the mind is that we need our minds to battle the problems we have with our minds. Imagine trying to fix a broken toaster and the only tool you have is a very same broken toaster. When we come back, how to reset our relationship to pain and pleasure in a way that produces enduring satisfaction. You're listening to Hidden Brain. I'm Shankar Vedantam.

This is Hidden Brain. I'm Shankar Vedantam. In our previous episode, which I highly recommend you listen to if you haven't heard it yet, Stanford University's psychiatrist Anna Lembke explained how our minds come with an internal seesaw. It's designed to keep things in balance to achieve what is called homeostasis.

When you bite into a delicious dessert or bet on a sports game and wait excitedly for the result, you're pressing on the pleasure side of the seesaw, you trigger a burst of dopamine to return. To balance the brain compensates by pressing down on the other side of the seesaw. Over time, if we press too hard or too often on the pleasure side, the brain starts to compensate more and more forcefully leaving us with a dopamine deficit. This can leave us feeling down and miserable and prompt us to go find our next jolt of pleasure. You can see how this quickly can become a vicious cycle. Anna, it's clear that simply seeking out more pleasure and more intense pleasure or more constant pleasure is not the answer. And you often recommend something that you call a dopamine fast to your patients. How does it work?

Anna Lembke:

Well, the dopamine fast is a little bit of a misnomer in the sense that we're not actually ingesting dopamine. In fact, what we're doing is using substances and behaviors that trigger the release or increase in firing in dopamine that we make in our brain. What the dopamine fast refers to is to abstain from the substance or behavior for long enough for our brain to get the memo, "Oh, wait a minute. I'm not getting this external source anymore. It's time for me to start to make more of my own endogenous or innate dopamine to upregulate our own dopamine receptors and increase dopamine transmission." Because in response to substances and behaviors that release a lot of dopamine in our brain, this fire hose of dopamine, what our brains essentially do is down-regulate dopamine transmission, not just to baseline but below baseline, which is this state that's really akin to a clinical depression.

Shankar Vedantam:

There is an important caveat to this recommendation. The more severe the addiction, the more a dopamine fast will produce painful symptoms known as withdrawal. In some cases, withdrawal can be so severe that it can pose medical risks of its own.

Anna Lembke:

Anybody with a severe addiction is going to need medical supervision and support, and especially if they're physiologically dependent to a chemical like alcohol or benzodiazepines or opioids such that they would be at risk for life-threatening withdrawal. Because essentially what happens in withdrawal is that we experience the opposite of whatever that drug does for us. And with sedatives like alcohol, opioids, and benzos, we can experience a physiologic storm including life-threatening seizures. So individuals who are struggling with that kind of severe chemical dependency should not just quit cold turkey. They need medically monitored detoxification or tapering in order to get off of their drug of choice. But the principle is still the same that they need to get off of that chemical in order to allow their brain to heal.

Shankar Vedantam:

So you once treated a patient whom you call Delilah, a young woman who was a heavy user of cannabis. So you broached the idea of a dopamine fast to her, and what was her reaction?

Anna Lembke:

Well, first of all, she came to me seeking help for anxiety and depression, not seeking help for cannabis. In fact, she identified cannabis as the only thing that helped with her anxiety, and she wanted me to prescribe a pill or offer some kind of psychotherapy that would help with her anxiety and depression. But what I said to her, which is what I say to many people who now come to me wanting help with anxiety and depression and other psychiatric symptoms whom I discover are using high dopamine rewards excessively, is that instead of prescribing them a pill or recommending any kind of psychotherapy, what I invite them to do is to engage in an experiment which is the dopamine fast for four weeks in order to reset reward pathways because there's a possibility, I tell them that just by doing that alone, their anxiety and depression may get substantially better without our having to do any other intervention. So that's what I suggested to Delilah.

Shankar Vedantam:

So you say that four weeks of abstention are also necessary to begin to see one's life more clearly to accurately perceive cause and effect when it comes to our moods and the things that are bringing us up and down. What do you mean by that and how did that work out with Delilah?

Anna Lembke:

When we're chasing dopamine, it's very difficult to see the true impact of our drug of choice, whether a substance or behavior on our lives. All we see is the immediate relief that we get from it. We're not able to see that over time what's happening is that we're changing our brains in a way that's probably exacerbating the problem we're trying to solve. So I suggested to Delilah that she try giving up cannabis for a month in order to reset her reward pathways. And what she said to me is, "Why would I do that?

Cannabis is the only thing that helps with my anxiety." And I said to her, "I hear you that in the moment you get relief from the cannabis. But what I suggest to you is that what you're really doing is medicating withdrawal from the last dose rather than treating your underlying anxiety disorder. And that in fact, what the cannabis is doing over time is changing your hedonic or joy set point such that now you need more and more cannabis to feel any pleasure at all. And in fact, what I see is that people who use cannabis, that the pot can actually start to do the opposite and make them more anxious and even paranoid over time." And still she was not interested in stopping.

She said, "Maybe someday, but not now." And then I do something that I often do with patients and I try to get them to look at the larger timeline of their lives. So I said to her, "Well, I hear you that you're not interested in stopping now. When do you think you do want to change the way you're using cannabis? Do you think you want to be smoking the way you are now in 10 years?" She immediately responded, "Nope, I definitely won't be smoking this way in 10 years," implying that there was something about her current use that she could admit was not healthy.

So I said to her, "Okay, well you don't want to be smoking this way in 10 years. How about five years?" She says, "No, I don't want to be smoking this way in five years." And I said, "Okay, how about in a year?" And then she stopped and kind of thought about it and she said, "Okay, I get where you're going with this doc. You're basically telling me if I don't want to be doing it in 10 years or five years or a year from now, why not try stopping now?" And I said, "Exactly." And then she agreed to do it.

Shankar Vedantam:

And how did it tone out?

Anna Lembke:

Really interesting. She came back four weeks later and she said, "Dr. Lembke, you wouldn't believe it." And this is what's so funny. Patients will always say, "You wouldn't believe it," as if I'm going to be shocked. I said, "Tell me." She goes, "Well, first of all, stopping pot made me realize that I had been addicted to pot, something I really didn't realize before." And I said, "Well, how did you realize that?" And she said, "Well, first of all, the first week I was vomiting violently." So remember that with withdrawal is the opposite both psychologically and physiologically from whatever the drug was doing for us. And we know that cannabis can be an anti-emetic or an anti-nausea kind of effect. So when she stopped using it, she started vomiting. And that was the signal to her that her body had been changed by her chronic heavy use more even in her case than the temporarily increased anxiety and insomnia, which I had warned her about.

And then she said, "And you wouldn't believe it, but I feel so much better now after four weeks of stopping than I have in a really long time, I feel less anxious, I feel less depressed. I'm more able to enjoy things. I can breathe better. I feel physically better. I'm sleeping better." And this happens again and again and again. We see this so often in clinical care and people are so surprised because when we're in it, we don't see the harm, right? All we know is that, oh, God, smoking this joint makes me feel better after a long hard day. We can't see the ways in which the cumulative effects actually are making us feel worse.

Shankar Vedantam:

So this is not the only client who discovered that the symptoms she thought she was treating with the drug might actually have been caused by the drug. I understand that there has been research on this front, not just looking at individual patients, but a classic study conducted with a group of alcoholic men who also had clinical depression. Tell me about that study and what it found, Anna.

Anna Lembke:

Yeah, so this is a famous study by Brown and Shuckett where they took a group of adult men who met clinical criteria for alcoholism and also met clinical criteria for major depressive episodes. They put them in the hospital for four weeks during which time they had no access to alcohol, they made sure they didn't have life-threatening withdrawal, but also during which time they gave them no specific or general treatment for major depression. And what they found is that at the end of those four weeks, 80% of those individuals no longer met criteria for major depressive episode. In other words, just stopping drinking resolved their depression. And that is very consistent with what we see clinically. People who have anxiety, depression, insomnia, and attention just by stopping their substance or behavior of choice for four weeks largely resolves many of those symptoms in about 80% of patients who come in.

Shankar Vedantam:

This is consistent with your larger hypothesis that this is the plenty paradox at work that the overabundance of things that trigger dopamine in our heads is causing those gremlins in our brain to sort of lean so hard on the other side of the teeter-totter that now we are walking around feeling depressed and anxious, and if we try and just get back to equilibrium, we're going to feel much better when we're not chasing sort of those highs anymore to get rid of our feelings of depression.

Anna Lembke:

Yeah, exactly. I mean, we are clearly in the midst of a severe mental health crisis, especially affecting our youth, and there's lots of speculation for why that is. And a hypothesis that I've put forward is this idea that the source of our unhappiness is in fact our relentless pursuit of pleasure, the many drugified things in our world today that make that possible, and the ways that our brains are trying to compensate for that by actually going into this dopamine deficit state, which is very similar to clinical depression or anxiety, insomnia, et cetera.

Shankar Vedantam:

So one of the most important claims that you're making here is that the sea of plenty in which many of us find ourselves in nowadays is causally responsible for the fact that many of us actually might be more unhappy than we were 30 years ago, 50 years ago, 100 years ago. Are we sure that there is a causal connection between those two things, and if so, how are Be sure of that, Anna?

Anna Lembke:

It's a hypothesis based on inference, but let me tell you what the data points are. First of all, when you look at happiness surveys about 50 years ago, you could track that people who were living in wealthier nations were more happy than people living in poor nations and that they were getting happier over time. Starting about 20 years ago, people in the richest countries in the world started to be less and less happy. Now what the cause of that is, we don't know for sure, but you could make the inference as I have done that we reached some kind of tipping point in terms of a abundance where what started out as a good thing became an overabundance and is actually contributing now to our suffering. And by the way, that holds true also for increasing rates of depression, anxiety, and suicide all over the world, which are going up all over the world, but which are rising fastest in the wealthiest nations.

So again, this kind of plenty paradox. You have even here in the United States, rising rates of anxiety, depression, and suicidal thinking among teenagers, corresponding specifically with the past 20 years and the increasing amounts of time that people are spending on the internet and consuming digital media. And then you have a much smaller data point, which is what we see clinically when we intervene and ask people to stop ingesting these high reward substances and behaviors. People who come in seeking help for anxiety, depression, and suicidal thinking. And what we find is that their anxiety, depression, and suicidal thoughts in the vast majority get better without her having to do anything else other than cut out for a period of time, their high dopamine, substances and behaviors.

Shankar Vedantam:

When we come back, techniques to get addictive behaviors under control, and the crucial role that relationships and community can play in helping us to reset our brains. You're listening to Hidden Brain. I'm Shankar Vedantam. This is Hidden Brain. I'm Shankar Vedantam. Psychiatrist Anna Lembke is the author of Dopamine Nation, Finding Balance in the Age of Indulgence. She argues that when we seek out pleasures on a nonstop basis, whether those pleasures are legal indulgences or illegal substances, we mess with the neurochemistry of the brain. Paradoxically, the more we chase pleasure, the more the brain tries to compensate leaving us in a dopamine depleted state. Anna recommends multiple techniques to help get indulgences under control. She calls these self binding techniques.

Anna Lembke:

Self binding techniques create both literal and metacognitive barriers between ourselves and our substance or behavior of choice so that we can press the pause button between desire and consumption. And there are many different ways to do that. I sort of organize it into time, space, and meaning to give us a fighting chance to be able to abstain.

Shankar Vedantam:

So what would some of these look like? For example, the physical or spatial self binding that you talk about? What does that look like?

Anna Lembke:

That looks like, for example, not having the substance in the house, if it's alcohol or potato chips or cookies or whatever it is, not having it in the house is a really simple one. My patients talk about when they travel, calling the hotel in advance and having the hotel remove the mini bar from the room. In some cases, remove the minibar and the television set so there's not access to the kind of cable channels that make people vulnerable. I've had patients use things like the kitchen safe so that they lock their device in there, they can't get it out for a certain period of time.

Shankar Vedantam:

It could also sometimes help to decide when you are going to engage in an activity.

Anna Lembke:

So this is the way to use time as a self binding construct. What I think is really interesting is the way that we essentially organize our time around rewards in the modern world in a way that I think is unprecedented. We sort of look forward to our coffee in the morning, and then we can't wait to get home at night and watch our shows. And so what I ask patients to do is to be aware of that and then use time to their advantage.

For example, if they've done the dopamine fast and now they want to go back to using their substance or behavior, but they want to use in moderation, they could commit to, for example, only playing video games two days a week, two hours a day, and specify when that is. Or if they want to have some mindless scrolling on social media, they can say, "Okay, I'm going to dedicate a half hour a day and this is when it's going to be, and then I know I'm going to do mindless scrolling or YouTube watching, but outside of that, I'm not going to do that, or I'm going to wait until I finish this exam or turn in my paper or get this job promotion. And then to use that as a way to bind themselves."

Shankar Vedantam:

I understand you had a patient, Mitch, who was addicted to sports gambling, and he had to take some pretty extreme measures to bind himself to keep himself from using his drug of choice.

Anna Lembke:

Yeah. So he had to do something called self banning where he basically went to the casinos and put himself on a ban list, which is very common among pathological gamblers, pathological sports bets. It's really hard with the new online apps, but you can also ban yourself on an online app. The other thing that he did was he avoided what I call the stepping stone effect, where certain behaviors are not necessarily our substance or behavior of choice, but they're a stepping stone to it. So he realized that he couldn't really watch sports in any capacity. He couldn't read about sports in the paper, he couldn't listen to sports radio. He couldn't watch sports on television or on the computer because as soon as he did that, the cravings to bet were just overwhelming.

Shankar Vedantam:

This is like people who have, let's say, an alcohol dependence problem, and you are taught don't walk by the bar on your way home from work, take a different route. So in other words, the things that you put in your environment end up shaping the choices that you make.

Anna Lembke:

Oh, absolutely. Such a key point to expect ourselves to be able to change without changing our environment in a dopamine overloaded world is just expecting us to not be human. I deal with a lot of families where the kids are addicted to video games or social media, and the parents are like, "I don't know why he just won't stop, or she just won't stop." Meanwhile, their house is like fiber optic high speed internet. They've got a screen in every room, in every bedroom, everybody's got 12 devices. No, right? No. And also at school's huge problem. The kids are allowed to have their phones during class how can a teacher possibly compete with YouTube? There's no way.

Shankar Vedantam:

So one of the most radical suggestions that you have and radical in the sense that I think it would appear to many people to be very counterintuitive in how to digest, is that one way to deal with compulsive over consumption is to actively seek out its opposite. You say that we should deliberately seek out experiences of pain and hardship. Now most of us try our best to avoid pain. Why would we choose to deliberately invite pain into our lives?

Anna Lembke:

Yeah. I know this sounds really wackadoodle, but there's actually science behind it. It's the science of hormesis and hormesis is Greek for to set in motion, and what we're talking about is very mild to moderate doses of adaptive or healthy pain as tolerated. And if you don't like the word pain, maybe use the word discomfort or challenge or something along those lines. Although often it does involve some physical duress at the right doses to upregulate our own healing mechanisms, but not so much that it causes irreversible harm. And what the science of hormesis shows in humans and in animals is that if you expose an organism to mild to moderate doses of painful, toxic, or noxious stimuli, you will actually make that organism healthier, more resilient, more robust, and we have evidence for that, overwhelming evidence for that through exercise, but also some emerging evidence for ice-cold water plunges.

There's also some evidence showing that prayer and meditation, which are not necessarily painful, but do require effortful engagement and a certain kind of concentration, which is not immediately necessarily pleasurable, those behaviors also release dopamine. Things like exposure therapy, forcing ourselves to do things that make us psychologically uncomfortable. These are all things that are hard in the initial experience, but essentially trigger our body to sense injury. And in sensing injury, our body start to upregulate our protective hormones, like again, our endogenous opioids all ultimately leading to the release of dopamine. So it's a really great way to overall reset our hedonic or joy threshold to the side of pleasure, which means that we're more resilient in the face of pain and we're generally happier.

Shankar Vedantam:

Let me summarize what you're saying and make sure I'm understanding this correctly. You're basically saying your essential argument here is that there is a system in the brain that tries to maintain homeostasis. When we press down on the pleasure side of the balance, the brain gremlins get on the pain side of the balance to try and compensate it and recover equilibrium. But if we were to press down on the pain side of the balance, now homeostasis starts to work in some ways in our favor because the gremlins hop onto the pleasure side of the balance, and they basically get us to a state where we're feeling better on average than we were doing before.

Anna Lembke:

That's exactly right. And there is overwhelming evidence to support this. So for example, we know that if you track dopamine levels as well as other feel good neurotransmitters like endogenous serotonin, norepinephrine, endogenous opioids, endogenous cannabinoids, what you find is that initially when people engage in exercise, those neurotransmitters are low, but over the latter half of exercise, they slowly start to rise. And then when the exercises stopped, those neurotransmitter levels remain elevated for hours afterwards. And of course, this is our runner's high, and then eventually those elevated levels of dopamine will go back down to baseline levels homeostasis, but without ever going into that dopamine deficit state. In other words, by paying for our dopamine upfront, we get those feel good experiences, which we need, right? We're humans. We can't just hang out in homeostasis, but we can get those good feelings without ever having to go into our cash, dopamine reserves, so to speak.

Shankar Vedantam:

You made an interesting analogy a second ago, and I want to just draw attention to it, which is that there is an analogy here between the way we engage with our brains and the way we engage with money. You can buy things on credit, and that is sometimes valuable and smart to do, but it does mean that you're getting the good stuff first and then paying for it later. So that's what we do when we intentionally trigger dopamine in our heads. We're getting the good feelings now, but have to deal with it later. You are arguing that focusing on the pain side of the equation in some ways is, as you say, paying for the dopamine upfront. You're doing the do difficult thing now in exchange for the reward down the road.

Anna Lembke:

Exactly. And you can see the ways in which actually the way we pay for things makes us all more vulnerable to addiction because now they have these credit cards where you don't even have to pay for them in real time. You can pay for them later, which is just terrible.

Shankar Vedantam:

I'm wondering if it will sound to many people that you're almost recommending a life of asceticism here. Are you recommending that people become aesthetics, Anna?

Anna Lembke:

I'm recommending a new form of asceticism for the modern age. And what I mean by that is we are living in an unprecedented time of overwhelming access to highly reinforcing drugs and behaviors such that I think that our existence is going to be reliant upon figuring out how to navigate this world of overabundance. And so in fact, in order to be healthy, we actually have to intentionally veer slightly to the side of pain and insulate ourselves from pleasure in order to preserve balance.

Shankar Vedantam:

Have you done this yourself?

Anna Lembke:

Oh, yeah. I do this on a regular basis.

Shankar Vedantam:

What do you do?

Anna Lembke:

Well, I like to start my day with pain, namely doing some kind of exercise, mainly walking or swimming because I'm in my 50s now, but every morning when I wake up, trust me, I do not want to get out of bed, but I absolutely force myself to do it most of the time because I know I'll feel so much better afterwards. And it's just a great anxiolytic and mood stabilizer for me. And then we've raised our family with a lot of forced marches and outdoor wilderness experiences, which were challenging and difficult. We've insulated ourselves from digital media in the sense that we didn't have any devices or wifi, even wifi to the home until our eldest went to high school. And then she came back and said that she essentially couldn't function as a high school student without wifi in the home.

They change the schedule every day. You have to log on everything just to know what class you're supposed to go to. It's crazy. So I'm really sad because now we have wifi and fiber optic, and it makes it a lot harder for me personally to manage my consumption. I'll get into these bad YouTube watching habits in the evenings. You can just imagine. But anyway, that's something that we did. We bike a lot of places instead of driving. In fact, we have a 25 year old minivan, which has 75,000 miles on it. And when my husband tried to re-register for the insurance, they didn't believe us that it only had 75,000 miles. They made us get an affidavit.

Shankar Vedantam:

Yeah. So what is the reward for living this way, Anna? What do you see in your life? Do you think you've seen effects in your mind on your brain?

Anna Lembke:

Oh, yeah. I used to think that my life was really hard and that was the source of my unhappiness. But now I actually think that all along my life was actually too easy, and that's why I was unhappy.

Shankar Vedantam:

One of the most striking things about stories of addiction is that they often involve increasing levels of social isolation. Think of the person who is up playing endless first person shooter video games in an apartment by himself at four o'clock in the morning, or the furtive heavy consumer of pornography, the young woman addicted to pot. Anna I feel like we may have painted an overly negative picture of dopamine in this conversation. Yes, you can have an unhealthy relationship with dopamine, but the problem is not with dopamine per se, but the ways we go about triggering it. You say that relationships are a powerful way to trigger dopamine in a healthy fashion. Can you talk about that idea?

Anna Lembke:

Yeah. So my colleague, Rob Malenka here at Stanford is neuroscientist. He and his colleagues have shown that oxytocin, which is our love hormone, binds to dopamine releasing neurons in the reward pathway. So that makes a lot of sense because we know when we fall in love, we feel high, right? That's a great feeling. And from a survival point of view or an evolutionary point of view, our brains want us to make connections to other people because we're more likely to find mates, more likely to be able to protect ourselves from predators, more likely to be able to steward scarce resources.

So our brains get us to make those connections by releasing dopamine and making sure that it feels good. The problem with addiction is that essentially our substance or behavior of choice comes to replace those human connections. And so we move further and further into isolation, and we meet those basic needs through our drug rather than through making deep human connections. And so part of getting into recovery from addiction means moving out of isolation and trying to make deep and rewarding intimate connections with other people because essentially that's what we're really looking for, but we get fooled by these kinds of false stand-ins for human connection.

Shankar Vedantam:

I'm wondering if you can tell me a little bit about the role of community here. There are many groups that have sprung up to try and fight addictions, groups like AA or NA or Gamblers Anonymous, for example. Tell me about the role that they play, and in some ways, is it part of the same equation that we're looking at here, the role of human relationships in battling addiction?

Anna Lembke:

Yeah. So AA, Alcohol's Anonymous and Narcotics Anonymous, in my opinion, are among the most remarkable social movements of the last 100 years. These are amazing grassroots organizations composed of people with addiction trying to help other people with addiction, and it's remarkably successful for those who actively participate. So you'll read a lot in the media now about how AA and other 12 sub organizations don't work, but that's not really a faithful representation of the evidence. There are many people who will not participate or get anything out of it, but for those who actively participate, engagement in AA and other 12 step groups is as effective and possibly even more effective than professional treatment.

So what is the secret of these 12 step groups? Well, first of all, they provide a sober social network. They provide a specific path for recovery, but importantly, they're also really de-shaming because you realize, "Oh, wow, I'm not the only one, and I have this thing that happened to my brain because I'm human and I have this particular vulnerability and other people have experienced and done similar things that I have done in pursuit of their drug." And that is an incredible burst of intimacy and yes, dopamine that we get then from being taken into the fold of like-minded individuals who understand us and accept us in all our brokenness.

Shankar Vedantam:

One important idea that Anna has adopted in her own life powerfully resonates with the message of groups such as AA and NA. Change begins with telling the truth.

Anna Lembke:

So this was really something that I learned from my patients over many years of seeing patients get into recovery from severe addictions. What I noticed was that those who seemed to get into the best recovery and be able to maintain recovery the longest were those who were committed to telling the truth. That was a central value for them, which they saw as just pivotal for maintaining sobriety or recovery. And I thought that was really interesting. What is it about truth telling that enables recovery and enables people to stay in recovery?

Because it just was such a consistent theme. Whether they got into recovery through 12 steps like AA or NA or just through their own journey, it was inevitable that they would be like, "Oh, yeah, no, I can't lie." And when they said that they weren't just talking about, I can't lie about my addictive behaviors, they meant they couldn't lie about anything, that the lying itself was sort of the first breach in the dam for them and that they had to be truthful in all things in order to maintain recovery. So that was really interesting to me, and I began to explore that both from a scientific perspective as well as try to employ it in my own life.

Shankar Vedantam:

One of the things I find so striking about this conversation, Anna, is that you are someone who spends her day helping patients, but I'm not getting the sense that you see yourself as better or even different from the people you're trying to help. I understand that you're a fan of the philosopher Martin Buber, who has talked about what it's like to truly engage with another person.

Anna Lembke:

He talks about this I and Thou moment, which he believed can occur between any two individuals who just make the effort to be fully present, who with each other, and it's a divine moment where everything else falls away. It's not sexualized love, it's something akin to love. But what's so interesting about this I and Thou concept is that it can be achieved in a nanosecond with anybody. You could achieve it with a stranger.

This idea being that when we kind of come to the encounter fully open and vulnerable in our shared humanity and we see each other, that's a really special and remarkable experience, and I try to create that in my work with patients because that alone is healing.

I've probably learned more from my patients than I think I've given them in return. I really see people in recovery from severe addictions as modern day profits because these are folks who have had to figure out pleasure and pain and consumption in a dopamine overloaded world, and they've had to do it as a matter of life and death, and they've been able to do it. And so they really provide this roadmap of deep wisdom for the rest of us.

Shankar Vedantam:

Anna Lembke is a psychiatrist and a researcher in the behavioral sciences at Stanford University. She's the author of Dopamine Nation, Finding Balance in the Age of Indulgence. Anna, thank you so much for joining me today on Hidden Brain.

Anna Lembke:

Oh, you're welcome. It was a real pleasure.

Shankar Vedantam:

Hidden Brain is produced by Hidden Brain Media. Our audio production team includes Brigid McCarthy, Annie Murphy Paul, Kristin Wong, Laura Kwerel, Ryan Katz, Autumn Barnes and Andrew Chadwick. Tara Boyle is our executive producer. I'm Hidden Brain's executive editor. Our unsung hero this week is Howard Wolf. Howard is president of the Stanford Alumni Association, and he invited me some time ago to attend a symposium featuring interesting research at the university. Anna Lembke was one of the speakers, and within minutes of listening to her, I knew we needed to have her on Hidden Brain. Howard is one of the most wise and generous people I know and a gifted communicator in his own right. Thanks for putting these great ideas on our radar, Howard.

If you would like to help us build more stories like this, please act now. Visit support.hiddenbrain.org and join the hundreds of other Hidden Brain listeners who have agreed to help. Again, that's support.hiddenbrain.org. I'm Shankar Vedantam. See you soon.