Overcome Addictions and Obsessions of All Kinds | Dr. Anna Lembke

Dr. Anna Lembke 0:00 In the severest cases of addiction, people are not actually addicted to that substance or that behavior. What they're addicted to is control. Through my addictive behaviors, I can create this world within a world where my focus narrows. I-- Everything else falls away. I've simplified things. I just have this one lever, like a rat in a cage, and as long as I can press that lever, I know I can change the way that I feel.

Andrew Huberman 0:33 Welcome to the Huberman Lab Podcast, where we discuss science and science-based tools for everyday life. [upbeat music] I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. My guest today is Dr. Anna Lembke. Dr. Anna Lembke is the director of the Dual Diagnosis Addiction Clinic at Stanford University School of Medicine and one of the world's leading experts in addiction, dopamine dynamics in the human brain, and how dopamine and other neurochemicals in the brain govern risk-taking, reward, and healthy versus unhealthy pursuits. Today, we discuss the latest science of addiction and dopamine dynamics and what Dr. Lembke herself has observed clinically in terms of the different kinds of addictions out in the world and how people can successfully overcome each of them. We also discussed her new book, Radical Surrender, which I can tell you, because I've read it, is an absolutely fascinating and actionable exploration into how giving up our attempt to control certain things actually allows our brain to access new strategies to overcome major challenges, including addiction, as well as codependency, and altogether live healthier, better lives. Most people are aware of what dopamine is and how it can work for better or for worse, as well as what addiction is and the various ways that people strive to overcome addiction. Dr. Anna Lembke's perspective on these topics is uniquely different, actionable, and today you're going to learn about all of it. Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is, however, part of my desire and effort to bring zero cost to consumer information about science and science-related tools to the general public. In keeping with that theme, today's episode does include sponsors. And now for my conversation

Andrew Huberman 2:14 with Dr. Anna Lembke. Dr. Anna Lembke, welcome.

Dr. Anna Lembke 2:17 Good to see you again, Andrew.

Andrew Huberman 2:19 Great to have you back. Your book, Dopamine Nation, and many things that you were saying in and around that book have become true. So I want to start off by saying thank you. You were right. Most of the world is addicted to the internet in some form, social media. You were calling this, and I think now roughly eight years out from heavy use of social media, I think almost everybody can say they have to do some sort of active distancing from screens, from phones, in order to recapture some semblance of a healthy life. So you saw that train coming. What's next? [laughs]

Dr. Anna Lembke 3:03 Yeah, yeah. I mean, I think there has been a big sea change just in terms of awareness, not, not unfortunately in terms of our behaviors. If, if anything, the medium has become even more compulsively reinforcing. We're all struggling. But certainly in terms of the conversation, the awareness of potential harms, the addictive nature of the devices and the medium itself, I think there is a lot more awareness now, and that, and that's good.

Andrew Huberman 3:29 Are you seeing this clinically? Are, are people coming in specifically with the issue, "I can't unplug from..." whatever it is, Instagram, X, Reddit, YouTube-

Dr. Anna Lembke 3:41 Yes

Andrew Huberman 3:41 ... media-

Dr. Anna Lembke 3:42 Yes

Andrew Huberman 3:42 ... more generally?

Dr. Anna Lembke 3:43 Yep. So they're bringing themselves in or, um, very often parents are bringing adolescents in. Our adolescent clinic now, about fifty percent of the referrals are for digital media addiction in some form.

Andrew Huberman 3:56 Five zero?

Dr. Anna Lembke 3:57 Five zero percent of the referrals at this point for our adolescent clinic. Huge problem.

Andrew Huberman 4:02 Does it l- look like classic addiction? And maybe we could define, or if-

Dr. Anna Lembke 4:07 Yeah

Andrew Huberman 4:07 ... you would, define that again for us.

Dr. Anna Lembke 4:08 Yes.

Andrew Huberman 4:09 Yeah.

Dr. Anna Lembke 4:09 So, so addiction broadly defined is the continued compulsive use of a substance or a behavior despite harm to self and/or others. Sometimes that's a harm that we can see, sometimes it's a harm that we don't see but others see. Um, we look for the 4 Cs, out of control use, compulsive use, craving, and continued use despite consequences. We also look for tolerance, needing more of the drug over time to get the same effect, and also withdrawal, finding that we're experiencing a painful physiologic response to stopping or cutting back.

Andrew Huberman 4:41 What's so unique about social media and online addiction is that it's often woven into vocation-

Dr. Anna Lembke 4:51 Yes

Andrew Huberman 4:51 ... social connection.

Dr. Anna Lembke 4:52 Yes.

Andrew Huberman 4:53 We could draw some parallels, like alcohol when I was growing up, there were like-- there was like happy hour, people with social lubricant. So you could go to a party and not drink and get some of the experience, but not all the experience. Now that's different with fewer people drinking.

Dr. Anna Lembke 5:08 Yes.

Andrew Huberman 5:09 But with digital addictions, it's almost like the opt out can seem or perhaps it's pretty bleak to people. Like, who else are-- who are you gonna talk to and how?

Dr. Anna Lembke 5:18 Yeah, and I think this is a, a central part of the problem, that it's not just an individual problem, it is a collective problem. It's one thing to tell your kid to get off of their device and go outside and play hide and seek, but if there's no other kids out there, it's hard to get a game together. So I think looking at it as something akin to let's say pollution, right? We c- we're not gonna solve the pollution problem by just having everybody try to use cloth rather than plastic bags, although we could try to do that, and that would be a good thing. We also need top-down guardrails like controlling the amount of waste that people can dump into rivers and oceans and into the air and, and all of that stuff. And I think we're gonna have to conceptualize digital media similarly. Like, we as individuals have agency and need to exercise that agency, but we also need government, schools, corporations that make and profit from these digital devices to really come to the table and help us help ourselves as we recognize the enshittification, you've probably heard that term, of technology where first the product adds value, but as time goes on, it's engineered to actually exploit value from the user as the corporations get richer and richer. This is a, a process called enshittification of technology. I can't remember the, the name of the guy. Maybe someone can look it up and I can sound like I remember his name. But it's, it's a great term because it is sort of the progression that you see in a lot of digital media products.

Andrew Huberman 6:43 Take us back to the circuitry-

Dr. Anna Lembke 6:45 Mm.

Andrew Huberman 6:45 The brain circuitry that underlies, uh, these and all forms of addiction. Can you tell us about dopamine and the circuitry, and what's involved in resetting the circuitry?

Dr. Anna Lembke 6:56 So dopamine is a neurotransmitter. Neurotransmitters are molecules that we make in our brains that allow for fine-tune control of the electrical circuits. Our brain is basically a bundle of wires. Those are the neurons. But they don't actually connect end to end. There's a spa- a gap or a space between them. That gap is called the synapse, and dopamine is a neurotransmitter that bridges that gap, being released from the presynaptic neuron, binding to a receptor on the outside of the postsynaptic neuron, and then controlling those electrical circuits. Dopamine has many different functions in the brain, but one of its primary functions is in reward and reinforcement. Very broadly speaking, the more dopamine that's released in the dedicated part of the reward pathway in the brain, and the faster that dopamine is released, the more likely we are to experience that substance or behavior as reinforcing and usually pleasurable when it's, you know, in concert with the other symphony of neuromodulators like endogenous opioids, endogenous cannabinoids, et cetera. For example, in mice and rats, chocolate increases dopamine firing 55% above baseline. Sex is 100%. Nicotine is 150%, all the way up until methamphetamines, which is 1000%, which is why I like to say that's why we first have dinner, then have sex, then have a cigarette.

Andrew Huberman 8:13 [laughs]

Dr. Anna Lembke 8:15 [laughs]

Andrew Huberman 8:15 Um, and even though the data you just, uh, cited are from rodents, uh, can we assume that parallel kind of scaling of dopamine with different, um, behaviors and, and substances is also occurring in humans?

Dr. Anna Lembke 8:28 Yes-

Andrew Huberman 8:29 Okay

Dr. Anna Lembke 8:29 ... we can. I mean, it's not an exact one-to-one, and it's much harder to mea-measure absolute dopamine levels in humans than it is in rats. In rats, you can put a probe right in the nucleus accumbens, measure dopamine levels, um, directly. You know, we're not doing that in humans. It's usually relative comparisons, but there are, there are ways to, to measure dopamine levels. But the idea is the same, that the more dopamine that's released, the faster that it's released in that dedicated reward pathway, the more likely that substance or behavior is to be reinforcing. And we know that things like social media, gambling, sex activate the same reward pathway as drugs and

Dr. Anna Lembke 9:03 alcohol.

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Andrew Huberman 11:26 off. So if somebody engages in a behavior or takes a substance and is like, "I love this," you've talked before about there being a, uh, a sort of, um- Inverse of that, um, that takes place as that experience wears off. It doesn't necessarily, you know, cast them forward just feeling much better about everything in life. What do we know about the circuitry underlying that?

Dr. Anna Lembke 11:52 One of the most important processes to understand in order to appreciate what happens in the brain as we go from recreational use of an intoxicant to maladaptive addictive use is to understand this concept of homeostasis. Homeostasis is a limited number of conditions that the organism needs to remain within in order to survive. And the metaphor that I like to use for that is to imagine that in your reward pathway, there's a scale or something like a balance, um, a beam on a central ful-fulcrum, and when it's at rest, that's baseline homeostasis. Pleasure and pain very simply work, uh, at like opposite sides of a balance. When we experience pleasure, it tips one way. Pain, it tips the other. And the rules governing th-th-that-- this balance begin with the primary rule that the, the balance wants to restore homeostasis, such that with any deviation from neutrality, our brains will work very hard to get back to that level balance. And the way our brains do that is what happens that makes us vulnerable to addiction. So for example, if, uh, if I do something pleasurable, which for me is like, you know, watching s-celebrity gossip videos and eating chocolate, that releases dopamine in my reward pathway. My pleasure-pain balance tilts to the side of pleasure. No sooner has that happened than my brain's gonna work to restore a level balance. I like to imagine that as these neuroadaptation gremlins hopping on the pain side of the balance to bring it level again. But the gremlins like it on the balance, so they don't get off as soon as it's level. They stay on until I'm tilted an equal and opposite amount to the side of pain. That's the come down, the hangover, or just that moment of craving, right? Wanting to watch one more video even though I told myself that I wouldn't. Now, if I manage to resist the urge, uh, and I stop watching videos, then the gremlins get the message that their job is done. They hop off, and homeostasis is restored. But if I continue to consume my drug of choice over days to weeks to months to years, those gremlins multiply. They get bigger, they get stronger, they're lifting weights, and eventually they end up camped out on the pain side of the balance. And now I've changed my hedonic or joy set point. I need more of my drug in more potent forms, not to get high and feel good, but just to level the balance and feel normal. And when I'm not using, I'm walking around with a pleasure-pain balance tilted to the side of pain, experiencing the universal symptoms of withdrawal from any addictive substance or behavior, which are anxiety, irritability, insomnia, depression, and craving. And this is why so many people will relapse even though they can see that their lives are better when they're not using. It's 'cause their brains aren't necessarily better. They're in a chronic reward deficit state.

Andrew Huberman 14:39 Mm-hmm.

Dr. Anna Lembke 14:39 It's also why many people think that the reason they use their drug of choice is to self-medicate anxiety or depression, because withdrawal-mediated symptoms include anxiety and depression. And when they use their drug of choice, they do feel better temporarily because it restores homeostasis. But in the end game, all they're doing is adding more gremlins to the pain side of the balance and digging themselves deeper into that reward deficit hole. And that really is important to understand because it informs how we treat addiction. What we need to do to treat addiction, first and foremost, is to restore a level balance or get folks back to homeostasis. We can do that in, in one of two ways. They can abstain for long enough for those gremlins to get the message they need to hop off and for homeostasis to be restored. And for most substances and most people, that means ten to fourteen days of acute withdrawal, where you feel like it's never gonna get any better. There's no light at the end of the tunnel. But usually by weeks three or weeks four, about eighty percent of folks will report starting to feel significantly better. The other way to restore homeostasis is to give folks some medication that we can actually put on the pleasure side of the balance that has a long enough half-life that it doesn't induce this sort of, uh, cycle of accumulating these gremlins, and that's things like buprenorphine or methadone to treat opioid addiction.

Andrew Huberman 16:03 I realize the answer to the question I'm about to ask doesn't really exist in the mechanistic neurobiological literature, but clinically speaking, I'm curious how the following scenario might work.

Dr. Anna Lembke 16:13 Mm-hmm.

Andrew Huberman 16:13 So somebody is addicted to cocaine or to gambling or to sex or to online behavior, and they come into your clinic and they say, "My life is really challenged because of this." And you say, "Okay, you're going to need to abstain, and we're going to need to give you some other supports in that time." Social connection, you know, uh, somebody else in the sobriety community. Maybe you think about what led you to this, et cetera, et cetera.

Dr. Anna Lembke 16:40 Right.

Andrew Huberman 16:41 That all seems great, but it also seems problematic based on the model you described, because some of those things are also going to give some dopamine reward. Maybe the person also says, "Listen, I can abstain from, uh, high potency THC edibles and online behavior, but I, I need nicotine."

Dr. Anna Lembke 16:57 Mm-hmm.

Andrew Huberman 16:57 "I need the nicotine."

Dr. Anna Lembke 16:59 Mm-hmm.

Andrew Huberman 16:59 Or, "I'm gonna start the nicotine to kind of get me over the bump."

Dr. Anna Lembke 17:01 Right. Right.

Andrew Huberman 17:02 Nicotine tickles this dopamine pathway. It puts, you know, some, some weight on that side of the scale, so to speak. So the question is, if somebody's trying to get away from a certain unhealthy addictive behavior-

Dr. Anna Lembke 17:14 Right

Andrew Huberman 17:14 ... do they need to abstain from other dopamine-inducing behaviors, even if they aren't life-threatening, career-threatening, even if they aren't currently addicted to them?

Dr. Anna Lembke 17:23 Right. So great, great question. Let me back up a little bit and just say, so if somebody comes in and they says, uh, they say, "I'm addicted to X, Y, or Z," the first thing out of the gate is not, "Okay, you need to abstain from that." So, so just to make it very clear, we, we establish a therapeutic alliance. We discuss, you know, their use, the impact that it's had on their lives. We talk about, uh, you know, some of the basic neurobiology, and then we sort of find out where they are and what their motivation and their degree of confidence. So just want to say that. And, and in our outpatient setting, if someone had repeatedly tried to quit on their own and been unable to, we, we wouldn't just say, "Well, try again." We would say, "Hey, maybe you need a higher level of care," something like an intensive outpatient treatment or maybe a residential treatment. So just to, you know, make sure that your listeners know, like, these are nuanced conversations.

Andrew Huberman 18:10 Mm-hmm.

Dr. Anna Lembke 18:11 But to get to your point, all reinforcing substances and behaviors do work on the same final common pathway, and dopamine has become a kind of common currency for measuring the addictive potential of many different substances and behaviors. They all have their own unique chemical cascade, but they all ultimately will release dopamine in the nucleus accumbens. Now, clinically speaking, y- you would think that if somebody was using nicotine, alcohol, and cannabis and was just willing to give up one of those, that it wouldn't have, like, a restorative impact because you've got the other things going on. But it turns out, clinically, what we see is even if they're only willing to give up, let's say, nicotine, which is a common scenario, like, you know, "I'm not gonna give up my cannabis, but I want to stop nicotine products," as long as they don't replace it with something else or escalate their cannabis use or escalate their alcohol use or start, you know, uh, compulsively watching pornography or what have you, as long as they really just remove that thing, we see improvements.

Andrew Huberman 19:13 Hmm.

Dr. Anna Lembke 19:13 We see improvements. So there, there is this sort of fine-tuning that goes on, and we will totally meet patients where they are and say, "Hey, what are you motivated to tackle? What's the most problematic in your life?" Now, w- where we will make exceptions to this is, number one, if a patient just wants to give them all up at once, which we sometimes see, and there's data to support doing that. So for example, there are studies showing that for people who are addicted to alcohol and nicotine products who give up both at the same time compared to people who just give up alcohol but keep smoking, if you follow them prospectively, the people who gave up both at the same time tend to have better outcomes, which is-- you know, makes sense from-

Andrew Huberman 19:56 Mm-hmm

Dr. Anna Lembke 19:56 ... like, the neuroscience perspective, right? 'Cause you're now not constantly pinging your reward pathway with any really potent intoxicant. So we will ask people to give up more than one substance if they're obviously paired. So for example, if drinking coffee is almost always followed by craving for a cigarette, then we might ask them to give up caffeine and the cigarettes, you know, for this period of time. The other thing is that we introduce it really as an experiment. We invite them to be the scientists in their own lives and to give it up for 30 days, not a lifetime. Why 30 days? Because on average, that is the amount of time it takes to begin to reset reward pathways.

Andrew Huberman 20:37 Yeah, what I'm trying to understand, I think many people ask me about this-

Dr. Anna Lembke 20:41 Hmm

Andrew Huberman 20:41 ... is if I'm trying to move away from a particular compulsive or addictive behavior-

Dr. Anna Lembke 20:47 Right

Andrew Huberman 20:47 ... what do I need to be mindful about in other areas of my life?

Dr. Anna Lembke 20:51 Right.

Andrew Huberman 20:52 Now, some of that's obvious, right?

Dr. Anna Lembke 20:53 Mm-hmm.

Andrew Huberman 20:53 Work, social connection, sleep, exercise, all of these things we know are healthy.

Dr. Anna Lembke 20:57 Right.

Andrew Huberman 20:57 We should continue to do those-

Dr. Anna Lembke 20:58 Right

Andrew Huberman 20:58 ... as much as possible. But replacement behaviors, in my completely naive, uh, clinical expertise, because I have none, uh, truly-

Dr. Anna Lembke 21:07 [laughs]

Andrew Huberman 21:07 Um, it is very common. Like, you go to a 12-step meeting, uh, let's just say you used to see a lot of smoking, now you see a lot of, uh, oral nicotine use.

Dr. Anna Lembke 21:16 Mm-hmm.

Andrew Huberman 21:16 You see a lot of tattoos. You see a lot-- [laughs] Now, there's some other things going on there, but there's this idea that everybody is going to be addicted to something.

Dr. Anna Lembke 21:24 Mm-hmm.

Andrew Huberman 21:24 And you just need to carefully pick your something.

Dr. Anna Lembke 21:26 Recovery is going to be something different for everybody. The philosophy in 12-step recovery is that even if you abstain from all the intoxicants, you're not really in recovery if you're not practicing a values-based life-

Andrew Huberman 21:42 Mm-hmm

Dr. Anna Lembke 21:43 ... if you're not following the 12 steps. There's this whole notion of the dry drunk, where you may not be using any intoxicants at all and be completely abstinent, and yet if you are still enacting your sort of narcissistic pathology, then you're not in recovery. So that's a very, let's say, like, philosophical and spiritual definition of addiction. And so, yes, I mean, do- Dopamine Nation is all about the, that we live in a drugified world, that almost everything has become more accessible, more reinforcing, more, more plentiful, you know, making us all more vulnerable to the problem of addiction. But I still think the aspiration is not just to move from, you know, one addiction to another, although that's very common, this Whac-A-Mole problem, but really to kind of get at those core behaviors that drive compulsive reuse a- and try to get ourselves out of that addiction vortex. So, you know, the, the dopamine fast or the 30 days of abstinence, you know, or the, or the stopping using substances is really just the first step. I mean, recovery is ultimately about so much more than that, and it, it really is a biopsychosocial spiritual disease, and so we have to intervene at all of those levels.

Andrew Huberman 23:00 If our circuitry is primed for this, like we, we-- we're in a world that's filled, uh, with things that can easily tap into these dopamine reward and motivation circuitries, that we really are all walking around sort of lured to this or to that, and that people find their thing. It's just a question of whether or not you can find something that's not detrimental to self or others. Like it-- Now you can gamble online so easily.

Dr. Anna Lembke 23:26 Right.

Andrew Huberman 23:26 Pornography is readily accessible.

Dr. Anna Lembke 23:28 Right.

Andrew Huberman 23:28 Um, social media is socially acceptable, and it's become the mainframe for, um, interaction among humans, at least a certain generation of humans. So how are we supposed to navigate in this world, uh, given that the circuitry's within us, there's no escaping that, the lures are everywhere, and in some sense, the algorithms and just our, our deficits in life as, as well as what we're drawn to, um, basically set us up to engage in things until they become too much? I mean, is, is this part of everybody's life arc to figure out what your tripwire is and then get over it, and then that's the j- is this part of the hero's journey?

Dr. Anna Lembke 24:06 I think we are all struggling with some form of compulsive over- overconsumption in the modern age because everything has been drugified. I mean, I've called it the, the modern plague. I've called addiction the modern plague, and I think that's accurate. I think if you look in the foreseeable future, you know, fifty, a hundred, five hundred years, we're living in a world of plenty. Um, more and more machines will be doing our work. People will progressively have more leisure time, more disposable income, more access to luxury goods, even for the poorest of the poor. And so the question then becomes: What do we do with ourselves? And the hope had always been that we would sit around and have deep philosophical discussions and clean up, you know, the garbage in the planet and help each other, but it looks like we're mostly just, um, you know, masturbating to images online, um, some version of that. So it, it, it's a, it's a very important question, you know, beyond the question of just the mechanics of early recovery and abstaining, sort of what, what then? What then? And it is why I think this spiritual element in particular is so important. First of all, there are m- many people with severe addiction for whom the spiritual transformation was the only way that they were able to get into recovery. Without that piece, it would have been impossible for them. And I think many humans are dealing with, uh, the problems that people with addiction are, are dealing with. You know, um, as my friend Kent Dunnington has said, that people with addiction are, are modern-day prophets because they show us who we really are. And I would add to that, that people with addiction who can get into recovery in this world really do have a wisdom that we could all learn from because we are living in a drugified world. And this is, again, where I think this, the spiritual piece, however we define that pathway. You know, in 12 Steps, it's-- the, the, the essence of it really is acknowledging that we don't have control, uh, over our addictive behaviors and many other things, conceiving of a power greater than ourselves, however you define it, as long as it's not you. And then finally, you know, being willing to give our will over to that power in the hopes of, uh, being restored to sanity. And I really like that phrasing because it suggests that we were once sane and that we can be restored to being sane, and that that's part of the journey. So I do think that that sort of deeper meaning and purpose in the spiritual pivot is, is really essential.

Andrew Huberman 26:40 I want to talk about your new book, A Radical Surrender, and I want to talk about the spirituality piece. But before I do that, I, I want to just, um, ask your opinion about two areas, uh, related to addiction that we see a lot of, uh, online. One is there's a clip out there now, and I entirely believe that this was his experience because he's self-reporting it. Ben Affleck is, was talking about getting over, I think it was alcohol addiction.

Dr. Anna Lembke 27:06 Yeah.

Andrew Huberman 27:06 He's been asked several times, you know, "What allowed you to finally do that?" And he just said, "Well, the consequences just finally became intense enough, scary enough that you just won't stand for it anymore." So it's perhaps an interesting window into this process and the dopamine circuitry and, and, and what's required to exit the addictive cycle once and for all. The other thing that we hear is that childhood trauma and early events and family structures and, um, and their deficits are at the root of all of it. And I realize none of this is mutually exclusive with the model that-

Dr. Anna Lembke 27:41 Right

Andrew Huberman 27:41 ... you presented, but there does seem to be a, a sort of divide in the public understanding and belief about addiction-

Dr. Anna Lembke 27:50 Hmm

Andrew Huberman 27:50 ... where many people feel like, oh, no, you know, it's-- this is all the, the, um, playing out of an unhealthy narrative that occurred early. If we can understand that early set of dynamics, then we can escape the addictive cycle.

Dr. Anna Lembke 28:04 Right.

Andrew Huberman 28:04 So I'd like to know if that's true or not, sometimes, oftentimes, always, never. And I also think that Ben's description is really important because at the end of the day, even if one incorporates a higher power in order to move through addiction, there's this piece of like, enough. Enough is enough.

Dr. Anna Lembke 28:24 Mm-hmm.

Andrew Huberman 28:24 And that can come from the outside many-

Dr. Anna Lembke 28:26 Mm. Yeah

Andrew Huberman 28:26 ... many times, but ultimately, the person has to do it for themselves. So just like a- any thoughts on that or reflections about what could be going on with enough is enough and with trauma and, in particular, early childhood trauma as it relates to addiction?

Dr. Anna Lembke 28:43 Yeah. So there's lots of evidence showing that childhood trauma is a significant risk factor for addiction. It's very clear that if you are raised in a home where you experience physical, sexual, emotional abuse, neglect, chaos, you are at increased risk for all kinds of mental and physical health consequences, including addiction. I also really appreciate a rat experiment where a rat is trained to know that if it presses a lever, it will get cocaine. Most rats will then press that lever till exhaustion or death. But if the cocaine is taken away, eventually that behavior will extinguish. The rat will stop pressing the lever. It will go off and do other things. If you then expose that rat to a very painful foot shock, the first thing the rat will do is run back and, and start pressing the lever again. In other words, not only can stress, and childhood stress in particular, be the progenitor Of developing addiction later in life. But in the midst of trying to recover or of recovery itself, if you're exposed to a very extreme stressor, those neural networks are highly sensitive. They may die down, but the embers are still there, and they can easily get reactivated by stress and trauma. So super important to acknowledge that risk factor. But there are also other risk factors. There are genetic risk factors, right? So if you have a biological parent or grandparent with an alcohol use disorder, you are at increased risk to develop an alcohol use disorder, even if you're not raised in an alcohol-using home. There are access risk factors, so-- And that, that's one of the main focuses of Dopamine Nation. Like, simply having access to a drug means you're more likely to use it, more likely to change your brain in the process, and more likely to get addicted. Which is also why addiction doesn't discriminate. Like, you can have the perfect family, the near-perfect childhood, you can have a great job, you can have great friends, and you can still get addicted because you're surrounded by addictive substances and behaviors, which, once you use them, will change your brain into this very specific physiologic, uh, you know, phenomenon. So, uh, you know, these, these two things exist simultaneously. I think the danger that can happen and, and, and in my career span was very common, is that you have psychiatrists and psychologists and man-many different types of mental health providers who aren't very well trained in addiction, so don't know much about it, don't want to ask about it because they haven't learned much about it and don't have the tools to intervene. And so when a patient presents with a substance use disorder or behavioral addiction, we'll spend a, a lot of time trying to find the reason behind the addiction. And that is not productive, especially not initially, when that person is deep in their addiction. For people to really be able to process the trauma that might be contributing to the addiction, they first need to get into at least early re-recovery, get back to homeostasis, get their prefrontal cortex back online, not be constantly craving and dysregulated, and then they can ga-engage i-in the trauma work. The other thing, too, that I think is, is-- happens with the narrative of addiction, and this is just very common, 'cause I've been listening to many narratives, you know, over many years. When people are in their addiction, they are very quick to blame others for their problems and not take responsibility themselves, and which is why the 12 steps can be so effective, especially, you know, your own, uh, sort of character inventory. What did, what did I contribute to the problem, right? Forcing people to look at what they contributed as part of the 12 steps, even if the only thing they contributed was just showing up or maybe repeating the same patterns and not changing them from patterns, maladaptive patterns from childhood. It's really important to acknowledge that that kind of victim narrative is just not productive for getting into recovery. It's important to process the trauma. It's important to know, you know, when you've been wronged, where and how. But it's equally important to know what you've contributed, how you are perpetuating the problem, a-and to move on from there. Now, getting to, uh, the idea of consequences. I-I don't know if you've seen this, a great Key & Peele sketch where [laughs] It, uh, uh, I don't remember the details exactly, but, uh, w- Key or Peele or one of them, you know, he's getting up there, and he's talking to a-- He's, like, in re-- I guess he's in recovery, and he's talking to a bunch of high school students. And he's talking about, "Yeah, the only way to get into recovery is consequences." And then at one point, a big wrecking ball comes in and, like, hits him. And he's, "See, I told you, consequences." Anyway, I'm probably butchering the scene, but I, I just found it hilarious. Practically speaking, in the reality of treating addiction, m-many people with severe addiction do not get into recovery until they have serious consequences. And I think part of the phenomenon there is because the brain is just very masterful at minimizing consequences related to addictive behaviors. So we just-- What, like, whatever happens, you know, a DUI, a car crash, a lost relationship, uh, you know, pancreatitis, our brain just does this clickety, clickety click. Some weird, really weird mental math that's like, "Well, it's, it's actually okay," or, "It's not really, you know, the substance," or, "It wasn't really related to that behavior." We're just really, really good at that. You know, it's called denial, as you know, and it's incredibly powerful. And at some point, after a certain number of consequences, the denial just crumbles, and this is, uh, commonly referred to as, you know, hitting, hitting rock bottom. It's just-- It's a moment where you get and you're just like, "Okay, I, I can't pretend that this isn't happening anymore." And for some people, that place is just, like, the expression on their loved one's face when they're caught using late at night when they were pretending that they were, you know, sober. And just the expression of the loved one. For other people, they, you know, they, they're home-- They gotta end up homeless or in jail or bankrupt or much more significant consequences before. So people are different. You got your high bottoms, your low bottoms. But the bottom line is everybody sort of has that moment where it's like, "Okay, the-- Like, I, I just can't do this anymore."

Andrew Huberman 35:03 I don't know if there are any data on it, but do interventions work?

Dr. Anna Lembke 35:06 There are wonderful intervention-interventionists out there. Many of them are people who have, um, you know, struggled with addiction themselves, and they can be very helpful, yeah, especially when they come into a home where parents are really struggling with a child, either an adult child or a minor, and just at their wit's end, um, to try to, you know, extract some kind of behavior change. Especially since, again, with these computers and the digital medium, you know, people, kids can just stay in their rooms and stay at home and sort of, you know, engage in this sort of constant looping, sort of self-titillation and not emerge. And parents very often can be held hostage to that.

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Andrew Huberman 37:00 subscription. Let's talk about surrender and spirituality and everything that goes with surrender. I can't remember if the story was at a particular stage or not the last time we spoke on this podcast, but I do recall sharing a story, it's a true story, about a, a friend who was badly addicted to drugs and alcohol and had gone through multiple relapses, gone to, um, various private clinics, uh, like, had tried so many different things, and I think I asked you, like, "Do you just give up?" Right? "Do you just give up?" That story ended up in a pretty wild place. Um, he, uh, he won't mind me sharing this, um, I checked with him. One of their kids had gotten into a stash. There was a whole mess. Like, it was like ch- it was like, this is it, or I'm taking the kids, I'm going.

Dr. Anna Lembke 37:51 Right.

Andrew Huberman 37:51 That's it. That's it. He ended up, um, going to a place where the entire treatment was, uh, faith-based.

Dr. Anna Lembke 38:01 Mm-hmm.

Andrew Huberman 38:02 And I remember when he told me he was headed off there, I was like, "Okay, this is, like, [clears throat] like, no." He went there for a week or so, um, came out. Um, that was something like f- four and a half years ago. He's actively in 12 step, and that's keeping him going.

Dr. Anna Lembke 38:21 Right.

Andrew Huberman 38:22 Um, never seen him or his family in better shape. It's super impressive.

Dr. Anna Lembke 38:27 Mm-hmm.

Andrew Huberman 38:28 So I ate my words.

Dr. Anna Lembke 38:29 [laughing]

Andrew Huberman 38:30 Uh, there's something there.

Dr. Anna Lembke 38:32 Yeah.

Andrew Huberman 38:32 Something happened.

Dr. Anna Lembke 38:33 Yeah, yeah.

Andrew Huberman 38:33 So the question is, what happened? We know what would've h- needed to happen for the circuitry.

Dr. Anna Lembke 38:39 Right.

Andrew Huberman 38:39 But clearly, something worked that hadn't worked a- anywhere else, any way else, and it was really bad. It was like re- it was as bad as it could get.

Dr. Anna Lembke 38:49 Yeah.

Andrew Huberman 38:50 And th- he had wra- wrapped his truck around a pole at 7:00 a.m.-

Dr. Anna Lembke 38:53 Mm-hmm

Andrew Huberman 38:53 ... after taking pills. This was prior to that.

Dr. Anna Lembke 38:56 Mm-hmm.

Andrew Huberman 38:56 I mean, he'd had so many of these-

Dr. Anna Lembke 38:58 Right

Andrew Huberman 38:58 ... in the short time that I'd known him, and, and now it's been a long time. So I'm like, "Man, that is awesome." When I ever see him, I'm like, "So great." And he's just like, he will tell you, like, I'm, I mean, this isn't propaganda for me. He'll tell you, God, Jesus got him sober.

Dr. Anna Lembke 39:12 Mm-hmm.

Andrew Huberman 39:12 And I'm like, "So what the heck's going on?"

Dr. Anna Lembke 39:15 Yeah, I mean, it, it is fascinating, and in my career, I have seen that many times over, um, you know, eith- either through 12 step or many different types of religious practices, people who couldn't get into recovery in any other way, and then this, this spiritual pivot, um, just became key for them. And I think the core of understanding this phenomenon is to appreciate that in the severest cases of addiction, people are not actually addicted to that substance or that behavior. What they're addicted to is control. So we evolved over millions of years of evolution to reduce uncertainty, and it's what's kept us alive in a chaotic and dangerous world full of famine, flood, fire. We are born with a mental model of the world, what I'll call a mind map. Um, our mind map is different from the mind map of a fish, so we're not, we're not born with tabula rasa. It's not just a, a blank slate. We a- already have an elaborated series of neural networks that prepare us to anticipate the world that we live in as human beings. And as we grow and develop and have human experiences, we're constantly predicting what will happen in the world, and when our predictions are right, that feels good and is reinforcing. It releases dopamine, right? And when our predictions are wrong, we have really one of two choices. We can update the map, or we can update the world. Now, updating the world takes an interesting form. It's a way of further foraging and seeing if maybe I need to collect more data. It's a way of redirecting our attention, uh, so that now we're attending to things that match with our mental model. But the bottom line is that we're constantly seeking to assert control and reduce uncertainty, and it's adaptive, and it's what's kept us alive. What has happened in the modern world is that we have developed so many levers to control our experience that we have become addicted to control itself. So we are constantly optimizing, right? We're relationship maxing. We're career maxing. We're looks maxing. We're counting our steps, our sleep, our accomplishments, our calories, other people. We're trying to engineer perfection and get the perfect mental model of the world to the point where Our efforts to exert control are now quite divorced from what is actually happening in the world, and addiction is the quintessential example of that. Through my addictive behaviors, I can create this world within a world where my focus narrows. I-- Everything else falls away. I've simplified things. I just have this one lever, like a rat in a cage, and as long as I can press that lever, I know I can change the way that I feel. Now, as the disease progresses, my drug stops working, and maybe I even feel worse when I use it, but it doesn't matter because I'm in control of changing the way that I feel in that moment. It's like with gambling addiction. People think that people who get addicted to gambling are addicted to money. They're not addicted to money. They're addicted to the game, which is why loss chasing happens, where pathological gamblers will tell you that a part of them actually wants to lose because they know when they lose, they have a justification to stay in the game longer. The game is a world. It's a world within a world where I am God. I press the lever. I control on this minuscule level, and it's distorted, and it's messed up, and the rest of my [laughs] life is going to hell. But right here and right now, everything's simple. I have that feeling of grip. I'm exercising control. This is all by way of saying that i-in my opinion, it's not only people with, you know, classic addictions who are struggling with this addiction to control, but it's all of us now. Again, because we have so many levers for control, we've made ourselves masters of the universe. We, we exert our will over material reality in every way, and as a result, we are much more miserable. So, for example, what I see in clinical care, especially among young people, is incredibly anxious people who hate themselves. Why are they anxious? They're terrified they're going to choose wrong and end up missing out on their best life. It's a constant FOMO. It's like, "Oh, but, but if I choose this career, then I'm-- maybe that-- I-- maybe I should be going to this career." It's this idea, if I am the only arbiter of my destiny, then, like, what if I mess it up? It's all on me. So there's terror and anxiety, and there's also this illusion that, well, because we can control so much, we should be able to get it perfectly right, such that any fall from perfection, people are just filled with self-loathing shame. There's no sacred ballast of sort of forgiveness or grace. It's like, "I messed up. I messed up my life." And of course, with the internet, our shame has legs. It ricochets all around the world. And, you know, very sadly, you know, working at a, at a prestigious university, I see, you know, young people with all the promise, all the gifts, who end their own lives in the wake of what a generation ago would've been a disappointment, but not a life-threatening one, right? A, a, a grant not received, a social rejection, an, an academic reprimand. Young people taking their own lives because the shame and the self-loathing in a world in which we're expected to manipulate our experience to achieve perfection, it's too much. We, we've lost our tolerance for imperfection. We've lost our tolerance for uncertainty. Now, just not getting the right, you know, soy mocha latte in the morning sends us for a tailspin. And that all leads to ultimately what is, what is the answer to that? What is the antidote? It's the spiritual pivot. It is radical surrender. It's acknowledging the limits of what we can control, giving that will over however we define it, and merging with our lives unfolding rather than trying to engineer some future perfection.

Andrew Huberman 45:58 Incredible. I've never thought about this, uh, addiction to control. Some years ago, you told me something that, uh, really stuck in my mind and made me, uh, kind of take a look at myself for a moment [laughs] where you said that addicts like to, like, line up their pills or kind of count their, their, uh, bags. I've never been a powder taker, uh, except creatine. Um-

Dr. Anna Lembke 46:20 [laughs]

Andrew Huberman 46:21 I, I confess. I confess. It's bettered my life. You do you, but it's bettered my life. And this need to quantify.

Dr. Anna Lembke 46:27 Hmm.

Andrew Huberman 46:28 And I was just thinking about that for a moment in light of what you just said, because that behavior could be viewed as you're, you're establishing some certainties about the future. "I know I've got this. I can get into a certain feeling state if I need to. I can do that, you know, X many days apart if I need to extend it." You know, the-

Dr. Anna Lembke 46:46 Right

Andrew Huberman 46:46 ... the fear of, you know, basically not being able to control one's future state.

Dr. Anna Lembke 46:51 Right.

Andrew Huberman 46:52 You know, for many years, uh, before it became essentially legal or decriminalized, I had friends that, uh, were pretty chronic, uh, cannabis users.

Dr. Anna Lembke 47:00 Mm-hmm.

Andrew Huberman 47:00 And they didn't re-really meet the, you know, classic definition of addiction. But then I would always just say, "Well, how do you do when you travel?" And they're like, "Not well, but I, you know, like, take-- put it in my shoe." This is before edibles became really common, right?

Dr. Anna Lembke 47:14 Okay. Okay. [laughs]

Andrew Huberman 47:15 You know, so, like, they, they were basically telling me that they, they could do fine without it-

Dr. Anna Lembke 47:18 Mm-hmm

Andrew Huberman 47:18 ... but they just don't do without it.

Dr. Anna Lembke 47:19 Right. Yes.

Andrew Huberman 47:20 And, and I found them to be-

Dr. Anna Lembke 47:21 They could do fine without it until they actually had to go without it.

Andrew Huberman 47:23 Exactly.

Dr. Anna Lembke 47:24 Right. Right.

Andrew Huberman 47:24 Exactly. So they're, you know, and they were pretty irritable if they-

Dr. Anna Lembke 47:28 Mm-hmm

Andrew Huberman 47:28 ... hadn't had it or if they weren't certain when they could.

Dr. Anna Lembke 47:32 Right.

Andrew Huberman 47:32 And these extreme levels of motivation to, like-

Dr. Anna Lembke 47:34 Hmm

Andrew Huberman 47:35 ... ensure they could get high in the future-

Dr. Anna Lembke 47:37 Right

Andrew Huberman 47:37 ... came about. And I'm not trying to point fingers at them. I think we all-

Dr. Anna Lembke 47:40 Yes

Andrew Huberman 47:40 ... have components of this.

Dr. Anna Lembke 47:41 Right.

Andrew Huberman 47:42 So there are a number of things that you've said about addiction that, that weave into this control piece.

Dr. Anna Lembke 47:45 Mm-hmm.

Andrew Huberman 47:47 How is it, though, that we can separate out the healthy, mildly unhealthy, and truly unhealthy versions of this? So for instance, many people enjoy exercise, and it gives them some feeling about their body aesthetics, their future body aesthetics, their longevity, and that Could be semi-unhealthy to really unhealthy, but we're all told we need to exercise.

Dr. Anna Lembke 48:08 Right.

Andrew Huberman 48:08 So at what point are we addicted to exercise?

Dr. Anna Lembke 48:11 Right.

Andrew Huberman 48:11 If you exercise and you fulfill your job and family obligations, you're not, you know, waking up to run in the middle of the night just because-

Dr. Anna Lembke 48:18 Mm-hmm

Andrew Huberman 48:18 ... you're healthy.

Dr. Anna Lembke 48:19 Yeah.

Andrew Huberman 48:19 Are you addicted?

Dr. Anna Lembke 48:20 Mm-hmm.

Andrew Huberman 48:20 I mean, are you addicted to control?

Dr. Anna Lembke 48:22 Mm.

Andrew Huberman 48:22 And where do you draw the line? It can become a very-

Dr. Anna Lembke 48:24 Yeah

Andrew Huberman 48:24 ... jagged line, too.

Dr. Anna Lembke 48:26 Yes. Uh, and you know, I'm not sitting here in judgment of people who have highly controlled lives and are thriving and doing great. Again, we are wired to reduce uncertainty. It is completely adaptive to do that. Um, what I am talking about is the mismatch, and it's, you know, a similar argument with Dopamine Nation. The mismatch in Dopamine Nation that I talked about is this plenty paradox, where we reflexively approach pleasure and avoid pain. It works great in a world of scarcity. It's a disaster in a world of plenty. In Radical Surrender, I'm, I'm talking about a control paradox, where we evolved to reduce uncertainty in a chaotic world. That was essentially our teleologic mandate, right, or our reason for existence. If you look at active inference in the free energy principle, that is essentially the underlying theory of that neurocognitive branch of science, that we all exist to reduce uncertainty, to exert our will to predict and to control. The problem is, again, a mismatch between what is highly adaptive in an organically uncertain world and what now becomes maladaptive in a world that we've essentially paved over, right? And now we control everything. In fact, one of the big dangers, in addition to anxiety and self-loathing, is nihilistic boredom, because there's nothing that we're not in control of. So now we have nothing to exert our need to control on, right? And so what do we do in response to that? We engineer uncertainty, and this is at the heart of social media, slot machines, um, sports betting, right? Why do people love sports? And I love sports, too, so I'm not saying it's unhealthy to love sports. But it may be the last bastion where we don't know the outcome. It's genuinely uncertain. Unless they're cheating and it's rigged, it's ju- we don't know, and it's, it's complex, and it's many factors. People want to give themselves over to destiny with a capital D, right, to, to something greater than themselves. At the same time that we have a strong evolutionary psychology to control, we also have a strong need to surrender to something greater than ourselves, and both of those things coexist and may even work physiologically in our brains through an opponent process mechanism. So a lot of the, the science on this, and it's emerging science on spirituality, will tell you that our spirituality network can't actually get activated when our control network is online, because the control network is inhibiting the spirituality network.

Andrew Huberman 51:04 Hmm.

Dr. Anna Lembke 51:04 So as long as we have a way to control a situation, we're going to inhibit, for example, the peri- periaqueductal gray, which is sort of like the hub of this spirituality network. And that aligns perfectly with what you see in the last two hundred to five hundred years as we've been able to apply science and technology to exert more control over our day-to-day existence. People are moving away from spiritual practices. They're moving away from faith-based organizations. Churches and temples are being turned into nightclubs and community centers. People are becoming more and more secular. And, and yet when some crisis occurs, all of a sudden that sort of, it reignites sort of this, like, people-- Even atheists, you know, will, will pray in a moment of absolute terror. It, it's, the circuitry is there, but we don't access it on a regular basis because we're so busy trying to control our next

Dr. Anna Lembke 51:58 move.

Andrew Huberman 51:59 You mentioned periaqueductal gray. Uh, you and I are familiar with that.

Dr. Anna Lembke 52:03 Yes.

Andrew Huberman 52:03 Uh, we should probably inform the listeners and viewers about PAG, P-A-G.

Dr. Anna Lembke 52:09 [laughs]

Andrew Huberman 52:09 We first, uh, met, uh, f- 'cause we were team-teaching neuroanatomy, uh-

Dr. Anna Lembke 52:13 Yes

Andrew Huberman 52:13 ... right? And in neuroanatomy, we teach that the PAG, it, it's, it's a really cool structure, right? It's got these different kinda, like, wedges of, like, represents pain, pleasure, sensory input. It's a, kind of an integrative hub-

Dr. Anna Lembke 52:26 Right

Andrew Huberman 52:26 ... as I understand.

Dr. Anna Lembke 52:27 Yes.

Andrew Huberman 52:27 But, but that's a very superficial understanding. You'll t- you'll tell us what is known about PAG in the context of what you're talking about, and are there any components of the circuitry that make it make sense that PAG would be involved in the experience of, of spirituality or letting go of control?

Dr. Anna Lembke 52:46 Yeah. So the PAG is intimately associated with our threat response, so fight, flight, and freeze. In fact, there's a wonderful experiment where human brains are neuroimaged while playing Pac-Man, and as long as the, you know, Pac-Man enemy is far away, the prefrontal cortex, the control centers, light up. But as soon as that Pac-Man is just about to die, you know, within the presence of the ghost, the PAG just goes wild. It absolutely light- lights up.

Andrew Huberman 53:15 Hmm.

Dr. Anna Lembke 53:15 So it's very essential in the face of, like, imminent death in sort of coordinating, like, what am I doing now? And then there's a very fascinating, uh, experiment or, or series of experiments that have come out looking at lesions in humans and lesions that either increase or decrease spirituality, whether, you know, uh, parts of the brain remo- removed d-during, due to trauma or cancer or epilepsy. And what they found was that spirituality is a circuit, and the circuit, the hub of it is probably the PAG. And it makes sense that a part of the brain that's intimately associated with imminent threat and death would also be associated with spiritual surrender or, you know, letting go of control- And accessing, uh, this sort of network that essentially is going to function to allow us to come up with an entirely new approach 'cause what we've been doing hasn't been working. So the PAG is rich in, uh, mu-opioid receptors, which are our natural pain relievers. The PAG is rich in oxytocin receptors, which is our connection or love hormone. And both of those being activated then also stimulates a vast array of serotonin receptors. And serotonin, when it functions in this regard in the PAG, is essential for increasing neuroplasticity or learning in the face of rapid change. And again, getting back to addiction, what, what's happening with addiction is that we are rigidly holding onto our mental model and these control loops even when they've stopped working for us, and this is essentially the def- definition of neurosis. The definition of neurosis, I think it was Freud way back when, said, "Neurosis is doing the same action over and over again and expecting a different outcome." But that's essentially what, what addiction is, right? You're, you're, you're engaging this behavior. You can see that your life is going to hell, but somehow you keep thinking it's gonna, it's gonna be different this time. It's really in large part a function because our prediction machines or our mental models become calcified or rigidly ensconced. We're, we're too attached to them. And so we do need to, on some level, have this spiritual pivot, let go of control, hit this bottom, surrender it, give it over. The control networks finally shut down. This PAG and spirituality network, you know, comes online, and we have the ability to sort of melt down these neuronal connections and, and begin anew. And many people will talk about when they have a sort of a spiritual, let's say, awakening or just a moment of transcendence that allows them to move forward, it is as if they can perceive more, right? The, the, the leaves are greener. The sky is bluer. This is probably really happening. Like perception is enhanced. I'm no longer trying to impose my rigid mental models on the world. Instead, I'm letting go of those pres- the precision of my predictions. I'm letting that flatten, and I'm opening myself to what is really happening in the world. So it's like this embracing reality, acknowledging the limits of my will, giving it over, and then having the experience of serenity. So it is an affective experience, whether we're talking about the spiritual pivot or prayer. It's an affective experience of hope, serenity, peace, which then enables a different kind of action in the world.

Andrew Huberman 56:56 It's a, um, ceasing to, uh, rely on the algorithms, the strategies that we've been using.

Dr. Anna Lembke 57:03 Right.

Andrew Huberman 57:04 And it becomes this openness to the reality that that wasn't working.

Dr. Anna Lembke 57:10 Yes.

Andrew Huberman 57:10 Those things weren't working.

Dr. Anna Lembke 57:11 Yes.

Andrew Huberman 57:11 There's something else. I don't yet know what those new strategies are.

Dr. Anna Lembke 57:15 Yes.

Andrew Huberman 57:16 So I'm going to give it over to God-

Dr. Anna Lembke 57:18 Yeah

Andrew Huberman 57:18 ... as they say in 12-step.

Dr. Anna Lembke 57:20 Yes. I'm gonna, number one, ack- acknowledge the limits of my control.

Andrew Huberman 57:23 Mm-hmm.

Dr. Anna Lembke 57:23 So I'm gonna right-size my ego. I'm gonna acknowledge that all of these things that I'm doing, like I'm running around like a chicken with my head cut off, you know, trying to manage it 'cause, you know, it take... It's a lot, you know, i- in our disease, right? We're-- [laughs] It's, it's a constant management.

Andrew Huberman 57:37 Yeah.

Dr. Anna Lembke 57:37 And I'm just gonna stop. I'm gonna just, as one of my patients said, "I realized I was at checkmate. There were no more moves," which I just thought was a great analogy. It's like, "Yeah, it's checkmate. I'm, I, I'm out of moves." You just stop. You, you recognize the limits of your will, and you just-- That this pivot of giving it over to a power greater than ourselves. So this is the mysterious process. But again, I think we're just wired for this. We evolved for this pivot. Um, and when that happens, it, it starts a whole physiologic process which

Dr. Anna Lembke 58:08 is restorative.

Andrew Huberman 58:09 So I realize I had it completely wrong. I assumed that the potency of the giving it over to a higher power was about acknowledging our inability to strategize in, in a way that's good for us and just sort of the recognition, like, my brain can't do it on its own. I'm gonna adopt this other rule system that is not of me and make it of me.

Dr. Anna Lembke 58:35 I don't know that that's wrong. I mean, that's, that's the language that you've come up with that makes it make sense for you-

Andrew Huberman 58:41 Mm-hmm

Dr. Anna Lembke 58:41 ... um, that kind of pivot, I think.

Andrew Huberman 58:43 The place where I get stuck is everything I know to be true about the dopamine re- reward reinforcement circuitry that you've described says that giving up control ought to send somebody further down the path of addiction, not overcome it, right? 'Cause it's like, okay, let's say this had alcohol in it, and I felt like I literally couldn't help, help it. I could ask Rob to help me out.

Dr. Anna Lembke 59:06 Mm-hmm.

Andrew Huberman 59:06 I could ask you to take the cup out of the room.

Dr. Anna Lembke 59:08 Mm-hmm.

Andrew Huberman 59:08 We could talk about it.

Dr. Anna Lembke 59:08 Mm-hmm.

Andrew Huberman 59:08 We could talk about what led to, you know, a tendency to drink, but there's this kind of weird twist in all this where if I just say, "Wait a second, I can't do it."

Dr. Anna Lembke 59:16 Yeah.

Andrew Huberman 59:16 You're not here. Producer Rob isn't here, so I'm just gonna, I'm gonna give it over to God.

Dr. Anna Lembke 59:21 Yeah.

Andrew Huberman 59:22 And then suddenly, uh, and I've seen this over and over again.

Dr. Anna Lembke 59:24 Yes.

Andrew Huberman 59:25 Right? I've experienced this. Like then, then we can abstain.

Dr. Anna Lembke 59:29 Yep.

Andrew Huberman 59:29 It, it doesn't w- work with our existing models of just the dopamine reward circuitry-

Dr. Anna Lembke 59:34 Mm-hmm

Andrew Huberman 59:34 ... because it would say, like, I'm gonna take my hands off the steering wheel-

Dr. Anna Lembke 59:36 Yeah

Andrew Huberman 59:36 ... and the car's actually gonna drive better, and it's not a Tesla.

Dr. Anna Lembke 59:40 In many ways, at least when it comes to this, dopamine and serotonin work like all, like opposites, right? So, so dopamine is the ultimate gain function modulator. It's what tells your brain, "Whatever you're doing now, get more of it. Do more of it, more of that thing," and it's a very strong signal. Whereas s- whereas serotonin is the, "Oh, wait a minute, um, retreat, uh, reevaluate, and potentially find a new way around-

Andrew Huberman 1:00:04 Mm-hmm

Dr. Anna Lembke 1:00:04 ... because what you've been doing isn't working."

Andrew Huberman 1:00:07 Mm-hmm.

Dr. Anna Lembke 1:00:08 And in fact, repeated frustration or our inability to accurately predict what's coming next or to solve the problems in our lives There's a lot of evidence that shows they're characterized by the proliferation of 5-HT2A serotonin receptors. So it's almost like our brain is getting ready for this transformative moment when we finally acknowledge, "My mental maps are not working. Uh, this is not working." And it, it, it's-- and you have to come pretty low to get there 'cause nobody likes to give up control 'cause we all want more dopamine, right? We all want the gain function modulator. But that moment when we finally accept that we are not in control and we let it go, then you get a very different... I mean, first of all, there, there's, uh, maybe a spiritual thing happening-

Andrew Huberman 1:00:57 Mm-hmm

Dr. Anna Lembke 1:00:57 ... like a God thing happening, I don't know. But also, we have the natural wiring to have a very then different physiologic experience where we-- our executive function, our planning, all of that goes quiet, and you get this massive activation of serotonin, which is the downregulation of our precision predictions, right? So now we're, we're, we're saying, "Hey, my rigid mental models are not working," and it's a moment of plasticity, so it's like we're going back in time to a more open, receptive state. And you get with that, and again, a felt experience, an affective experience of analgesia, so, right, less pain, of connectedness, of the thought that where I couldn't rely on my own strength, I can rely on the strength of surrender and giving it over. And that is what allows people then, through that experience, to s- to not have that drink. They're getting the strength from the surrender itself, right? And then also, I think importantly for many people, from the handing it over, right? This idea that, okay, I'm not in control, but this higher power is, and I'm just gonna try to follow that, right? Instead of me trying to juggle 14 balls in the air, I'm, I'm gonna let them all drop, and I'm just gonna show up here, and I'm gonna do the next right thing, and I'm gonna take it one day at a time. So you also narrow the sort of scope of what you're trying to manage.

Andrew Huberman 1:02:35 The serotonin piece is really interesting. I know you have mixed, skeptical, you'll update us, feelings about the use of psychedelic medicine for, um, treatment of addiction, like taking a drug to get over drugs. But in the case of at least, let's just say, psilocybin, I mean, its main mechanism for engaging plasticity is to, you know, activate the serotonergic pathway and these particular receptors. Seems not coincidental. Um-

Dr. Anna Lembke 1:03:02 Yes

Andrew Huberman 1:03:03 ... maybe, maybe unmasking connections, maybe allowing new contingen- contingencies to be formed. But I'm also reminded, it is a really cool paper, uh, it doesn't get talked about very much, but a guy b- by the name of Lamberto Maffei did some really cool studies reopening critical period plasticity-

Dr. Anna Lembke 1:03:18 Mm-hmm

Andrew Huberman 1:03:18 ... by administering, it was rats, SSRIs.

Dr. Anna Lembke 1:03:21 Mm.

Andrew Huberman 1:03:22 And you could reopen plasticity. And I know SSRIs get a really bad rap these days. But in both cases, psilocybin and SSRIs, the net effect is increased serotonergic, uh, tone in-

Dr. Anna Lembke 1:03:33 Yes

Andrew Huberman 1:03:33 ... in the synapses.

Dr. Anna Lembke 1:03:34 Right.

Andrew Huberman 1:03:35 So, you know, love them or hate them, uh, the, the SSRIs are effectively getting to a similar-ish place of increasing serotonin and thereby plasticity.

Dr. Anna Lembke 1:03:44 So much of what we're beginning to understand about the spirituality and spiritual surrender is through the research with psychedelics and psilocybin. So that, that research is amazing. You know, people's subjective experience, I mean, I've talked to many people for whom their first access to the sacred in our secular world was through psilocybin or other psychedelic. So it, it's very clear that not only has this given us a tool to begin to understand what may be happening with spiritual surrender, but for many people, it, it's, it's a pivotal moment in their lives, life-changing and incredibly positive. My reservation just comes with, I want to make sure that people also understand the risks associated-

Andrew Huberman 1:04:30 Mm-hmm

Dr. Anna Lembke 1:04:30 ... with it and that the sort of, um, you know, the promise just doesn't get, uh, too far ahead of the, the evidence. 'Cause of course, in my clinic, what I see is people misusing and addicted to psychedelics in many different forms.

Andrew Huberman 1:04:44 Including s- uh, psilocybin?

Dr. Anna Lembke 1:04:45 Yeah, absolutely.

Andrew Huberman 1:04:46 Okay.

Dr. Anna Lembke 1:04:46 Yeah.

Andrew Huberman 1:04:46 'Cause the, the word out there is that, you know, it has a very, very high, uh, you know, lethal dose, uh, that, you know, it's far safer than alcohol.

Dr. Anna Lembke 1:04:57 Right.

Andrew Huberman 1:04:57 Um, you know, you know, barring people with, uh, you know, a predisposition to psychosis or, or mania, you know, this is kind of the, the new frontier. And, and I've, I've talked openly, I've had positive experiences with-

Dr. Anna Lembke 1:05:08 Yeah

Andrew Huberman 1:05:08 ... clinical u- use, not recreational-

Dr. Anna Lembke 1:05:10 Right

Andrew Huberman 1:05:10 ... use, but clinical use of, of psilocybin. But it is no easy ride. I mean, it's, it's an-- I mean, to be quite blunt, it's, it's an ass-kicking of a whole other kind.

Dr. Anna Lembke 1:05:18 Mm-hmm.

Andrew Huberman 1:05:18 And it involves therapy before, during, and after. And it-- I felt it benefited me tremendously-

Dr. Anna Lembke 1:05:23 Mm-hmm

Andrew Huberman 1:05:23 ... but I can think of, uh, many, many people for whom it would probably be the worst possible thing for them to do.

Dr. Anna Lembke 1:05:30 Right. It's, it's highly unpredictable is p- part of it, probably more unpredictable than other drugs. You just don't know what, what kind of response someone is going to have. And also importantly, the, the early data that was out there about saying it was much less harmful than, let's say, alcohol, was primarily attributable to the fact that not many people were using it.

Andrew Huberman 1:05:48 Mm-hmm.

Dr. Anna Lembke 1:05:49 We published a paper looking at the number of, uh, ED visits and hospitalizations as a result of hallucinogens, and what we have shown is that as use goes up, the number of ED-related harms and hospital admission-related harms also goes up.

Andrew Huberman 1:06:04 Sorry, ED?

Dr. Anna Lembke 1:06:05 Sorry, emergency department-

Andrew Huberman 1:06:06 Gotcha

Dr. Anna Lembke 1:06:06 ... harms. Yeah. So, so the, the, you know, that early narrative about it being much less harmful than other drugs, I, I don't think that's gonna pan out. And, and our studies show that it's already-- the related harms are already increasing. Uh, psychosis, you know, suicide, pers- persistent hallucinosis, uh, severe mood. So again, you know- Every drug is going to have risk, benefits, and alternatives, and I'm not sitting here saying we shouldn't study it or that there's no benefit, 'cause clearly I've met and talked to many people who have had, um, amazing benefit. But I've also talked to and seen a lot of harm. So it's just a matter of being really thoughtful about it and, and sort of following

Dr. Anna Lembke 1:06:50 the data.

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Andrew Huberman 1:08:29 So we've got this model now, if I'm not mistaken, that a lot of addiction is the need to control, sometimes so much so that it's really the thing separate from the high.

Dr. Anna Lembke 1:08:40 Right.

Andrew Huberman 1:08:40 It's the ability to get high.

Dr. Anna Lembke 1:08:42 Yeah.

Andrew Huberman 1:08:42 It's the ability to, um, control the sleep score-

Dr. Anna Lembke 1:08:45 Right

Andrew Huberman 1:08:45 ... dare I say.

Dr. Anna Lembke 1:08:46 Right. [laughing]

Andrew Huberman 1:08:47 I don't know that-- I know a few people for whom their, you know, their, um, commitment to, for lack of a better word, protocols, uh, has taken them away from life. I mean, I get asked about this a lot. I think that the line at, between optimization, a healthy life, and over-optimization is just all of the practices are so that you can lean into the rest of your life-

Dr. Anna Lembke 1:09:06 Yeah

Andrew Huberman 1:09:06 ... with more vigor and for longer-

Dr. Anna Lembke 1:09:08 Right, right

Andrew Huberman 1:09:08 ... and more presence.

Dr. Anna Lembke 1:09:08 Yeah.

Andrew Huberman 1:09:08 And like that's all-- the whole purpose of a good night's sleep is not just to get another good night's sleep.

Dr. Anna Lembke 1:09:12 Yeah.

Andrew Huberman 1:09:12 But with that said, it seems that the PAG gets activated when we run out of options. Nothing's working.

Dr. Anna Lembke 1:09:19 Right. Mm-hmm.

Andrew Huberman 1:09:20 Then serotonin-related mechanisms and other neuromodulators help our brains come up with new, new plans that might work.

Dr. Anna Lembke 1:09:32 Yeah.

Andrew Huberman 1:09:33 But the only way to take that step is in acknowledging that what I've been doing hasn't worked, and the new plan is gonna come... The word surrender kinda makes it seem like it's, it's gonna come from out there.

Dr. Anna Lembke 1:09:44 Mm-hmm. Right.

Andrew Huberman 1:09:45 Not, not from the PAG-

Dr. Anna Lembke 1:09:47 Mm-hmm, mm-hmm

Andrew Huberman 1:09:47 ... but from out there.

Dr. Anna Lembke 1:09:48 Yeah.

Andrew Huberman 1:09:48 But you're saying in a, in the strictly neurobiological model, the PAG is actually, like, offering up new opportun- new strategies to try. Like, "Hey, maybe try this strategy instead."

Dr. Anna Lembke 1:09:59 Well, I mean, I, I think, you know, in talking about the PAG and serotonin and psychedelics and what's happening in the brain, all we're really saying is that there's a, there's a neurobiological machinery that gets activated in this moment of spiritual surrender and in surrendered practices, right? So, like, w- in, in prayer focused on surrender, again, the prefrontal cortex goes quiet. Uh, the PAG and other related structures become activated, possibly in, like, an opponent process mechanism. That in and of itself is not a commentary on whether or not there is a higher power who's actually, you know, involved in providing wisdom and guidance. I think the subjective experience is very much that we are opening ourselves up to guidance from a higher power, and people will talk about getting that wisdom and getting that guidance, um, and even, you know, hearing the voice of, you know, their higher power, however they conceive of that. And it's such a subjective thing. And m- for many people, their higher power is simply nature or the cosmos or the beauty and mystery of the universe, and that's not... You know, they may talk to nature, but that's because we're human and that's how we interrelate, not because they think that their higher power is human, right? So these are all very personal, subjective, and I mean, I have a lot of respect and honor for w- however people are conceiving of, of their higher power. What I think is really salient for me, having grown up in a secular household, having practiced psychiatry, being in, you know, the bastion of science and rational materialism, is that this sort of inward-looking reflection, which is so predominant in mental health treatment, this sort of like, "If I look inward far enough and know myself well enough and find my authentic self, I'll find the answers there," and for me personally, that was helpful to a point but was not helpful when I was faced with, like, a serious existential crisis in the form of, as I talk about in "Radical Surrender," our son being diagnosed with and dying from leukemia. Like, the-- I did many hours of psychotherapy. I read every paper there was on, you know, Q, Q two three translocation congenital leukemia. That was empty for me, and it really wasn't until I got to this point of sort of a spiritual pivot and say, "I'm not in control, and no other human being can tell me why this happened. You know, I'm going to surrender my attempts to over-manage this situation, and I'm just going to instead sort of just show up for life and see what happens." And in my life, that has made all the difference. So, you know, my sort of rock bottom, so to speak, was, was different maybe from someone with severe addiction and yet really quite similar because in many ways prior to that moment, I also was addicted to control, to achievement, to optimization. I was going to tell my husband how he should grieve, you know, in the wake of that loss, and we were gonna have another baby right away and replace the baby that we lost.