Outworker
Stories of healing, personal development, and inner work. Founded on the idea that the relationship with oneself is the most important to develop, but the easiest to neglect, Outworker shares conversations aimed at helping you develop that relationship.
Outworker
#073 - Dr. Anna Lembke - Dopamine Is Hijacking Your Brain & Here’s How To Reset
Dr. Anna Lembke explains how dopamine—meant to help us survive—is actually now working against us. Hijacked by endless access to pleasure, our brains have become stuck in a cycle of craving and withdrawal. We get into how modern life is fueling addiction, why discomfort is essential for balance, and how honesty and pain can be powerful tools for healing. This is a deep dive into the true cost of overstimulation and what it really takes to reset.
Timestamps:
00:00 What Is Dopamine?
03:39 How Dopamine Plays A Role In Addiction
06:09 Technology Reshaping Dopamine & Addiction
12:56 Brain Processing Pain & Pleasure
16:06 Knowledge As Medicine
18:36 We've Pathologized Pain
23:08 Rise In Chronic Pain Without Clear Diagnosis
32:44 Why Dr. Lembke's Practice Is Concentrated On Addiction
36:50 Mental Health vs. Lack Of Self Care
42:00 Importance Of Honesty In Overcoming Addiction
46:44 Spirituality For Overcoming Addiction
51:05 How Dr. Lembke Navigated Losing A Child
52:50 Difference Between Recovery & Healing
53:46 Setting Yourself Up For Success
57:11 Dr. Lembke's Work Being Grounded In Storytelling
1:02:50 The Hope Behind Dr. Lembke's Work
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What’s up outworkers. Dr. Anna Lembke explains how dopamine—meant to help us survive—is actually now working against us. Hijacked by endless access to pleasure, our brains have become stuck in a cycle of craving and withdrawal. We get into how modern life is fueling addiction, why discomfort is essential for balance, and how honesty and pain can be powerful tools for healing. This is a deep dive into the true cost of overstimulation and what it really takes to reset.
Tim Doyle (00:06.242)
I feel like dopamine has become such a culturalized buzzword that we actually don't understand what it means or how it works. So we'd love to lay the groundwork there to start. What is dopamine?
Anna (00:19.057)
Yeah, it's a great point. It's kind of become a meme or a metaphor, which I don't think is all bad if it allows people to focus on compulsive overconsumption and addiction and changing those behaviors.
Yeah, at some point, I think it's true. We can sort of distort the meaning a bit. So dopamine is a chemical that we make in our brain. It's a neurotransmitter. Neurotransmitters are the molecules that bridge the gap between neurons. Neurons are the long spindly cells that conduct the electrical circuits. They don't actually touch end to end. There's a gap between them. And neurotransmitters bridge that gap to allow for fine-tuned control of those electrical circuits.
Like all neurotransmitters, the dopamine system is complex. Dopamine has many different functions depending upon where it's released and how much it's released and what else is going on in the brain at the same time. But as a general rule of thumb, when dopamine is released in the reward pathway, in the reward pathway in the brain, that's usually in response to a reinforcing substance or behavior.
and it tells the brain, that is a good thing. You should definitely check that out and potentially try to get more of it. So it's not that dopamine is good or bad. It's not that like we're getting addicted to dopamine. Dopamine is a signal and it's the go approach, explore, exploit signal as opposed to the stop, retreat, avoid, runaway signal.
And in general, dopamine has become a kind of common currency for neuroscientists to measure the addictive potential of a substance or behavior. And a lot of that work is based on rats and mice where they stick a probe in the brain right into the reward pathway, the nucleus accumbens, they measure dopamine levels. We're always releasing dopamine at a baseline tonic level. And then they just saw how much dopamine increased firing.
Anna (02:27.345)
in the reward circuitry in response to different substances and behaviors. So in response to food, in a rat, dopamine levels increase 50 % above baseline. In response to sex, it's 100%. Nicotine is 150%. Cocaine's like 200%. Hepatidamines like 1,000%. And those percentages actually map pretty well onto rodent behavior.
And by that I mean like if you put a rat in a cage with a lever to press for cocaine or amphetamine, they will essentially press that lever till exhaustion or death. But that's not so true for chocolate, right? They'll press it, they like chocolate, but they won't get into that cycle where they'll actually die for chocolate.
Tim Doyle (03:18.574)
So what's the relationship then to build off of that? What's the relationship between dopamine and addiction?
Anna (03:27.321)
Well, anything that releases a lot of dopamine all at once in our reward pathway is something that we will want to experience most likely again. And in experiencing that again and again, we essentially change the physiology of dopamine release in the reward pathway such that over time, we stop releasing dopamine or really release less dopamine in response to a given substance or behavior.
and can even go into a dopamine deficit state as our brain tries to compensate for too much chronic dopamine. And then once we're in that dopamine deficit state, now we need to keep using more of our drugs and more potent forms, not to feel good or to solve a problem, but actually to stop feeling bad. in this constant state of withdrawal. And that's the state of being addicted where that reward pathway actually gets mistaken by the brain as a
something that we need for survival, even though it's not only not something that we need for survival, but actually the more we get of it, the less healthy we will become. So we can get into this kind of, on this hedonic treadmill where that reward pathway gets hijacked by something that's not good for us, but that our brain mistakes as necessary for survival.
Tim Doyle (04:49.038)
That's an interesting, I like what you said there and it's so basic where it shifts from, it's not so much about starting to feel good as it is, okay, I'm doing this so I can stop feeling bad.
Anna (05:01.945)
Right, and slipping from, this feels good to, I need to do this to stop feeling bad, it happens gradually, right? And it happens in a way that we're not typically aware of it. And so we can get into this mistaken belief that, this is still helping me because it's true in the immediate aftermath or right when we're using our drug of choice, we feel temporarily better, but.
Really all we're doing is digging ourselves deeper into that dopamine deficit hole and actually making ourselves feel worse, which is why the intervention is really to abstain for long enough for those reward pathways to go back up to healthier baseline levels so that we can really see that, this isn't actually helping me. I'm just basically at this point medicating withdrawal from my last dose.
Tim Doyle (05:51.704)
You've been in this space for a while. How has technology reshaped the way that we understand dopamine and addiction?
Anna (05:59.983)
Yeah, so one of the main messages in my book, Dopamine Nation, is that technology has allowed us to drugify almost everything we consume and many things that we do, many behaviors. And by drugify, I mean we've made things more accessible than ever before. can now, you 24-7 with a touch of our smartphones, you know, order almost everything, anything we want and have it delivered like a pizza to our doorstep.
or for that matter have instantaneous access to digital drugs, right, which are only multiplying as we speak. So an access, simple access is one of the biggest risk factors for addiction. The easier it is to get some kind of frictionless, feel-good substance or behavior, the more likely we are to use it, and hence the more likely we are to get addicted to it.
Access has also led to drugification of our everyday experience through increased quantity. So quantity and frequency, although we don't use quantity and frequency to diagnose addiction, they matter. And the more we use of a substance or behavior and the more often we use, the more likely we are to get addicted. And this is really the first time in human history when like we have almost infinite access to a whole host of highly potent.
substances and behaviors. Digital media, TikTok literally never runs out. I mean, can you imagine if you had an infinite amount of cocaine, right? That would be serious. And we already have quite a lot of access if you can afford it, you know, to cocaine, but digital media is free and it's infinite. And, you know, even traditional drugs, things like cigarettes, right? So when the cigarette rolling machine was invented in the 1880s,
You know, we went from being able to produce, let's say, four cigarettes a minute to 10,000 cigarettes a minute. Maybe not immediately, but it's essentially the progression with the technology. you know, the more you have of something, the more likely you are to get addicted. The third way that technology has allowed for the drugification of everyday life is through potency. So when you look at drugs that have been around for
Anna (08:21.527)
millennia like alcohol and opioids. I mean those are still here but the big difference from 100, 200, 300 years ago and before is that we have now these incredibly potent forms like fentanyl which is know 50 to 100 times more potent than opium and it's also we can make it in a laboratory without any plant precursor so no need to like get a field and
plant some poppies and wait for them to grow and harvest them. Now you can just make fentanyl in a laboratory pretty cheaply. You even really need to be much of a chemist and you can buy the ingredients online and you can do that. So it just means that we've turned these things that like used to be sort of, you know, soft drugs in some cases into really hard drugs.
And you know, like things like cannabis is the classic example, right? So, you know, 30, 40 years ago, the average cannabis product that you could get was about 10 to 20 % THC content, THC being the active ingredient that gets people high and is addictive. And now you can find formulations of cannabis that's like 90 plus percent THC. So it's really a totally different landscape. We've turned cannabis
Tim Doyle (09:40.568)
Wow.
Anna (09:44.899)
into a hard drug and many, many more examples like that. And what that means also is that as people become addicted, because they develop tolerance, they typically need more potent forms over time with the same effect. And now those more potent forms are accessible. Same thing with digital media. know, people get addicted to pornography and in the olden days, you had to go to the smoke shop and you had to be of age to get the Playboy magazine and you had to look at your centerfold and wait a whole month to get another one. And now
you know, any child can go online and find very potent, know, deviant, even illegal forms of pornography very easily. And without even really meaning to necessarily can find themselves consuming these highly potent forms. So it's a very different landscape. So you've got access, quantity, potency. Novelty is a big thing too. You know, like our brain is always looking for the next new thing and our
capitalist economy has a remarkable ability to continually make a variation on the theme and make something new and different and exciting. And then finally, sort of technology has the ability also for kind of a simulated uncertainty. So we know that intermittent rewards or intermittent reinforcement, some degree of reward uncertainty is actually more reinforcing or more addictive.
than predictable uncertainty. So think about gambling or slot machines. It turns out that it's the fact that you get reward only intermittently and not predictably that makes slot machines so reinforcing. And of course, we've now gamified so many things. On the digital platforms, video games have gamified loot boxes. Social media has different.
ways of gamplifying that experience by giving occasional rewards or even just the uncertainty of social media. So that also is very potentially addictive and engaging. So technology has really drugified our lives.
Tim Doyle (11:52.898)
Yeah, I find that component of technology most interesting about how it's the ease of access that it's made now for addictions to occur and just removing those hoops that people would physically have to jump through to access whatever it may be has just been completely removed. What's the importance behind understanding that the brain processes
Anna (12:14.885)
Yeah, yes.
Tim Doyle (12:22.584)
pain and pleasure in the same place.
Anna (12:25.521)
I think it's important to understand this opponent process mechanism. I use a metaphor of balance like a teeter totter as a way to represent how we process pleasure and pain. They work like opposite sides of a balance when we experience pleasure, tips one way, pain it tips the other.
and when it's at rest, it's level with the ground. Now this is obviously an oversimplification. We can experience pleasure and pain simultaneously. For example, when we eat spicy food, that's both pleasure and pain. But in general, the way that many physiologic systems work is through this opponent process mechanism where if we do something pleasurable, that releases dopamine.
that tilts our pleasure pain balance to the side of pleasure, but no sooner has that happened than our brain wants to go back to baseline, which is homeostasis. And it does that first by tilting an equal and opposite amount to the side of pain. That's the come down, the hangover, the blue Monday, or just that moment of craving, right? Eating a piece of chocolate and even before it's completely melted in our mouths, finding that we're already craving that second piece of chocolate. Watching a TikTok video and be like, I'm going to watch another TikTok video, right? So that's...
I think that's really driven by this opponent process mechanism, that state of craving that then drives us to get more of whatever it is. And the reason that we're wired like that is because we evolved in a world of scarcity and ever-present danger, such that the only way that we could survive is if we were never satisfied with what we have, always wanting more. As soon as we got something that was important for survival, we would go into this
you know, pain or craving state, which will then drive us to keep looking for more. And in a world of scarcity, you wouldn't find it, right, necessarily, or not, at least without extreme effort, so that eventually, you know, you would, after tilting to the side of pain, you would go to the baseline state, and you know, you'd sort of, you'd be hungry still, like maybe you'd be in pain if you were hungry, but when you got food, that would tip you up. What we have now,
Anna (14:32.653)
is that with repeated exposure to these highly reinforcing substances and behaviors, that initial deflection to pleasure gets weaker and shorter duration, but that after response to pain gets stronger and longer, eventually we can get stuck with our pleasure pain balance kind of tilted to the side of pain. That's this chronic dopamine deficit state, and that's the state of addiction again. Now we need our drug of choice not to feel good.
or to satisfy a survival need, but actually just to stop feeling bad.
Tim Doyle (15:05.038)
When we're caught in this pain pleasure cycle and I'm not saying for an addict, but somebody who's just, know, within bad habits or whatever, I think it's easy just to react and feel like you're at the mercy of what's happening. And I'm a big believer that knowledge to a degree can be medicine and just having a basic understanding and basic understanding and education of what's going on can allow you to.
stop being a cog in the machine, so to speak, and it kind of just allows yourself to observe yourself more mindfully. What are your thoughts on that and how do you think, whether it's with your work, especially reading your book, Dopamine Nation, or whatever it is, just having a basic understanding about dopamine and how your body is working can really help.
Anna (15:59.109)
I absolutely agree with that. mean, that's much of what we do in clinical care is plain old psycho education, right? And kind of trying to explain to people what is happening to them, what's happening in their brains. And when people have a heuristic or a model for understanding their behavior, it gives them a place to enter.
to try to change those behaviors. Now, knowledge alone is never going to be enough. You can completely understand what's happening and still feel, you you start to change it. But it's a really good doorway in because people can, for example, we see a lot of people who's...
primary problem is addiction, but they will come in and say their primary problem is anxiety or depression or inattention and that this drug that they found is the only thing that helps them. But by explaining the pleasure pain balance to them, I can say to them, yeah, I appreciate that in the moment it works for you, but in the long run, probably all it's doing is driving you further down into this dopamine deficit state and now you're just medicating withdrawal from the last time you used.
I suggested experiment, and I like to use the language of experimentation that you stop using for long enough to sort of reset reward pathways and then see how you feel. And people are more willing to do that when they understand, kind of have a model for why that would make sense.
Tim Doyle (17:25.932)
Yeah, it goes to the point they talk about the cure versus the cause. Like what you think you you're using is really the cure, but it's actually the long term cause of what's just keeping you stuck within that cycle. I'm really interested to dive deeper into the pain component within addiction, but just your whole philosophy on pain as a whole in your view within our society, especially within younger generations.
Anna (17:38.393)
Yes.
Tim Doyle (17:55.31)
Do you feel like we've whitewashed or even pathologized the idea of healthy pain and discomfort?
Anna (18:02.363)
Definitely. And I don't blame the younger generation or think that they're even necessarily, you know.
they're really on the receiving end of a cultural change that's been going on for decades. to about 150 years ago, leading surgeons of the day in the mid 1800s or so, when general anesthesia was discovered to allow people not to experience pain during surgery, the leading surgeons of the day actually didn't want to use it. And the reason they didn't want to use it is because they had a firm belief that
doesn't kill you makes you stronger and they even believe that physiologically it would boost the immune response and help people heal. Now to us living in the 21st century that sounds totally insane and yet we have taken you know the pendulum so far in the other direction that we're now terrified to let people experience any pain at all. We're convinced that any kind of pain physical or mental will
leave a kind of psychic scar and they'll suffer from post-traumatic stress disorder. They'll be on the psychiatrist couch for the rest of their lives. We've completely lost touch with the notion that pain and suffering actually makes us more resilient.
and this is contrary to science, you know, so it's not, it's also contrary to like every major leading philosophy or theology, all of which say that, you know, after darkness comes the dawn or some equivalent, but
Anna (19:44.473)
It's also contrary to science because, for example, we spent the last 30 years or so overdosing pain patients and surgery patients with opioids. And not only did that not really help their pain in the long run, but it also, in fact, does make the healing process slower. So there's actually truth in that having a kind of acute pain response might indeed expedite healing.
It's manifested in many other ways in the science where there's a whole branch of science now called hormesis, which is the study of the ways in which exposing an organism to mild to moderate doses of pain or noxious stimuli like radiation, extreme cold, extreme heat, starvation.
actually can make an organism stronger and more resilient. And hormesis is a Greek term, it means to set in motion. And essentially what is being set in motion with exposure to toxins or painful stimuli is the body's own healing mechanism. And we know from studies in humans that when people immerse themselves in ice cold water plunge, or they engage in exercise to an intensive enough degree,
that essentially what happens is the body senses injury and in response starts to up-regulate our own feel-good neurotransmitters like dopamine, but also serotonin or penephrine, our endogenous opioid system, our endogenous cannabinoid system. So all of those things turn out to be true. Now you can take that to an extreme. We're not saying that people should like engage in life-threatening behaviors or that they should cut on themselves. By the way, cutting works by that exact same mechanism, but it's not healthy because you're, you know, you're, you're injuring your,
your body. But it is really true that when we expose ourselves to sufficiently high but not harmful doses of pain, we are getting stronger, we are getting more resilient, and we are getting a little bit high, right? That's the runner's high. So, and that turns out to be a healthier way to get our dopamine because we pay for it upfront by putting in the labor, and that's exactly how we evolved. We were evolved to have to work really hard
Anna (22:04.165)
to get a little bit of reward. Not the way we work now, we live now, which is where we don't do any work at all for a whole lot of reward.
Tim Doyle (22:12.93)
You've said there's been an increase in the number of patients you've seen with physical pain, but without any clear injury or specific problem. Why do you think that's the case? And what do you point to as the cause for that?
Anna (22:27.695)
Yeah, it's not just like patients I see. We know from epidemiologic studies and just from the medical literature that the number of people who experience chronic pain in America, which is pain that lasts most days for three months or more, who have no identifiable source of injury in the body, that that's increasing.
And it's a mystery as to why that is. Of course, we do have an aging population. More people are living longer with chronic illnesses. So for a segment of the population, we can see why they would have more pain. But there are lots and lots of young people who, for quite mysterious reasons, are experiencing severe chronic pain. And we really don't know why. And I suspect that
what's happened is that we've so disengaged our everyday lived experience from our bodies. We're so disembodied, but I think that we now, our brain now senses even normal internal and external somatic signals as pain. Like we're so sedentary and we're so not doing the things that the body was meant to do that now the brain isn't really getting much
sensory input at all from the body and is getting confused by the signals that it is getting and perceiving those signals as pain.
Tim Doyle (24:04.514)
Wow, that's fascinating. Yeah, I dealt with a lot of bad chronic back pain actually for seven months and what helped me, I'd be curious to know if you were aware of his work, know, Dr. John Serrano and his work within the mind body connection in chronic pain.
Anna (24:21.017)
I haven't heard of that specifically, but I know there are lots of great people out there looking at mind, body, connection and pain, but I'd love to hear more.
Tim Doyle (24:29.152)
Yeah, mean that so I did all conventional physical types of treatments shots, pills, chiropractor, PT was very close to getting a surgery, but thankfully did not. And none of it helped me. But then I got introduced to the mind body connection and understanding how my mind and my mental wiring was playing a role on me continuing to feel this physical pain for months on end.
And within a couple of weeks, I saw massive improvements.
Anna (25:03.503)
That is so amazing. What specifically did you do to stop feeling pain in the way that you were feeling it?
Tim Doyle (25:13.186)
So few big components were I did a deep dive into the work of Dr. John Sarno. He's no longer alive, but yeah, S-A-R-N-O.
Anna (25:22.105)
Is it S-A-R-N-O? Okay.
Tim Doyle (25:29.176)
So did a deep dive into his work and all of his education and how the mind and stress and emotions can manifest physically in the body. And then a lot of it was getting back to my normal way of living because I basically had.
based off of what doctors were telling me, was like, okay, don't work out, don't bend over, don't sit down. So I pretty much put myself into a mental box. And it was like, all right, I need to break out of that box. Because it was like this pain that I was feeling, I was told was because of damage, but then I learned, no, it's not because of damage, it's simply just a sensation that your body is feeling.
So if you move, doesn't mean something's wrong. It's just that you got to shake the rust off, so to speak, and get out of that mental wiring.
Anna (26:25.051)
Right. Yeah. So you got into that mentality that hurt equals harm and that you're like an egg shell and you need to go like, maybe like this. And then you got that spiral of sort of like, I have back pain. Anything I do, I have to be careful and it's going to make it worse. It sounds like what you did is you just dispelled all of that. And you said, you know, I'm going to listen to body signals, but I'm not going to react to everything that I feel as danger.
Tim Doyle (26:30.209)
Exactly.
Tim Doyle (26:46.402)
Yeah.
Anna (26:54.481)
you know, danger time.
Tim Doyle (26:56.214)
Yeah, and I think the biggest thing if I were to point to something physiologically, it would be what was damaged the most was my nervous system because I was just in a constant state of fight or flight, always on edge. Every little feeling, every little movement, I was always just like, this means something's wrong. Like, don't move this way. like I just felt something something's wrong. So like my nervous system was just shot.
Anna (27:06.572)
Yeah. Yeah.
Anna (27:18.737)
Bye.
Anna (27:23.363)
Yeah, it's a great point. And that's what happens with what we call centralizing pain disorders, where the pain is essentially in the brain. You develop a neural circuit, and then the more you think about your pain and the more you focus on your pain, the more you focus on that part of your body, the stronger that neural circuit gets. So then, yeah, you're feeling more pain, but it's actually happening in your brain.
Tim Doyle (27:37.975)
Exactly.
Anna (27:46.063)
Yeah, so the key there is to really recognize the circuit and be aware that it's just happening in your brain and it's not something, it's not like the four alarm fire that you think it is.
Tim Doyle (27:58.904)
Yeah, the challenge that was for me at the start, and I know it is for a lot of people because I had an MRI image that showed some type of structural damage. And I know a lot of people can get into the mental box as well of, no, I have this evidence. have this MRI image if something's wrong. And it's like, listen, you pick out anybody in a lineup, you nine out of 10 people are going to show some type of
disc irregularity on some type of MRI image. But I think it's really fascinating that what you're saying, because I've seen it as well of, no, people don't have anything, but they're still feeling pain.
Anna (28:39.097)
Yeah, yeah. Well, you're right. And it's such a, you all this technology. It's another great example of technology and how it's really a double edged sword. Because of course, once you go looking for a problem in the body, trust me, you'll find it. You will find it. Yeah, exactly. And you know, and the truth is, as you say, if you had a hundred people and you lined them all up and you looked and they had no symptoms and you you, you know, you let's say did an MRI of their back.
Tim Doyle (28:50.939)
Yeah, exactly. It's like a mechanic.
Anna (29:06.316)
some very large percent of those individuals would show back abnormalities by MRI, right? But actually have never have had any pain. So yeah, the point being is like a lot of the pain is in our brains and a lot of our top down. So we have, you know, you have signals that get sent to the brain and then you have the brain that filters those signals and then either amplifies them or, you know, depresses them.
And if you're telling your brain every time you feel something, oh no, oh no, then you're just going to get that amplification. But you know, there are other ways to say to yourself, you know, this is just my brain. As you say, kind of like a little rusty, I'm going to do some stretches. I'm going to, you know, exercise, go for a swim. I mean, you don't want to ignore body signals. So it's a fine line, but you also don't want to like turn it into something that it's not.
Tim Doyle (29:59.33)
Yeah, 100 % agree. And that was just one more big component of it. There was a big meditation component to my work or what I like to call, I branded it as talking with my brain. So those moments when I did feel pain, I would go into that meditative sort of talking with my brain state and understanding this doesn't mean something's wrong.
and just being mindful. instead of focusing on the sensation, I'm actually just going into this internal dialogue with myself. So I'm no longer focused on the sensation anymore, but it's more so I'm talking about it and then, the sensations gone.
Anna (30:29.681)
interesting.
Anna (30:37.931)
Interesting, interesting. So somehow you found a way of engaging in some kind of internal dialogue to break the circuit or break the cycle.
Tim Doyle (30:39.438)
Yeah.
Tim Doyle (30:48.022)
Yeah, and I think it also went to the nervous system component where I was also just allowing my nervous system to finally relax and understand that everything was okay.
Anna (31:00.685)
Interesting. Yeah, and did you ever get into taking opioids or other pills for the pain?
Tim Doyle (31:06.362)
I was prescribed a steroid pack at the start, but never, opioids. was a steroid pack, cortisone injections, physical therapy, spinal decompression, dry needling, massage, very close to getting a surgery. And none of it helped. But then did this mind body work and it was like, wow, I'm feeling very good now.
Anna (31:29.905)
That's so great. Yeah, but you can really see having had that experience how easy it would be to get a prescription for an opioid to take it. And of course, it doesn't just work as an analgesic, it also releases dopamine and then all of a sudden your mood is all you're feeling better. And you could so, yeah, right? You could just get right wrapped up into that whole cycle.
Tim Doyle (31:38.252)
100%, yeah.
Tim Doyle (31:45.282)
Yeah.
Tim Doyle (31:51.148)
Yeah. And getting back to your work. So you didn't originally get into addiction work consciously or naturally. There was a pivotal experience. So you had a patient that you were seeing for about a year who had gotten into a car crash and you had found out that she was using heroin again. And that's info that you were not aware of and all the time that you were working together. How did that experience?
affect you and the path that your work took.
Anna (32:23.971)
Yeah, thanks for asking about that. So that was a pivotal moment in my career because I experienced a whole lot of shame with regards to that patient. Realizing that although she had never volunteered her heroin use, I had also never once asked her about drugs and alcohol and I had seen her for whole year and her family was actually paying for her care, paying me to see her.
to specifically address her drug and alcohol problem. And I didn't know that and didn't address that and actually made a fool of myself and endangered her. that was a moment I realized, wow, I have got to learn about addiction and I've got to address it in patient care.
It ended up being the huge shift in my practice. This was now almost 30 years ago, but I started asking patients about their drug and alcohol use and lo and behold, they were happy to talk about it. No one else had asked them. Yes, as a matter of fact, I'm an alcoholic or, know, maybe they didn't use that language, but it all came out.
And amazingly, when we address that in conjunction with their other mental health problems, people just got so much better. mean, their trajectories were in another universe in terms of their improvements in life. And then not only did their lives improve, the lives of their family members, their coworkers, their friends, so many things get better when people get in recovery from addiction.
And although it's a lot of hard work, it's also in many ways so simple, right? Because it's not like you're piling on one more drug after another, which is what I had been doing. Like, let's do a mood stabilizer, an antidepressant, an anxiolytic, a sleep aid. It's like, no, let's just stop drinking. It's amazing. So it's been super rewarding work. I love working with the patients. They're really neat people.
Anna (34:25.903)
Recovery is amazing, you as I've talked about, really think that people in recovery from severe addiction are like modern day profits for the rest of us because they show us who we are and show us how to live in this dopamine saturated world. So I've been really lucky to work with this population.
Tim Doyle (34:43.97)
How much of addiction do you think comes down to a subtle incremental moving of the goalposts versus an immediate escalation into extreme behavior?
Anna (34:57.233)
It depends on the person. I think for most people it's this slower more insidious process where what starts out is like perfectly rational either recreational or problem-solving consumption gradually goes from being fun and adaptive to being like less fun, but I'm still doing it and this isn't really
you know, helping me anymore, but I'm still doing it. And then, you know, kind of not even be able to see, you know, when we cross the line. I think that's more typical, but certainly in my career, I have seen patients who it seems like within days or weeks of having, of being exposed to a substance are immediately plunged into.
addictive behaviors. And I'm not even talking about like after they've been addicted to other things and now they're trying some new thing. I mean like even that first exposure for some people it just seems to be almost immediate. Although I'd say that's less common.
Tim Doyle (35:58.946)
Mental health has obviously become more transparent and that's an incredible thing. But I think one of the dangers within that is that we're quick to have that be the answer to everything. If we have a problem with ourselves or something just feels off, then it's, it's my mental health. Talk to me about the distinction you make between mental health or mental illness and lack of self care.
Anna (36:28.689)
Yeah, well, I mean, I agree with you. think, you know, on the one hand, it's great that we've destigmatized mental health in many arenas and that people can be more open about their mental health struggles. They can access treatment more readily. That's all generally good. But what I've seen with each successive generation is people now almost construct their entire identities around their
know, diagnosis, sort of, am what I'm diagnosed type thing. I'll never forget when I went to a local high school and met with some of the students after a lecture I gave, and this was a small group of, you know, students who I guess were either more interested or in leadership roles, and there were about seven or eight of them, went around the table to introduce themselves, and to my absolute amazement, each of them introduced themselves and then told me their diagnosis, and I was just like, wow.
On the one hand, was kind of like, this is so great, people are open. But mostly I felt like, really, is that all you are? I'm Jenna, and I have OCD. So we're like, OK.
Tim Doyle (37:32.342)
Yeah, it's weird. It's become kind of like a proud calling card.
Anna (37:35.373)
Yeah, right, right. It can do. yeah, and the problem with that, you know, around your whole identity being really any one thing, frankly, but being a mental health diagnosis is then you sort of construct a whole worldview kind of based on your diagnosis, and then you're almost looking for
triggers or reasons why, okay, now I'm feeling bad about this because this happened to me and caused my PTSD. And now this person saying this in that way is actually recapitulating what happened to me. So you can get to things where now you're, you know, it's this whole kind of victim narrative, which, you know, people talk about a lot, but you know, 20 years ago, people weren't really calling out that whole victim problem, but it, you know, it started a long time ago where, you know,
people actually could get compensated for their victim role, right? Like, you know, a government compensation. And now with the advent of social media, you can get a lot of social media kudos, you know, for sort of declaring yourself as having one thing or another. So I don't know, it's a hard one because again, on the one hand, good to name these patterns, good to know we're not alone, good to access treatment and not have to feel terrible about that.
Tim Doyle (38:41.656)
Yeah.
Anna (38:56.795)
But on the other hand, like everything, we tend to take it too far and then it becomes everything of who we are. And then to your question about self-care, and then we're not even doing the behavioral things that our grandmother could have told us that we need to do in order to stay mentally healthy, go to sleep when the sun goes down, wake up when the sun rises, eat breakfast and two other healthy meals in a day, or eat healthily.
Avoid drugs and alcohol, exercise. These are not mysterious things. And yet you think they didn't exist or we just invented them or something. And then people don't do those things, but they take a pill. And then they want the pill to make up for all those other things they're not doing.
Tim Doyle (39:48.62)
I also think within our culture,
Tim Doyle (39:53.646)
you have this line in your book, you say the reason we're all so miserable, maybe because we're working so hard to avoid being miserable. And to put a different spin on that, I think we could also say the reason we're all so miserable is like to a degree, it feels like if there's not some part of us that's miserable, then it means that we must be neglecting some part of ourselves or we're not we're not doing the inner work. So in a way, we come
more comfortable and see our misery almost like a good thing in a way. And it's really backwards. What are your thoughts on that?
Anna (40:30.627)
Yeah, yeah, like, yeah, we sort of glorify or fetishize being miserable or something like that. Yeah, it's interesting. I know in your, among your generation, a very common phrase, which I think is a counterbalance to the thing we've been talking about, that my kids who I think are about your age have said, mom, it's not that deep.
Tim Doyle (40:53.123)
Yeah.
Anna (40:54.833)
And I really think that's your generation going, yeah, you know, we don't have to sit here and psychoanalyze, introspect and pick at every single pimple. Just let's, moving on people, it's not that deep. And so, you know, every generation will correct for these things. So good for you all, it's not that deep.
Tim Doyle (41:00.546)
Yeah.
Tim Doyle (41:14.51)
Addiction on its own is obviously very dangerous, but then it can become a catalyst for dishonesty, deceit, leading a double life and having that dual identity. How do you see honesty as being that counteracting force? And why is it so crucial for people, especially if they're an addict and trying to navigate their selves out of addiction?
Anna (41:39.875)
Yeah, so this is something that I learned from my patients. Over many years, I began to observe that the patients who were able to get into recovery from severe addictions and stay in recovery had learned for themselves or had learned in Alcoholics Anonymous or by some other method that they essentially couldn't lie.
And this meant that they couldn't just lie about using, right? They also couldn't lie about simple everyday things like what they had for breakfast. Because they discovered that even if they lied about the little things not connected to their drug use, that would trip them into the lying habit, which is part and parcel of the disease addiction. So when people get in their addiction, you they're lying about their use, but they're also lying about the craziest things. It's like they almost get addicted to the lying as much as anything else.
So that means that recovery, and by the way, why is that? Well, there's like an adrenaline rush from lying. There's also like this illusion of control. Like I'm controlling people's perceptions and controlling reality by lying, because only I know what really happened. Or maybe even I'm deluding myself. But anyway, I'm like, in my delusions, I have this kind of sense of control.
And in truth, by leading this kind of double life, we're really getting further and further away from what's really happening and really having some modicum of control over our lives. So recovery is all about radical honesty, telling the truth no matter what and seeing lying as really a harbinger of a potential relapse.
And I just think that's so cool. And I started to try to incorporate radical honesty in my own life and discovered that it really, really is the best policy and that telling the truth is something that we could all benefit from. We're natural liars. think studies have shown that the average adult tells one to two lies per day. And most of those lies, we tell the sort of
Anna (43:45.893)
protect ourselves, to hide small selfish acts, or make ourselves look a little more interesting, or we tell ourselves that we lied to protect another person's feelings or to make them feel better. But really, if you start to analyze all those little lies, they really accumulate. And in the end, I don't think they're good for anybody, not for us, not for other people. And that if we really want to live well, we should tell the truth and even try to anyway. Nobody's perfect. I know I'm...
still struggle on a daily basis to be totally honest. But most of time it is the best policy and it probably works on a lot of different levels. It promotes self-awareness so that we know what's really happening. It promotes intimacy when we tell people the truth about ourselves, especially things that we're ashamed of. We think they're going to go running away screaming, but actually they come closer and they...
embrace us. probably stimulates, telling the truth probably stimulates the prefrontal cortex, which is also the part of our brain that we use to delay gratification. So I think it can work on a lot of different levels. And I think it's the path to, you know, it's no coincidence, again, that every major philosophy and religion has basically concluded that telling the truth is the best policy.
Tim Doyle (45:05.742)
dishonesty, just like addiction that we were talking about earlier, very similar with that incremental moving of the goalposts where the more easy it gets to tell those little lies, it just becomes easier and easier to lie in general. Another thing that isn't
Anna (45:22.233)
And just to interject one there is because one that that's so true, like once we start lying, we get as a lying habit easier. But the truth is when we're lying a lot, it's actually a huge cognitive lift because now we have to use a lot of our mental power keeping track of who we told what. And that's exhausting. A lot of times when people get in recovery and they stop lying, they're like, it's so nice. They don't have to like try to remember, you know, which lie I told to which person I can tell the truth.
Tim Doyle (45:46.956)
Yeah. Yeah, I mean, massive weight taken off somebody's shoulders. Yeah, that's really interesting. It's not just the addiction itself, but it's the dishonesty. I'm not. Yeah.
Anna (45:51.353)
Yes, absolutely.
Anna (45:57.155)
Yeah, yep. All the energy that it takes to sort of put that together.
Tim Doyle (46:03.928)
Yeah, very interesting. Another component that isn't a central part of your writing in your book, but you allude to it in one section that I thought was really interesting. How do you see spirituality sometimes fitting into your work and potentially in the process of overcoming addiction?
Anna (46:23.953)
Yeah, great. I'm so glad you asked that. So originally, Dokmination had a chapter on spirituality, but I eventually took it out because I felt like I really couldn't do justice to it. And I'm now working on a new book that's totally on the topic of spirituality. So yeah, so you'll have to have me back. Yeah, yeah. So it's very clear that for many people, spirituality is a huge part of recovery. And I would say, especially in cases where nothing else has worked.
Tim Doyle (46:37.154)
Really? I'm excited for that then.
Anna (46:51.565)
It is really miraculous the ways in which spirituality can allow people to find recovery from severe addiction in instances where they just couldn't grasp it before. I know spirituality has been a big part of my life and sort of just recovering from my own neuroses. And I'm very interested in the role of spirituality in mental health.
Tim Doyle (47:18.006)
Yeah, to me, it feels like spirituality is one of the few positive outlets that we can go to that isn't a masking agent. And
I think masking agents within our society as a whole, especially within the medical system of just treating symptoms rather than getting to root causes has become such a massive issue. And you say there's a cost to medicating away every type of human suffering. And as we shall see, there's an alternative path that might work better embracing pain. I know this is something that we talked about earlier, but we'd love to dive deeper into that concept here.
with embracing pain instead of medicating suffering.
Anna (48:02.211)
Yeah. Yeah, I mean, I agree with you. think our modern health care system, including modern mental health, is almost antithetical in some ways to spirituality. There are some exceptions there. are some new forms of psychotherapy that are becoming popular that really
Tim Doyle (48:14.728)
Mmm. Yeah.
Anna (48:23.525)
are very similar in many ways to different spiritual pathways. This is things like acceptance and commitment therapy or dialectical behavioral therapy, which have huge spiritual components. And I think for that reason are getting more and more popular.
Tim Doyle (48:37.048)
Are you familiar with the work of Dr. Lisa Miller at all?
Anna (48:41.389)
Yes, she does. The the she's written the emotions book, right? no, she does. She's the sorry. Yes, right. So she's she's written a whole book on the neuroscience of spirituality, right?
Tim Doyle (48:47.247)
the awakened brain
Tim Doyle (48:55.148)
Yeah, it's incredible how spirituality and mental health that intersection. It's a remarkable book that I just finished.
Anna (49:02.033)
good. Yes, I've read her work. I haven't read her book yet, but it's on my list for sure. And now I'm going to have to move it up on my list. Yeah. Well, thank you. Yeah. What was I saying? I can't remember. yeah. you know, modern medicine and modern mental health.
Tim Doyle (49:13.186)
Not to sidetrack you there, but I just wanted to throw that in because I thought it was important.
Tim Doyle (49:24.6)
Talking about mental health and
Anna (49:32.045)
essentially say that suffering is a disease and that we need to get rid of it. And spiritual pathways say that suffering is the pathway to enlightenment.
suffering is the most valuable information you will ever have access to. I those couldn't be further apart, those two things. And as most of us figure out, if we live long enough, suffering is inevitable. So there's something fundamentally flawed with constructing the suffering as a disease. You just cannot do that because we just can't medicate or even psychotherapize our way out of every single problem.
we have to at some point stop, turn toward the pain, embrace it and acknowledge it as just part and parcel of being alive and being human. And I think that just naturally and inevitably leads to spirituality.
Tim Doyle (50:39.606)
You had a very challenging experience within your life, you lost a child. How did that entire experience and tying it into this embracing of pain, rather than trying to find ways to, I guess, overcome it? How did you navigate that entire experience?
Anna (51:03.375)
Yeah, thanks for asking. Well, I mean, on many different levels, like I think really honestly on a basic neurochemical level, you know, coming out of that grief reaction, there was almost, you know, once I processed the grief and was able to make some form of recovery from it, for many years afterwards,
as long as my kids were okay, I wanted nothing from life. I mean, you know, was all, it was like, it was all good for a really long time because it had been so bad. You know, that again, a little bit that opponent process idea. And then it definitely opened up a whole,
sort of spiritual path for me that I probably would have not have walked otherwise. Like I almost needed to have that very painful experience in order to be able to, in many ways, have the courage to sort of embrace this sort of quite anti-modern, let's say, know, non-secular route and, you know, essentially surrender to a power greater than myself, which has totally transformed my
life for the better.
Tim Doyle (52:24.046)
What do you see is the difference between recovery and healing?
Anna (52:29.489)
I mean, I think you could use those words interchangeably, but if you were going to make a distinction between them, which I think you're hoping to make by asking the question, I think recovery would be walking forward with the pain and not necessarily expecting.
that the pain will go away, but having the courage to take that next step anyway. Whereas healing might include in it some kind of expectation of getting rid of pain.
Tim Doyle (53:04.533)
Interesting. I'm always fascinated to ask that question to people because it's so subjective. So it's just, I'm always curious to hear people's different interpretations and definitions and seeing the distinction between the two. Another component that I'd be interested to hear your take on and to hear if there's any specific language that can be used for these types of experiences. So like,
Anna (53:16.771)
Yeah.
Tim Doyle (53:33.806)
to use myself personally. I eat very healthy, but there was a point in my life where, you know, I wasn't eating as healthy. I wanted to be more strict with my diet and I would cheat on my diet or if it's my phone in the morning where, you know, I don't want to be on my phone, but I do go on my phone and I'm like, like I hate that I did that. Like I hate that I cheated and I feel like I was able to get to a point, especially with my food and now with my phone as well that
If I had the urge or the inkling for wanting to do that, I could almost like detach for a quick second and like embody that feeling of like what it would be if I did it. And be like, Ooh, like I don't like that feeling. Like that's a uncomfortable feeling. So like, it's almost like the urge goes away and it's like, no, I don't want to do that.
Is there specific language for that type of experience or how would you explain what that is?
Anna (54:35.321)
Yeah, there are lots of language and lots of idioms in the addiction medicine field for that moment and good for you for discovering yourself. So sometimes we call that urge surfing, where you kind of let yourself surf on that feeling and what it would be like and then what you would really feel, you know, what you're hoping to get from it and then recalling past episodes, what you probably really would feel doing it and afterwards. In A-Lingo, there's a phrase, think through the drink.
which I think captures the exact same type of phenomenon. So yeah, that's very well known. Just kind of like pressing the pause button, reflecting for a moment, not letting ourselves just be on autopilot and reach for that stuff. I talk a lot about self-binding strategies, which are both literal and metacognitive barriers we can put between ourselves and our drug of choice so that we can press the pause button between desire and consumption and have more time to do what you do.
which is kind of think through the drink or urge surf. So for example, one example of a self-winding strategy would be to not keep your phone on your bedside table, but actually power it down and off and put it in another room when you go to bed so that you really make that separation so that if you wake up in the night or you wake up in the morning and you have that reflexive desire to reach for it, it's not there. And it not being there reminds you that yesterday, you you planned for this.
because you didn't want to reach for it and now you'd have to get up and go get it. And all of that just creates enough friction sometimes such that you can enact the life that you really want for yourself, which I think is what we all want, right? We want to do what we said we were going to do and what is aligned with our goals and values. So we have to structure our lives to optimize that because there are so many ways in which
modern culture and the modern ecosystem really conspires against us and promotes us doing all these unhealthy things.
Tim Doyle (56:41.174)
big fan of putting my phone on airplane mode that is what has helped me. It creates that barrier. How do you see your work as being about storytelling as much as it's about psychiatry and addiction?
Anna (56:45.433)
Great. Yeah.
Anna (56:57.773)
Yeah, in many ways I realize as a psychiatrist, all I'm really doing, you know, when I'm doing probably my best work anyway, is just helping people metabolize their own self narratives. Language is a tool. It's the most human tool and it's the way by which we actually organize our experience, our thought processes. It's the way we...
think about the past, it's really the only way that we understand lived time. There's no other way for us to conceptualize lived time other than to narrate it in a story. But what's so interesting to me that I learned over the years seeing patients is that you can actually tell whether or not somebody is recovering or going to be able to recover in the imminent, in the near future based on how they tell their stories.
And when people tell stories that seem quite divorced from reality, especially if they always see other people and things as the cause of their problems and don't identify with having any kind of contribution to that problem, then those are folks who are not really yet in a position to get better. Whereas when people are finally getting into recovery and recovered, they tell a narrative that's much more nuanced. There's much more gray area.
They're able to hold ambiguities and opposites at the same time. And most importantly, they're able to look at their own character flaws and what they have contributed to their problems. And I eventually concluded that narrative is not just the way we organize the past, our own past, but also it becomes our roadmap for the future. So if we're telling stories about ourselves in the world in a certain way, that's also gonna guide.
the way that we experience the world. And in fact, there's a whole interesting branch of cognitive neuroscience that has landed on the same thing, a very different place, which is active inference, which is this idea that we come into the world already with these kinds of templates about the world as it is. And through perception and action in a repeated loop, we basically update our mind maps.
Anna (59:15.217)
But there are ways that you can either diminish your perception or try to enact certain self-fulfilling prophecies such that you're not really living, you're not creating a narrative that's really going to be adaptive or healthy.
Tim Doyle (59:33.622)
Yeah, that's really fascinating. I think that whole...
Tim Doyle (59:42.23)
My experiences with chronic back pain really led to that where because I had that perception of what was happening.
was like, whoa, that's completely wrong. I thought I was dealing with one problem and it was actually something else that I was completely dealing with. And it was like, if I had that wrong perception on this thing, where else am I having a perception within my life that isn't serving?
Anna (01:00:11.067)
love it. And so many people in recovery from addiction say something else, like they have this certain view of, for example, how people are going to react. And then when they're working the 12 steps and they make amends, they're certain that people are going to be like, I never want to speak with you again. But instead they get this warmth and this love and they're like, wow, if that's how people respond to my being honest and apologizing, what else did I get wrong? And that's an exciting, I mean, a humbling moment, but also super exciting.
Tim Doyle (01:00:33.912)
Yeah.
Tim Doyle (01:00:41.1)
Yeah, and think that goes to the point I've heard you talk about with people who go through addiction or just tough things in general and they have that type of epiphany. You can't detach that from the entire experience of addiction and you can't say you have to be able to say like, like, no, I needed that within my life to be able to get to this point.
Anna (01:01:04.155)
Yes, exactly, exactly.
Tim Doyle (01:01:10.038)
your book, Dopamine Nation, and you've alluded to it a little bit with your own personal experiences. I was not expecting for there to be such a large personal reflection and almost like a memoir component of it. Was that always the thought process for you when you wanted to write the book or how did that come to be?
Anna (01:01:35.793)
Yeah, I mean, I never, I don't think, I mean, I had some, I would say, also, Tim, just so you know, have a meeting at three, so I have a few more minutes. I'm loving talking to you. I love how closely you read the book and your questions are great, but I only have a few more minutes. Yeah, yeah. Okay, let me tell Ben.
Tim Doyle (01:01:47.34)
Okay, one more question.
Tim Doyle (01:01:53.046)
One more question after this and that will be good.
Anna (01:02:00.945)
then.
Tim Doyle (01:02:06.744)
Sorry about that. have one more question after this and then we'll be good.
Anna (01:02:08.196)
No, no, not at all, not at all. No, because these questions are great actually there. I'm really enjoying talking with you. So yeah, so I think it was really my patient Jacob with the severe sex addiction that crystallized for me a moment of...
of the book, Dopamine Nation. And Dopamine Nation has in it a lot of ideas that I've been thinking about really for decades. It's almost sort of the culmination in many ways of many strains in many patterns in my life, but also my career.
But seeing him and then being able to see myself in him, you he had a severe pornography masturbation addiction, but I had my own compulsive problems with romance novels and erotica and realizing that he and I were just different shades of gray. That was the moment. And so it was, although I was very nervous about sharing my own romance novel reading addiction, I also realized that that was the heart of the book, right? there was, because I'm trying to draw an analogy between these
severe addictions and the things that all of us are struggling with in the modern age.
Tim Doyle (01:03:17.496)
What do you hope people take away from your work, not just about addiction, but about being human?
Anna (01:03:24.493)
I hope that people feel hopeful, that they can feel hopeful about changing behaviors that they want to change and not so ashamed that these are like, we're all part of the human race. We all have these same reward pathways. We can all be triggered in these ways. And also I hope people feel, as you sort of mentioned in beginning, that they have kind of a model or an understanding of what's happening and they can take that with them.
very simplified form, but a very portable, memorable way to say, okay, this is the balance and this is the gremlins and this is my dopamine and this is how I can try to enter this loop to change the behavior.
Tim Doyle (01:04:06.976)
Anna, it's been great talking with you. You're doing such important work. Thoroughly enjoyed your book, Dopamine Nation as well. Is there anywhere you'd want to send people to learn more about the work that you do?
Anna (01:04:20.193)
You know, just read my books. There's the dopamine nation and we came up with the official dopamine nation workbook, which is a step-by-step interactive guide for how to do the dopamine fast, how to prepare for it, what to expect and also what to do when it's over. So those are the places I would send folks and thanks for inviting me. I really enjoyed talking to you.
Tim Doyle (01:04:37.688)
Yeah, awesome. And can't wait to read your next book on spirituality and addiction whenever that comes out as well. Awesome. Great talk with you.
