Dopamine Nation
Anna Lembke, MD
Dopamine Nation – This book is about pleasure. It’s also about pain. Most important, it’s about the relationship between pleasure and pain, and how understanding that relationship has become essential for a life well lived.
Why?
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.
Scientists rely on dopamine as a kind of universal currency for measuring the addictive potential of any experience. The more dopamine in the brain’s reward pathway, the more addictive the experience.
In addition to the discovery of dopamine, 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.
We’ve all experienced that moment of craving a second piece of chocolate, or wanting a good book, movie, or video game to last forever. That moment of wanting is the brain’s pleasure balance tipped to the side of pain.
This book aims to unpack the neuroscience of reward and, in so doing, enable us to find a better, healthier balance between pleasure and pain. But neuroscience is not enough. We also need the lived experience of human beings. Who better to teach us how to overcome compulsive overconsumption than those most vulnerable to it: people with addiction.
This book is based on true stories of my patients falling prey to addiction and finding their way out again. They’ve given me permission to tell their stories so that you might benefit from their wisdom, as I have. You may find some of these stories shocking, but to me they are just extreme versions of what we are all capable of.
As philosopher and theologian Kent Dunnington wrote, “Persons with severe addictions are among those contemporary prophets that we ignore to our own demise, for they show us who we truly are.”
Whether it’s sugar or shopping, voyeuring or vaping, social media posts or The Washington Post, we all engage in behaviors we wish we didn’t, or to an extent we regret.’
This book offers practical solutions for how to manage compulsive overconsumption in a world where consumption has become the all-encompassing motive of our lives.
In essence, the secret to finding balance is combining the science of desire with the wisdom of recovery.
PART I
The Pursuit of Pleasure
Our Masturbation Machines
I went to greet Jacob in the waiting room. First impression? Kind. He was in his early sixties, middleweight, face soft but handsome . . . aging well enough. He wore the standard-issue Silicon Valley uniform: khakis and a casual button-down shirt. He looked unremarkable. Not like someone with secrets.
As Jacob followed me through the short maze of hallways, I could feel his anxiety like waves rolling off my back. I remembered when I used to get anxious walking patients back to my office. Am I walking too fast? Am I swinging my hips? Does my ass look funny?
It seems so long ago now. I admit I’m a battle-hardened version of my former self, more stoic, possibly more indifferent. Was I a better doctor then, when I knew less and felt more?
We arrived at my office, and I shut the door behind him. Gently, I offered him one of two identical, equal-in-height, two-feet- apart, green-cushioned, therapy-sanctioned chairs. He sat. So, did I. His eyes took in the room.
My office is ten by fourteen feet, with two windows, a desk with a computer, a sideboard covered with books, and a low table between the chairs. The desk, the sideboard, and the low table are all made of matching reddish-brown wood. The desk is a hand-me-down from my former department chair. It’s cracked down the middle on the inside, where no one else can see it, an apt metaphor for the work I do.
On top of the desk are ten separate piles of paper, perfectly aligned, like an accordion. I am told this gives the appearance of organized efficiency.
The wall décor is a hodgepodge. The requisite diplomas, mostly unframed. Too lazy. A drawing of a cat I found in my neighbor’s garbage, which I took for the frame but kept for the cat.
A multicolored tapestry of children playing in and around pagodas, a relic from my time teaching English in China in my twenties. The tapestry has a coffee stain, but it’s only visible if you know what you’re looking for, like a Rorschach.
On display is an assortment of knickknacks, mostly gifts from patients and students. There are books, poems, essays, artwork, postcards, holiday cards, letters, cartoons.
One patient, a gifted artist and musician, gave me a photograph he had taken of the Golden Gate Bridge overlaid with his hand-drawn musical notes. He was no longer suicidal when he made it, yet it’s a mournful image, all grays and blacks.
Another patient, a beautiful young woman embarrassed by wrinkles that only she saw, and no amount of Botox could erase, gave me a clay water pitcher big enough to serve ten.
To the left of my computer, I keep a small print of Albrecht Dürer’s Melencolia 1. In the drawing, Melancholia personified as a woman sits stooped on a bench surrounded by the neglected tools of industry and time: a caliper, a scale, an hourglass, a hammer. Her starving dog, ribs protruding from his sunken frame, waits patiently and in vain for her to rouse herself.
To the right of my computer, a five-inch clay angel with wings wrought from wire stretches her arms skyward. The word courage is engraved at her feet. She’s a gift from a colleague who was cleaning out her office. A leftover angel. I’ll take it.
I’m grateful for this room of my own. Here, I am suspended out of time, existing in a world of secrets and dreams. But the space is also tinged with sadness and longing. When my patients leave my care, professional boundaries forbid that I contact them.
As real as our relationships are inside my office, they cannot exist outside this space. If I see my patients at the grocery store, I’m hesitant even to say hello lest I declare myself a human being with needs of my own. What, me eat?
Years ago, when I was in my psychiatry residency training, I saw my psychotherapy supervisor outside his office for the first time. He emerged from a shop wearing a trench coat and an Indiana Jones–style fedora. He looked like he’d just stepped off the cover of a J. Peterman catalogue. The experience was jarring.
I’d shared many intimate details of my life with him, and he had counseled me as he would a patient. I had not thought of him as a hat person. To me, it suggested a preoccupation with personal appearance that was at odds with the idealized version I had of him. But most of all, it made me aware of how disconcerting it might be for my own patients to see me outside my office.
I turned to Jacob and began. “What can I help you with?”
Other beginnings I’ve evolved over time include: “Tell me why you’re here,” “What brings you in today?” and even “Start at the beginning, wherever that is for you.”
Jacob looked me over. “I am hoping,” he said in a thick Eastern European accent, “you would be a man.”
I knew then we would be talking about sex.
“Why?” I asked, feigning ignorance.
“Because it might be hard for you, a woman, to hear about my problems.”
“I can assure you I’ve heard almost everything there is to hear.”
“You see,” he stumbled, looking shyly at me, “I have the sex addiction.”
I nodded and settled into my chair. “Go on . . .”
Every patient is an unopened package, an unread novel, an unexplored land. A patient once described to me how rock-climbing feels: When he’s on the wall, nothing exists but infinite rock face juxtaposed against the finite decision of where next to put each finger and toe.
Practicing psychotherapy is not unlike rock climbing. I immerse myself in story, the telling and retelling, and the rest falls away.
READ MORE INSIDE…
“Dopamine Nation”
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