Dopamine Nation

The Science of Dopamine and Addiction

• One of the biggest risk factors for getting addicted to any drug is easy access to that drug. When it’s easier to get a drug, we’re more likely to try it. In trying it, we’re more likely to get addicted to it.
• Likewise, decreasing the supply of addictive substances decreases exposure and risk of addiction and related harms.
• To be sure, increased access is not the only risk for addiction. The risk increases if we have a biological parent or grandparent with addiction, even when we’re raised outside the addicted home. Mental illness is a risk factor, although the relationship between the two is unclear: Does the mental illness lead to drug use, does drug use cause or unmask mental illness, or is it somewhere in between? Trauma, social upheaval, and poverty contribute to addiction risk, as drugs become a means of coping and lead to epigenetic changes—heritable changes to the strands of DNA outside of inherited base pairs—affecting gene expression in both an individual and their offspring. These risk factors notwithstanding, increased access to addictive substances may be the most important risk factor facing modern people. Supply has created demand as we all fall prey to the vortex of compulsive overuse.
• I’ve seen a similar paradox in many of my patients over the years: They use drugs, prescribed or otherwise, to compensate for a basic lack of self-care, then attribute the costs to a mental illness, thus necessitating the need for more drugs. Hence poisons become vitamins.
• Dopamine is not the only neurotransmitter involved in reward processing, but most neuroscientists agree it is among the most important. Dopamine may play a bigger role in the motivation to get a reward than the pleasure of the reward itself. Wanting more than liking. Genetically engineered mice unable to make dopamine will not seek out food, and will starve to death even when food is placed just inches from their mouth. Yet if food is put directly into their mouth, they will chew and eat the food, and seem to enjoy it.
• dopamine is used to measure the addictive potential of any behavior or drug. The more dopamine a drug releases in the brain’s reward pathway (a brain circuit that links the ventral tegmental area, the nucleus accumbens, and the prefrontal cortex), and the faster it releases dopamine, the more addictive the drug.
• This is not to say that high-dopamine substances literally contain dopamine. Rather, they trigger the release of dopamine in our brain’s reward pathway.
• For a rat in a box, chocolate increases the basal output of dopamine in the brain by 55 percent, sex by 100 percent, nicotine by 150 percent, and cocaine by 225 percent. Amphetamine, the active ingredient in the street drugs “speed,” “ice,” and “shabu” as well as in medications like Adderall that are used to treat attention deficit disorder, increases the release of dopamine by 1,000 percent. By this accounting, one hit off a meth pipe is equal to ten orgasms.
• We’ve all experienced craving in the aftermath of pleasure. Whether it’s reaching for a second potato chip or clicking the link for another round of video games, it’s natural to want to re-create those good feelings or try not to let them fade away. The simple solution is to keep eating, or playing, or watching, or reading. But there’s a problem with that. With repeated exposure to the same or similar pleasure stimulus, the initial deviation to the side of pleasure gets weaker and shorter and the after-response to the side of pain gets stronger and longer, a process scientists call neuroadaptation. That is, with repetition, our gremlins get bigger, faster, and more numerous, and we need more of our drug of choice to get the same effect. Needing more of a substance to feel pleasure, or experiencing less pleasure at a given dose, is called tolerance. Tolerance is an important factor in the development of addiction.
• Ivan Pavlov, who won the Nobel Prize in Physiology or Medicine in 1904, demonstrated that dogs reflexively salivate when presented with a slab of meat. When the presentation of meat is consistently paired with the sound of a buzzer, the dogs salivate when they hear the buzzer, even if no meat is immediately forthcoming. The interpretation is that the dogs have learned to associate the slab of meat, a natural reward, with the buzzer, a conditioned cue.
• The pre-reward dopamine spike in response to the conditioned cue explains the anticipatory pleasure we experience when we know good things are coming.
• My colleague Rob Malenka, an esteemed neuroscientist, once said to me that “the measure of how addicted a laboratory animal is comes down to how hard that animal is willing to work to obtain its drug—by pressing a lever, navigating a maze, climbing up a chute.” I’ve found the same to be true for humans.
• Studies indicate that dopamine release as a result of gambling links to the unpredictability of the reward delivery, as much as to the final (often monetary) reward itself. The motivation to gamble is based largely on the inability to predict the reward occurrence, rather than on financial gain.
• My patients with gambling addiction have told me that while playing, a part of them wants to lose. The more they lose, the stronger the urge to continue gambling, and the stronger the rush when they win—a phenomenon described as “loss chasing.”
• Once the researchers stopped administering cocaine, the rats stopped running. One year later—a veritable lifetime for a rat—the scientists reinjected the rats with cocaine one time, and the rats were immediately running as they had on the final day of the original experiment. When the scientists examined the rats’ brains, they saw cocaine-induced changes in the rats’ reward pathways consistent with persistent cocaine sensitization. These findings show that a drug like cocaine can alter the brain forever. Similar findings have been shown with other addictive substances, from alcohol to opioids to cannabis. In my clinical work I see people who struggle with severe addiction slipping right back into compulsive use with a single exposure, even after years of abstinence. This may occur because of persistent sensitization to the drug of choice, the distant echoes of earlier drug use.
• This framework is easily remembered by the acronym DOPAMINE, which applies not just to conventional drugs like alcohol and nicotine but also to any high-dopamine substance or behavior we ingest too much of for too long, or simply wish we had a slightly less tortured relationship with. Although originally developed for my professional practice, I’ve also applied it to myself and my own maladaptive habits of consumption.
• The d in DOPAMINE stands for data. I begin by gathering the simple facts of consumption. In Delilah’s case, I explored what she was using, how much, and how often. When it comes to cannabis, the dizzying list of products and delivery mechanisms that Delilah described is standard fare for my patients nowadays.
• The o in DOPAMINE stands for objectives for using. Even seemingly irrational behavior is rooted in some personal logic. People use high-dopamine substances and behaviors for all kinds of reasons: to have fun, to fit in, to relieve boredom, to manage fear, anger, anxiety, insomnia, depression, inattention, pain, social phobia . . . the list goes on.
• The p in DOPAMINE stands for problems related to use. High-dopamine drugs always lead to problems. Health problems. Relationship problems. Moral problems. If not right away, then eventually. That Delilah could not see downsides—except the mounting conflict between her and her parents—is typical for teenagers . . . and not just teenagers. This disconnect occurs for a number of reasons. First, most of us are unable to see the full extent of the consequences of our drug use while we’re still using. High-dopamine substances and behaviors cloud our ability to accurately assess cause and effect.
• The a in DOPAMINE stands for abstinence. Abstinence is necessary to restore homeostasis, and with it our ability to get pleasure from less potent rewards, as well as see the true cause and effect between our substance use and the way we’re feeling. To put it in terms of the pleasure-pain balance, fasting from dopamine allows sufficient time for the gremlins to hop off the balance and for the balance to go back to the level position.
• Sometimes, patients ask if they can swap one drug for another: cannabis for nicotine, video games for pornography. This is seldom an effective long-term strategy.
• Neuroscientists S. H. Ahmed and George Koob have shown that rats given unlimited access to cocaine for six hours per day gradually increase their lever-pressing over time to the point of physical exhaustion and even death. Increased self-administration under extended access conditions (six hours) has also been observed with methamphetamine, nicotine, heroin, and alcohol. However, rats who have access to cocaine for only one hour per day use steady amounts of cocaine over many consecutive days. That is, they don’t press the lever for more drug per unit time with each consecutive day. This study suggests that by restricting drug consumption to a narrow window of time, we may be able to moderate our use and avoid the compulsive and escalating consumption that comes with unlimited access.
• High-dopamine goods mess with our ability to delay gratification, a phenomenon called delay discounting. Delay discounting refers to the fact that the value of a reward goes down the longer we have to wait for it. Most of us would rather get twenty dollars today than a year from now. Our tendency to overvalue short-term rewards over longer-term ones can be influenced by many factors. One of those factors is consumption of addictive drugs and behaviors.
• Addictions researcher Warren K. Bickel and his colleagues asked people addicted to opioids and healthy controls to complete a story that started with the line: “After awakening, Bill began to think about his future. In general, he expected to . . .” Opioid-addicted study participants referred to a future that was on average nine days long. Healthy controls referred to a future that was on average 4.7 years long. This striking difference illustrates how “temporal horizons” shrink when we’re under the sway of an addictive drug.
• The neuroscientist Samuel McClure and his colleagues examined what parts of the brain are involved in choosing immediate versus delayed rewards. They found that when participants chose immediate rewards, emotion- and reward-processing parts of the brain lit up. When participants delayed their reward, the prefrontal cortex—the part of the brain involved in planning and abstract thinking—became active. The implication here is that we are all now vulnerable to prefrontal cortical atrophy as our reward pathway has become the dominant driver of our lives.
• The drug becomes the reward when they succeed and the consolation prize when they fail.
• Muhammad was smart. So why couldn’t he figure out that every time he smoked, he wouldn’t be able to stick to his self-imposed time limits? Because once he started using cannabis, he wasn’t governed by reason; he was governed by the pleasure-pain balance. Even one joint created a state of wanting not easily influenced by logic. Under the influence, he could no longer objectively evaluate the immediate rewards of smoking against their long-term counterparts. Delay discounting ruled his world.
• Recent data show that even antidepressants, previously thought not to be “habit forming,” may lead to tolerance and dependence, and possibly even make depression worse over the long haul, a phenomenon called tardive dysphoria.
• Beyond the problem of addiction and the question of whether or not these drugs help, I’ve been plagued by a deeper question: What if taking psychotropic drugs is causing us to lose some essential aspect of our humanity?
• The sci-fi movie Serenity (2005), directed by Joss Whedon, imagines a future world in which national leaders conduct a grand experiment: They inoculate an entire planet’s population against greed, sadness, anxiety, anger, despair in hopes of achieving a civilization of peace and harmony. Mal, a rogue pilot, the movie’s hero, and the captain of the spaceship Serenity, travels with his crew to the planet to explore. Instead of finding Shangri-La, he finds corpses without a ready explanation for their death. An entire planet is dead in repose, lying in their beds, kicking back on their couches, slumped at their desks. Mal and his crew eventually puzzle it out: The genetic mutation deprived them of hunger for anything. Like real-life dopamine-depleted rats who starve to death rather than shuffle a few centimeters for food, these humans died for lack of desire.
• Exercise increases many of the neurotransmitters involved in positive mood regulation: dopamine, serotonin, norepinephrine, epinephrine, endocannabinoids, and endogenous opioid peptides (endorphins). Exercise contributes to the birth of new neurons and supporting glial cells. Exercise even reduces the likelihood of using and getting addicted to drugs.
• Riches and celebrity, another dimension of our dopamine economy, contribute to the addictive potential of these extreme sports.
• While truth-telling promotes human attachment, compulsive overconsumption of high-dopamine goods is the antithesis of human attachment. Consuming leads to isolation and indifference, as the drug comes to replace the reward obtained from being in relationship with others. Experiments show that a free rat will instinctively work to free another rat trapped inside a plastic bottle. But once that free rat has been allowed to self-administer heroin, it is no longer interested in helping out the caged rat, presumably too caught up in an opioid haze to care about a fellow member of its species.

Modern Life's Impact on Consumption

• Because we’ve transformed the world from a place of scarcity to a place of overwhelming abundance: Drugs, food, news, gambling, shopping, gaming, texting, sexting, Facebooking, Instagramming, YouTubing, tweeting . . . the increased numbers, variety, and potency of highly rewarding stimuli today is staggering. The smartphone is the modern-day hypodermic needle, delivering digital dopamine 24/7 for a wired generation. If you haven’t met your drug of choice yet, it’s coming soon to a website near you.
• The reduced drinking effects of Prohibition persisted through the 1950s. Over the subsequent thirty years, as alcohol became more available again, consumption steadily increased.
• Our dopamine economy, or what historian David Courtwright has called “limbic capitalism,” is driving this change, aided by transformational technology that has increased not just access but also drug numbers, variety, and potency. The cigarette-rolling machine invented in 1880, for example, made it possible to go from four cigarettes rolled per minute to a staggering 20,000. Today, 6.5 trillion cigarettes are sold annually around the world, translating to roughly 18 billion cigarettes consumed per day, responsible for an estimated 6 million deaths worldwide.
• Today’s cannabis is five to ten times more potent than the cannabis of the 1960s and is available in cookies, cakes, brownies, gummy bears, blueberries, “pot tarts,” lozenges, oils, aromatics, tinctures, teas . . . the list is endless.
• The world now offers a full complement of digital drugs that didn’t exist before, or if they did exist, they now exist on digital platforms that have exponentially increased their potency and availability. These include online pornography, gambling, and video games, to name a few.
• My patient Chi, a Vietnamese immigrant, got hooked on the cycle of searching for and buying products online. The high for him began with deciding what to buy, continued through anticipating delivery, and culminated in the moment he opened the package. Unfortunately, the high didn’t last much beyond the time it took him to rip off the Amazon tape and see what was inside. He had rooms full of cheap consumer goods and was tens of thousands of dollars in debt.
• Seventy percent of world global deaths are attributable to modifiable behavioral risk factors like smoking, physical inactivity, and diet. The leading global risks for mortality are high blood pressure (13 percent), tobacco use (9 percent), high blood sugar (6 percent), physical inactivity (6 percent), and obesity (5 percent). In 2013, an estimated 2.1 billion adults were overweight, compared with 857 million in 1980.
• The poor and undereducated, especially those living in rich nations, are most susceptible to the problem of compulsive overconsumption. They have easy access to high-reward, high-potency, high-novelty drugs at the same time that they lack access to meaningful work, safe housing, quality education, affordable health care, and race and class equality before the law. This creates a dangerous nexus of addiction risk.
• These brochures illustrate how the pursuit of personal happiness has become a modern maxim, crowding out other definitions of the “good life.” Even acts of kindness toward others are framed as a strategy for personal happiness. Altruism, no longer merely a good in itself, has become a vehicle for our own “well-being.”
• Over the past three decades, I have seen growing numbers of patients like David and Kevin who appear to have every advantage in life—supportive families, quality education, financial stability, good health—yet develop debilitating anxiety, depression, and physical pain. Not only are they not functioning to their potential; they’re barely able to get out of bed in the morning.
• Researchers interviewed nearly 150,000 people in twenty-six countries to determine the prevalence of generalized anxiety disorder, defined as excessive and uncontrollable worry that adversely affected their life. They found that richer countries had higher rates of anxiety than poor ones. The authors wrote, “The disorder is significantly more prevalent and impairing in high-income countries than in low- or middle-income countries.” The number of new cases of depression worldwide increased 50 percent between 1990 and 2017. The highest increases in new cases were seen in regions with the highest sociodemographic index (income), especially North America.
• The question is: Why, in a time of unprecedented wealth, freedom, technological progress, and medical advancement, do we appear to be unhappier and in more pain than ever? The reason we’re all so miserable may be because we’re working so hard to avoid being miserable.
• The phylogenetically uber-ancient neurological machinery for processing pleasure and pain has remained largely intact throughout evolution and across species. It is perfectly adapted for a world of scarcity. Without pleasure we wouldn’t eat, drink, or reproduce. Without pain we wouldn’t protect ourselves from injury and death. By raising our neural set point with repeated pleasures, we become endless strivers, never satisfied with what we have, always looking for more. But herein lies the problem. Human beings, the ultimate seekers, have responded too well to the challenge of pursuing pleasure and avoiding pain. As a result, we’ve transformed the world from a place of scarcity to a place of overwhelming abundance. Our brains are not evolved for this world of plenty. As Dr. Tom Finucane, who studies diabetes in the setting of chronic sedentary feeding, said, “We are cacti in the rain forest.” And like cacti adapted to an arid climate, we are drowning in dopamine. The net effect is that we now need more reward to feel pleasure, and less injury to feel pain. This recalibration is occurring not just at the level of the individual but also at the level of nations. Which invites the question: How do we survive and thrive in this new ecosystem? How do we raise our children? What new ways of thinking and acting will be required of us as denizens of the twenty-first century?
• The question of how to moderate is becoming an increasingly important one in modern-day life, because of the sheer ubiquity of high-dopamine goods, making us all more vulnerable to compulsive overconsumption, even when not meeting clinical criteria for addiction. Further, as digital drugs like smartphones have become embedded into so many aspects of our lives, figuring out how to moderate their consumption, for ourselves and our children, has become a matter of urgency.
• We can and should celebrate a medical intervention that can improve the health of so many people. But the fact that we must resort to removing and reshaping internal organs to accommodate our food supply marks a turning point in the history of human consumption.
• Just tracking how much time we spend consuming, for example, by clocking our smartphone use, is one way to become aware of and thereby mitigate consumption. When we make conscious use of objective facts like how much time we’re using, we are less able to deny them, and therefore in a better position to take action.
• Another variable contributing to the problem of compulsive overconsumption is the growing amount of leisure time we have today, and with it the ensuing boredom. The mechanization of agriculture, manufacturing, domestic chores, and many other previously time-consuming, labor-intensive jobs has reduced the number of hours per day people spend working, leaving more time for leisure. A typical day for the average laborer in the United States just before the Civil War (1861–1865), whether in agriculture or industry, consisted of working ten to twelve hours a day, six and a half days per week, fifty-one weeks per year, with no more than two hours a day spent on leisure activity. Some workers, often immigrant women, worked thirteen hours a day, six days a week. Others labored in slavery. By contrast, the amount of leisure time in the United States today increased by 5.1 hours per week between 1965 and 2003, an additional 270 leisure hours per year. By 2040, the number of leisure hours in a typical day in the United States is projected to be 7.2 hours, with just 3.8 hours of daily work. The numbers for other high-income countries are similar. Leisure time in the United States differs by education and socioeconomic status, but not in the way you might think. In 1965, both the less educated and more educated in the United States enjoyed about the same amount of leisure time. Today, adults living in the US without a high school diploma have 42 percent more leisure time than adults with a bachelor’s degree or higher, with the biggest differences in leisure time occurring during weekday hours. This is due in large part to underemployment among those without a college degree. Dopamine consumption is not just a way to fill the hours not spent working. It has also become a reason why people are not participating in the workforce.
• A gluten-free diet, which previously had effectively limited consumption of high-calorie processed foods such as cakes, cookies, crackers, cereal, pastas, and pizzas, now no longer does. For those who were using the gluten-free diet to avoid gluten, this might be good news. But for those who were benefiting from gluten-free as a category to limit consumption of bread, cakes, and cookies, the category no longer serves. The evolution of the gluten-free diet illustrates how attempts to control consumption are swiftly countered by modern market forces, just one more example of the challenges inherent in our dopamine economy.
• According to survey reports, the typical American today spends half their waking hours sitting, 50 percent more than fifty years ago. Data from other rich nations around the globe are comparable.
• By contrast, blue-collar jobs are increasingly mechanized and divorced from the meaning of the work itself. Working under the employ of distant beneficiaries, there’s limited autonomy, modest financial gain, and little sense of common mission.
• By 2002, the top-paid 20 percent were twice as likely to work long hours as the lowest-paid 20 percent, and that trend continues. Economists speculate that this change is due to higher rewards for those at the top of the economic food chain.
• It makes intuitive sense that when resources are scarce, people are more invested in immediate gains, and are less confident that those rewards will still be forthcoming in some distant future.
• So we’re drawn to any of the pleasurable forms of escape that are now available to us: trendy cocktails, the echo chamber of social media, binge-watching reality shows, an evening of Internet porn, potato chips and fast food, immersive video games, second-rate vampire novels . . . The list really is endless. Addictive drugs and behaviors provide that respite but add to our problems in the long run.

Pain and Pleasure Balance

• One of the most remarkable neuroscientific findings in the past century is that the brain processes pleasure and pain in the same place. Further, pleasure and pain work like opposite sides of a balance.
• Today, potent pharmaceutical-grade opioids such as oxycodone, hydrocodone, and hydromorphone are available in every imaginable form: pills, injection, patch, nasal spray.
• By contrast, doctors today are expected to eliminate all pain lest they fail in their role as compassionate healers. Pain in any form is considered dangerous, not just because it hurts but also because it’s thought to kindle the brain for future pain by leaving a neurological wound that never heals. The paradigm shift around pain has translated into massive prescribing of feel-good pills. Today, more than one in four American adults—and more than one in twenty American children—takes a psychiatric drug on a daily basis.
• We’re all running from pain. Some of us take pills. Some of us couch surf while binge-watching Netflix. Some of us read romance novels. We’ll do almost anything to distract ourselves from ourselves. Yet all this trying to insulate ourselves from pain seems only to have made our pain worse.
• Imagine our brains contain a balance—a scale with a fulcrum in the center. When nothing is on the balance, it’s level with the ground. When we experience pleasure, dopamine is released in our reward pathway and the balance tips to the side of pleasure. The more our balance tips, and the faster it tips, the more pleasure we feel. But here’s the important thing about the balance: It wants to remain level, that is, in equilibrium. It does not want to be tipped for very long to one side or another. Hence, every time the balance tips toward pleasure, powerful self-regulating mechanisms kick into action to bring it level again. These self-regulating mechanisms do not require conscious thought or an act of will. They just happen, like a reflex. I tend to imagine this self-regulating system as little gremlins hopping on the pain side of the balance to counteract the weight on the pleasure side. The gremlins represent the work of homeostasis: the tendency of any living system to maintain physiologic equilibrium. Once the balance is level, it keeps going, tipping an equal and opposite amount to the side of pain.
• I became acutely aware of this effect of high-dopamine addictive substances on the brain’s reward pathway in the early 2000s, when I started seeing more patients coming in to clinic on high-dose, long-term opioid therapy (think OxyContin, Vicodin, morphine, fentanyl) for chronic pain. Despite prolonged and high-dose opioid medications, their pain had only gotten worse over time. Why? Because exposure to opioids had caused their brain to reset its pleasure-pain balance to the side of pain. Now their original pain was worse, and they had new pain in parts of their body that used to be pain free. This phenomenon, widely observed and verified by animal studies, has come to be called opioid-induced hyperalgesia. Algesia, from the Greek word algesis, means sensitivity to pain. What’s more, when these patients tapered off opioids, many of them experienced improvements in pain.
• The paradox is that hedonism, the pursuit of pleasure for its own sake, leads to anhedonia, which is the inability to enjoy pleasure of any kind.
• My patients with addiction describe how they get to a point where their drug stops working for them. They get no high at all anymore. Yet if they don’t take their drug, they feel miserable. The universal symptoms of withdrawal from any addictive substance are anxiety, irritability, insomnia, and dysphoria. A pleasure-pain balance tilted to the side of pain is what drives people to relapse even after sustained periods of abstinence. When our balance is tilted to the pain side, we crave our drug just to feel normal (a level balance).
• We’ve all experienced the letdown of unmet expectations. An expected reward that fails to materialize is worse than a reward that was never anticipated in the first place.
• Pleasure and pain can occur simultaneously. For example, we can experience both pleasure and pain when eating spicy food.
• Not everyone starts out with a level balance: Those with depression, anxiety, and chronic pain start with a balance tipped to the side of pain, which may explain why people with psychiatric disorders are more vulnerable to addiction.
• Beecher made a remarkable discovery. Three-quarters of these badly injured soldiers reported little or no pain in the immediate aftermath of their wounds, despite life-threatening injuries. He concluded that their physical pain was tempered by the emotional relief of escaping “from an exceedingly dangerous environment, one filled with fatigue, discomfort, anxiety, fear and real danger of death.” Their pain, such as it was, gave them “a ticket to the safety of the hospital.”
• Science teaches us that every pleasure exacts a price, and the pain that follows is longer lasting and more intense than the pleasure that gave rise to it. With prolonged and repeated exposure to pleasurable stimuli, our capacity to tolerate pain decreases, and our threshold for experiencing pleasure increases.
• Please don’t misunderstand me. These medications can be lifesaving tools and I’m grateful to have them in clinical practice. But there is a cost to medicating away every type of human suffering, and as we shall see, there is an alternative path that might work better: embracing pain.
• Michael’s accidental discovery of the benefits of ice-cold water immersion is an example of how pressing on the pain side of the balance can lead to its opposite—pleasure. Unlike pressing on the pleasure side, the dopamine that comes from pain is indirect and potentially more enduring. So how does it work? Pain leads to pleasure by triggering the body’s own regulating homeostatic mechanisms. In this case, the initial pain stimulus is followed by gremlins hopping on the pleasure side of the balance.
• The initial response (pain) got shorter and weaker. The after-response (pleasure) got longer and stronger. Pain morphed into hypervigilance morphed into a “fit of joy.” An elevated heart rate, consistent with a fight-or-flight reaction, morphed into minimal heart rate elevation followed by prolonged bradycardia, a slowed heart rate seen in states of deep relaxation.
• How strange would appear to be this thing that men call pleasure! And how curiously it is related to what is thought to be its opposite, pain! The two will never be found together in a man, and yet if you seek the one and obtain it, you are almost bound always to get the other as well, just as though they were both attached to one and the same head. . . . Wherever the one is found, the other follows up behind.
• But pursuing pain is harder than pursuing pleasure. It goes against our innate reflex to avoid pain and pursue pleasure. It adds to our cognitive load: We have to remember that we will feel pleasure after pain, and we’re remarkably amnestic about this sort of thing. I know I have to relearn the lessons of pain every morning as I force myself to get out of bed and go exercise.
• Hippocrates, who wrote in his Aphorisms in 400 BC: “Of two pains occurring together, not in the same part of the body, the stronger weakens the other.”
• As the philosopher Friedrich Nietzsche famously said, a sentiment echoed by many before and after through the ages, “What doesn’t kill me makes me stronger.”
• Extreme sports—skydiving, kitesurfing, hang gliding, bobsledding, downhill skiing/snowboarding, waterfall kayaking, ice climbing, mountain biking, canyon swinging, bungee jumping, base jumping, wingsuit flying—slam down hard and fast on the pain side of the pleasure-pain balance. Intense pain/fear plus a shot of adrenaline creates a potent drug. Scientists have shown that stress alone can increase the release of dopamine in the brain’s reward pathway, leading to the same brain changes seen with addictive drugs like cocaine and methamphetamine. Just as we become tolerant to pleasure stimuli with repeated exposure, so too can we become tolerant to painful stimuli, resetting our brains to the side of pain.
• “Overtraining syndrome” is a well-described but poorly understood condition among endurance athletes who train so much that they reach a point where exercise no longer produces the endorphins that were once so plentiful. Instead, exercise leaves them feeling depleted and dysphoric, as if their reward balance has maxed out and stopped working,
• Here we are at the end, but it could be just the beginning of a new way of approaching the hypermedicated, overstimulated, pleasure-saturated world of today. Practice the lessons of the balance, so that you too can look back at the light of your progress.
• Lessons of the Balance The relentless pursuit of pleasure (and avoidance of pain) leads to pain. Recovery begins with abstinence. Abstinence resets the brain’s reward pathway and with it our capacity to take joy in simpler pleasures. Self-binding creates literal and metacognitive space between desire and consumption, a modern necessity in our dopamine-overloaded world. Medications can restore homeostasis, but consider what we lose by medicating away our pain. Pressing on the pain side resets our balance to the side of pleasure. Beware of getting addicted to pain. Radical honesty promotes awareness, enhances intimacy, and fosters a plenty mindset. Prosocial shame affirms that we belong to the human tribe. Instead of running away from the world, we can find escape by immersing ourselves in it.

Self-Binding and Control Strategies

• The key to creating effective self-binding is first to acknowledge the loss of voluntariness we experience when under the spell of a powerful compulsion, and to bind ourselves while we still possess the capacity for voluntary choice. If we wait until we feel the compulsion to use, the reflexive pull of seeking pleasure and/or avoiding pain is nearly impossible to resist. In the throes of desire, there’s no deciding.
• Further, self-binding has become a modern necessity. External rules and sanctions like taxes on cigarettes, age restrictions on alcohol, and laws prohibiting cocaine possession, although necessary, will never be sufficient in a world where access to an ever-growing variety of high-dopamine goods is practically infinite.
• Self-binding can be organized into three broad categories: physical strategies (space), chronological strategies (time), and categorical strategies (meaning). As you will see in what follows, self-binding is not fail-safe, particularly for those with severe addictions. It too can fall prey to self-deception, bad faith, and faulty science. But it is a good and necessary place to start.
• one form of self-binding is to create literal physical barriers and/or geographical distance between ourselves and our drug of choice. Here are some examples my patients have told me about: “I unplugged my TV and put it in my closet.” “I banished my game console to the garage.” “I don’t use credit cards. Only cash.” “I call hotels beforehand to ask them to remove the minibar.” “I call hotels beforehand to ask them to remove the minibar and the television.” “I put my iPad in a safety deposit box at Bank of America.” My patient Oscar, a rotund man in his late seventies with a scholarly mind, a booming voice, and a penchant for talking in soliloquies, so much so that he made a muddle of group therapy and had to drop out, had a habit of drinking to excess while working in his study, tinkering in his garage, and puttering in his garden. By trial and error he learned that to prevent this behavior, he had to remove all alcohol from his home. Any alcohol brought into the house needed to be locked up in a file cabinet for which only his wife had the key. Using this method, Oscar was able to successfully abstain from alcohol for years.
• But I warned you that self-binding is no guarantee. Sometimes the barrier itself becomes an invitation to a challenge. Solving the puzzle of how to get our drug of choice becomes part of its appeal.
• Physical self-binding is now available from your local apothecary. Instead of locking our drugs away in a file cabinet, we have the option of imposing locks at the cellular level. The medication naltrexone is used to treat alcohol and opioid addiction, and is being used for a variety of other addictions as well, from gambling to overeating to shopping. Naltrexone blocks the opioid receptor, which in turn diminishes the reinforcing effects of different types of rewarding behavior. I’ve had patients report a near or complete cessation of alcohol craving with naltrexone.
• It turns out that willpower is not an infinite human resource. It’s more like exercising a muscle, and it can get tired the more we use it.
• From lockboxes that limit our access, to medications that block our opioid receptors, to surgeries that shrink our stomachs, physical self-binding is everywhere in modern life, illustrating our growing need to put the brakes on dopamine.
• Another form of self-binding is the use of time limits and finish lines. By restricting consumption to certain times of the day, week, month, or year, we narrow our window of consumption and thereby limit our use. For example, we can tell ourselves we’ll consume only on holidays, only on weekends, never before Thursday, never before 5:00 p.m., and so on.
• Reflecting on the trajectory of his whole life, rather than just the present moment, allowed this young man to take a more accurate inventory of his day-to-day behaviors. The same was true of Delilah, who was willing to abstain from cannabis for four weeks only after imagining herself still smoking ten years hence.
• “There’s no way someone as smart as you can be addicted.” Just this once, Muhammad told himself, and then not again till graduation.
• The Stanford marshmallow experiment was a series of studies led by psychologist Walter Mischel in the late 1960s at Stanford University to study delayed gratification. Children between the ages of three and six were offered a choice between one small reward provided immediately (a marshmallow) or two small rewards (two marshmallows) if the child could wait for approximately fifteen minutes without eating the first marshmallow. During that time, the researcher left the room and then returned. The marshmallow was placed on a plate on a table in a room that was otherwise empty of distractions: no toys, no other children. The purpose of the study was to determine when delayed gratification develops in children. Subsequent studies examined what kinds of real-life outcomes are associated with the ability, or lack thereof, to delay gratification. The researchers discovered that of approximately one hundred children, one-third made it long enough to get the second marshmallow. Age was a major determinant: the older the child, the more able to delay. In follow-up studies, children who were able to wait for the second marshmallow tended to have better SAT scores and better educational attainment, and were overall cognitively and socially better-adjusted adolescents. One detail of the experiment that is less well known is what the children did during those fifteen minutes of struggling not to eat the first marshmallow. The researchers’ observations reveal a literal embodiment of self-binding: The children “cover their eyes with their hands or turn around so that they can’t see the tray . . . start kicking the desk, or tug on their pigtails, or stroke the marshmallow as if it were a tiny stuffed animal.”
• My patient Jasmine came to me seeking help for excessive alcohol consumption, up to ten beers every day. As part of the treatment, I advised her to remove all alcohol from her home as a self-binding strategy. She mostly took my advice, with a twist. She removed all alcohol save one beer, which she left in her refrigerator. She called it her “totemic beer,” which she regarded as the symbol of her choice not to drink, a representation of her will and autonomy. She told herself that she only needed to focus on not drinking that one beer rather than the more daunting task of not drinking any beer from the vast quantity available in the world. This metacognitive sleight of hand, transforming an object of temptation into a symbol of restraint, helped Jasmine abstain.
• Alex Honnold, now world-famous for climbing the face of Yosemite’s El Capitan without ropes, was found to have below-normal amygdala activation during brain imaging. For most of us, the amygdala is an area of the brain that lights up in an fMRI machine when we look at scary pictures. The researchers who studied Honnold’s brain speculated that he was born with less innate fear than others, which in turn allowed him, they hypothesized, to accomplish superhuman climbing feats. But Honnold himself disagreed with their interpretation: “I’ve done so much soloing, and worked on my climbing skills so much that my comfort zone is quite large. So these things that I’m doing that look pretty outrageous, to me they seem normal.” The most likely explanation for Honnold’s brain differences is the development of tolerance to fear through neuroadaptation. My guess is that Honnold’s brain started out no different from the average brain in terms of fear sensitivity. What’s different now is that he has trained his brain through years of climbing not to react to fearful stimuli. It takes a lot more to scare Honnold’s brain than the average person’s because he has incrementally exposed himself to death-defying feats. Of note, Honnold nearly had a panic attack when he went inside the fMRI machine to get pictures taken of his “fearless brain,” which also tells us that fear tolerance doesn’t necessarily translate across all experiences.
• The truth is, I am anxious and fearful, although few would guess those things about me. I maintain a rigid schedule, a predictable routine, and a slavish adherence to my to-do list, as a way to manage my anxiety. This means that others are often forced to bend to my will and the exigencies of my goals.

Honesty and Personal Growth

• “it’s a way of becoming familiar with yourself. Of letting your experience unfold without trying to control it or run away from it. All that distracting yourself with devices may be contributing to your depression and anxiety. It’s pretty exhausting avoiding yourself all the time. I wonder if experiencing yourself in a different way might give you access to new thoughts and feelings, and help you feel more connected to yourself, to others, and to the world.”
• Humans are not the only animals with the capacity for deception. The animal kingdom is rife with examples of deception as a weapon and a shield. The Lomechusa pubicollis beetle, for example, is able to penetrate ant colonies by pretending to be one of them, something it accomplishes by emitting a chemical substance that makes it smell like an ant. Once inside, the beetle feeds on ant eggs and larvae.
• guilty for lying and afraid that someone would find out. I realized that as long as I’m telling the truth, I don’t have to worry about any of that. I’m free.
• Radical honesty—telling the truth about things large and small, especially when doing so exposes our foibles and entails consequences—is essential not just to recovery from addiction but for all of us trying to live a more balanced life in our reward-saturated ecosystem. It works on many levels.
• They concluded that honesty can be strengthened by stimulating the prefrontal cortex, consistent with the idea that the “human brain has evolved mechanisms dedicated to control complex social behaviors.”
• But now I saw my behavior for what it was—a compulsive, self-destructive pattern—which took the fun out of it. I felt a growing resolve to stop the behavior for good.
• Telling the truth draws people in, especially when we’re willing to expose our own vulnerabilities. This is counterintuitive because we assume that unmasking the less desirable aspects of ourselves will drive people away. It logically makes sense that people would distance themselves when they learn about our character flaws and transgressions. In fact, the opposite happens. People come closer. They see in our brokenness their own vulnerability and humanity. They are reassured that they are not alone in their doubts, fears, and weaknesses.
• Social media has contributed to the problem of the false self by making it far easier for us, and even encouraging us, to curate narratives of our lives that are far from reality. In his online life, my patient Tony, a young man in his twenties, ran every morning to take in the sunrise, spent the day engaged in constructive and ambitious artistic endeavors, and was the recipient of numerous awards. In his real life, he could barely get out of bed, compulsively looked at pornography online, struggled to find gainful employment, and was isolated, depressed, and suicidal. Little of his real day-to-day life was evident on his Facebook page. When our lived experience diverges from our projected image, we are prone to feel detached and unreal, as fake as the false images we’ve created. Psychiatrists call this feeling derealization and depersonalization. It’s a terrifying feeling, which commonly contributes to thoughts of suicide. After all, if we don’t feel real, ending our lives feels inconsequential. The antidote to the false self is the authentic self. Radical honesty is a way to get there. It tethers us to our existence and makes us feel real in the world. It also lessens the cognitive load required to maintain all those lies, freeing up mental energy to live more spontaneously in the moment.
• When the people around us are reliable and tell us the truth, including keeping promises they’ve made to us, we feel more confident about the world and our own future in it. We feel we can rely not just on them but also on the world to be an orderly, predictable, safe kind of a place. Even in the midst of scarcity, we feel confident that things will turn out okay. This is a plenty mindset. When the people around us lie and don’t keep their promises, we feel less confident about the future. The world becomes a dangerous place that can’t be relied upon to be orderly, predictable, or safe. We go into competitive survival mode and favor short-term gains over long-term ones, independent of actual material wealth. This is a scarcity mindset.
• For me, honesty is a daily struggle. There’s always a part of me that wants to embellish the story just the slightest bit, to make myself look better, or to make an excuse for bad behavior. Now I try hard to fight that urge.
• A month later, Lori came back as scheduled. “I met with the church elders.” “What happened?” She looked away. “I was open in a way I’d never been before . . . except with you. I told them everything . . . or almost everything. I just put it all out there.” “And?” “It was weird,” she said. “They seemed . . . confused. Anxious. Like they didn’t really know what to do with me. They told me to pray. They said they would pray for me. They also encouraged me not to discuss my problems with other members of the church. That’s it.”

Social Connection and Shame

• Human beings are social animals. When we see others behaving in a certain way online, those behaviors seem “normal” because other people are doing them.
• The connections seemed real as long as he was doped but disappeared as soon as the opioids wore off. Drug-manufactured intimacy, he learned, didn’t last.
• In medicating ourselves to adapt to the world, what kind of world are we settling for? Under the guise of treating pain and mental illness, are we rendering large segments of the population biochemically indifferent to intolerable circumstance? Worse yet, have psychotropic medications become a means of social control, especially of the poor, unemployed, and disenfranchised? Psychiatric drugs are prescribed more often and in larger amounts to poor people, especially poor children.
• The evolution of Homo sapiens culminated in the formation of large social groups. Large social groups were possible because of the development of sophisticated forms of communication, allowing for advanced mutual cooperation. Words used to cooperate can also be used to deceive and misdirect. The more advanced the language, the more sophisticated the lies. Lies arguably have some adaptive advantage when it comes to competing for scarce resources.But lying in a world of plenty risks isolation, craving, and pathological overconsumption.
• Shame makes us feel bad about ourselves as people, whereas guilt makes us feel bad about our actions while preserving a positive sense of self. Shame is a maladaptive emotion. Guilt is an adaptive emotion. My problem with the shame-guilt dichotomy is that experientially, shame and guilt are identical. Intellectually, I may be able to parse out self-loathing from “being a good person who did something wrong,” but in that moment of feeling shame-guilt, a gut punch of an emotion, the feeling is identical: regret mixed with fear of punishment and the terror of abandonment. The regret is for having been found out and may or may not include regret for the behavior itself. The terror of abandonment, its own form of punishment, is especially potent. It is the terror of being cast out, shunned, no longer part of the herd.
• Lori was caught in the cycle of destructive shame. When she tried being honest with fellow church members, she was discouraged from sharing that part of her life, implicitly communicating that she would be rejected or further shamed if she were open about her struggles. She couldn’t risk losing what little community she had. But keeping her behavior hidden also perpetuated her shame, further contributing to isolation, all of which fueled ongoing consumption. Studies show that people who are actively involved in religious organizations on average have lower rates of drug and alcohol misuse. But when faith-based organizations end up on the wrong side of the shame equation, by shunning transgressors and/or encouraging a web of secrecy and lies, they contribute to the cycle of destructive shame.
• In AA, I learned to accept myself and other people for who they are. Now I have real relationships with people. I belong. They know the real me.”
• Mutual honesty precludes shame and presages an intimacy explosion, a rush of emotional warmth that comes from feeling deeply connected to others when we’re accepted despite our flaws. It is not our perfection but our willingness to work together to remedy our mistakes that creates the intimacy we crave. This kind of intimacy explosion is almost certainly accompanied by the release of our brain’s own endogenous dopamine. But unlike the rush of dopamine we get from cheap pleasures, the rush we get from true intimacy is adaptive, rejuvenating, and health-promoting.
• We tend to think of shame as a negative, especially at a time when shaming—fat shaming, slut shaming, body shaming, and so on—is such a loaded word and is (rightly) associated with bullying. In our increasingly digital world, social media shaming and its correlate “cancel culture” have become a new form of shunning, a modern twist on the most destructive aspects of shame. Even when no one else is pointing the finger at us, we’re all too ready to point it at ourselves. Social media propels our tendency toward self-shame by inviting so much invidious distinction. We’re now comparing ourselves not just to our classmates, neighbors, and coworkers, but to the whole world, making it all too easy to convince ourselves that we should have done more, or gotten more, or just lived differently.

Recovery and Healing Process

• “Persons with severe addictions are among those contemporary prophets that we ignore to our own demise, for they show us who we truly are.”
• As they say in AA, “I’m sick and tired of being sick and tired.”
• The depressed men in Schuckit’s study went into the hospital for four weeks, during which time they received no treatment for depression, other than stopping alcohol. After one month of not drinking, 80 percent no longer met criteria for clinical depression. This finding implies that for the majority, clinical depression was the result of heavy drinking and not a co-occurring depressive disorder. Of course there are other explanations for these results: the therapeutic milieu of the hospital environment, spontaneous remission, the episodic nature of depression, which can come and go independent of external factors. But the robust findings are remarkable given that standard treatments for depression, whether medications or psychotherapy, have a 50 percent response rate. Naturally I’ve seen patients who need less than four weeks to reset their reward pathway, and others who need far longer. Those who have been using more potent drugs in larger quantities for longer duration will typically need more time. Younger people recalibrate faster than older people, their brains being more plastic. Furthermore, physical withdrawal varies drug to drug. It can be minor for some drugs like video games but potentially life-threatening for others, like alcohol and benzodiazepines. Which brings us to an important caveat: I never suggest a dopamine fast to individuals who might be at risk to suffer life-threatening withdrawal if they were to quit all of a sudden, as in cases of severe alcohol, benzodiazepine (Xanax, Valium, or Klonopin), or opioid dependence and withdrawal. For those patients, medically monitored tapering is necessary.
• M Stands for Mindfulness “I want you to be prepared,” I said to Delilah, “for feeling worse before you feel better. By this I mean, when you first stop cannabis, your anxiety will get worse. But remember, this is not the anxiety you’ll have to live with off cannabis. This is withdrawal-mediated anxiety. The longer you can go without using, the faster you’ll get to that place where you’re feeling better. Usually patients report a turning point at around two weeks.” “Okay. What am I supposed to do in the meantime? Do you have any pills you can give me?” “There’s nothing I can give you to take the pain away that’s not also addictive. Since we don’t want to trade one addiction for another, what I’m asking you to do is tolerate the pain.”
• The i of DOPAMINE stands for insight. I have seen again and again in clinical care, and in my own life, how the simple exercise of abstaining from our drug of choice for at least four weeks gives clarifying insight into our behaviors. Insight that simply is not possible while we continue to use.
• The n of DOPAMINE stands for next steps. This is where I ask my patients what they want to do after their month of abstinence. The vast majority of my patients who are able to abstain for a month and experience the benefits of abstinence nonetheless want to go back to using their drug. But they want to use differently than they were using before. The overarching theme is that they want to use less. An ongoing controversy in the field of addiction medicine is whether people who have been using drugs in an addictive way can return to moderate, nonrisky use. For decades the wisdom of Alcoholics Anonymous dictated that abstinence is the only option for people with addiction. But emerging evidence suggests that some people who have met criteria for addiction in the past, especially those with less severe forms of addiction, can return to using their drug of choice in a controlled way. In my clinical experience, this has been true.
• For more than 7,000 years, hallucinogens, also known as psychedelics (magic mushrooms, ayahuasca, peyote), have had sacramental uses across diverse cultures. When hallucinogens became popular and widely available as recreational drugs in the counterculture movement of the 1960s, however, harms multiplied, leading to LSD being made illegal in most parts of the world. Today, there is a movement to bring hallucinogens and other psychedelics back into use, but only in the pseudo-sacred context of psychedelic-assisted psychotherapy. Specially trained psychiatrists and psychologists are now administering hallucinogens and other potent psychotropic agents (psilocybin, ketamine, ecstasy) as mental health remedies. Administering limited doses (one to three) of psychedelics interspersed with multiple sessions of talk therapy over many weeks has become the modern equivalent of shamanism.
• In 1993, the psychiatrist Dr. Peter Kramer published his groundbreaking book Listening to Prozac, in which he argued that antidepressants make people “better than well.” But what if Kramer got it wrong? What if instead of making us better than well, psychotropic drugs make us other than well?
• “I got into a routine where I immersed myself in ice water for five to ten minutes every morning and again just before bed. I did that every day for the next three years. It was key to my recovery.”
• That’s because the evidence is indisputable: Exercise has a more profound and sustained positive effect on mood, anxiety, cognition, energy, and sleep than any pill I can prescribe.
• “I don’t really like the feeling of being alive. Drugs and alcohol were a way to like it. Now I can’t do that anymore. When I see people partying, I’m still a little bit jealous of the escape they’re getting. I can see they get the reprieve. Cold water reminds me that being alive can feel good.”
• Recounting our experiences gives us mastery over them. Whether in the context of psychotherapy, talking to an AA sponsor, confessing to a priest, confiding in a friend, or writing in a journal, our honest disclosure brings our behavior into relief, allowing us in some cases to see it for the first time. This is especially true for behaviors that involve a level of automaticity outside of conscious awareness. When I was compulsively reading romance novels, I was only partially aware of doing so. That is to say, I was aware of the behavior at the same time I was not aware of it. This is a well-recognized phenomenon in addiction, a kind of half-conscious state akin to a waking dream, often referred to as denial. Denial is likely mediated by a disconnect between the reward pathway part of our brain and the higher cortical brain regions that allow us to narrate the events of our lives, appreciate consequences, and plan for the future.
• Consistent with the lived experience of people in recovery, truth-telling may change the brain, allowing us to be more aware of our pleasure-pain balance and the mental processes driving compulsive overconsumption, and thereby change our behavior.
• There is a well-known phenomenon in AA called “drunkalogues,” referring to tales of intoxicated exploits that are shared to entertain and show off rather than teach and learn. Drunkalogues tend to trigger craving rather than promote recovery. The line between honest self-disclosure and a manipulative drunkalogue is a fine one, including subtle differences in content, tone, cadence, and affect, but you know it when you see it.
• Autobiographical narratives are an essential measure of lived time. The stories we narrate about our lives not only serve as a measure of our past but can also shape future behavior. In more than twenty years as a psychiatrist listening to tens of thousands of patient stories, I have become convinced that the way we tell our personal stories is a marker and predictor of mental health. Patients who tell stories in which they are frequently the victim, seldom bearing responsibility for bad outcomes, are often unwell and remain unwell. They are too busy blaming others to get down to the business of their own recovery. By contrast, when my patients start telling stories that accurately portray their responsibility, I know they’re getting better.
• One of the preeminent AA mottos, often printed in bold type on its brochures, is, “I am responsible.”
• In my clinical practice, I often see one member of a family get into recovery from addiction, followed quickly by another member of the family doing the same. I’ve seen husbands who stop drinking followed by wives who stop having affairs. I’ve seen parents who stop smoking pot followed by children who do the same.
• One day his wife discovered his use. “The look of disappointment and betrayal in her eyes made me swear I would never drink again.” The shame he felt in that moment, and his desire to regain the trust and approval of his wife, propelled him into his first serious attempt at recovery. He started attending Alcoholics Anonymous meetings. He identified the main benefit of Alcoholics Anonymous for him as a “de-shaming process.” He described it this way. “I realized I wasn’t the only one. There were other people just like me. There were other doctors who were struggling with alcohol addiction. Knowing I had a place to go where I could be completely honest and still be accepted was incredibly important. It created the psychological space I needed to forgive myself and make changes. To move forward in my life.”
• Many months later, I realized Muhammad’s path to recovery was similar to my own. I made a conscious decision to reimmerse myself in patient care, focusing on the aspects of my work that had always been rewarding: relationships with my patients over time, and immersion in narrative as a way to bring order to the world. In doing so, I was able to emerge from compulsive romance reading into a more rewarding and meaningful career. I was also more successful in my work, but my success was an unexpected byproduct, not the thing I was seeking.
• The rewards of finding and maintaining balance are neither immediate nor permanent. They require patience and maintenance. We must be willing to move forward despite being uncertain of what lies ahead. We must have faith that actions today that seem to have no impact in the present moment are in fact accumulating in a positive direction, which will be revealed to us only at some unknown time in the future.
• “Recovery is like that scene in Harry Potter when Dumbledore walks down a darkened alley lighting lampposts along the way. Only when he gets to the end of the alley and stops to look back does he see the whole alley illuminated, the light of his progress.”

Parenting and Education Challenges

• Perceiving children as psychologically fragile is a quintessentially modern concept. In ancient times, children were considered miniature adults, fully formed from birth. For most of Western civilization, children were regarded as innately evil. The job of parents and caregivers was to enforce extreme discipline in order to socialize them to live in the world. It was entirely acceptable to use corporal punishment and fear tactics to get a child to behave. No longer. Today, many parents I see are terrified of doing or saying something that will leave their child with an emotional scar, thereby setting them up, so the thinking goes, for emotional suffering and even mental illness in later life. This notion can be traced to Freud, whose groundbreaking psychoanalytic contribution was that early childhood experiences, even those long forgotten or outside of conscious awareness, can cause lasting psychological damage. Unfortunately, Freud’s insight that early childhood trauma can influence adult psychopathology has morphed into the conviction that any and every challenging experience primes us for the psychotherapy couch.
• By protecting our children from adversity, have we made them deathly afraid of it? By bolstering their self-esteem with false praise and a lack of real-world consequences, have we made them less tolerant, more entitled, and ignorant of their own character defects? By giving in to their every desire, have we encouraged a new age of hedonism?
• Second, young people, even heavy users, are more immune to the negative consequences of use. As one high school teacher remarked to me, “Some of my best students smoke pot every day.”
• The m of DOPAMINE stands for mindfulness. Mindfulness is a term that is tossed around so often now, it has lost some of its meaning. Evolved from the Buddhist spiritual tradition of meditation, it has been adopted and adapted by the West as a wellness practice across many different disciplines. It has so fully penetrated Western consciousness that it’s now routinely taught in American elementary schools. But what actually is mindfulness? Mindfulness is simply the ability to observe what our brain is doing while it’s doing it, without judgment. This is trickier than it sounds. The organ we use to observe the brain is the brain itself. Weird, right? When I look at the Milky Way galaxy in the night sky, I’m always struck by how mysterious it is that we can be a part of something that looks so far away and separate. Practicing mindfulness is something like observing the Milky Way: It demands that we see our thoughts and emotions as separate from us and yet, simultaneously, a part of us.
• Children begin lying as early as age two. The smarter the kid, the more likely they are to lie, and the better they are at it. Lying tends to decrease between ages three and fourteen, possibly because children become more aware of how lying harms other people. On the other hand, adults are capable of more sophisticated antisocial lies than children, as the ability to plan and remember becomes more advanced.
• Sometimes as parents we think that by hiding our mistakes and imperfections and only revealing our best selves, we’ll teach our children what is right. But this can have the opposite effect, leading children to feel they must be perfect to be lovable. Instead, if we are open and honest with our children about our struggles, we create a space for them to be open and honest about their own.
• Many of these rules seem excessive and gratuitous, but when viewed through the lens of utility-maximizing principles to strengthen participation, reduce free riding, and augment club goods, they make sense. And kids flock to this team in particular, seeming to love the strictness, even as they complain about it.