The Link Between Narcissism and Addiction: Why It’s So Common? Feat. DoctorRamani

People that are here or will be watching this that are in a relationship with a narcissist currently or are tethered to one because of exes or relatives or things like that. What suggestion? I mean, you cover this in the book, you know, but I'd love to have you touch on some of this because I think you just really understand it.

Well, I say things like I hate to say it, and it's going to sound very dismissive. Don't engage with them. A lot of people, once you start engaging, you find yourself defending yourself. You find yourself over explaining things. There's a classical behavior in narcissistic personality styles called gaslighting. And when a person gaslights you, they deny your reality. The most classical manifestation of gaslighting is when somebody says, you're being too sensitive or that never happened. You know you're being gaslighted when you start recording conversations with your phone surreptitiously in your pocket for no other reason that you can play it back later and say, I'm not crazy. They really did say that. The number of times people in these relationships will put the text up and say, you see, you said it. To which the narcissist will say, you're a vengeful bitch. You know that? So they'll still turn your evidentiary base into a scathing analysis of your character.

Okay, you know what's interesting? I have an individual that I'm dealing with, currently dealing with in my life that I've recorded conversations for that exact reason. Because I know that if it wasn't, this person would say a reality that's not at all reality. And I needed to evidence of that.

So the gaslighting sets this tone in a relationship where you feel chronically invalidated, chronically devalued, and frankly, sometimes downright crazy. You know, again, to the point where you're recording conversations and your house looks like the Pentagon for all the cameras. And they don't care about the reality. Because I will tell you, I've worked with couples, one narcissist, one not in my office. And they will show video. You say, you didn't do that, and they'll play the video. Clearly they said it. And then the narcissist gets up and walks out of the office, you see? So they're not going to engage in it. So the engagement is where people get hurt. So I tell people, don't engage. You're saying, how the heck are you supposed to talk to someone if I don't engage with them? So let's Say he and I are sharing custody of a child and he's narcissistic. I'm not going to get into.

How's work going?

How you doing? Like five o'. Clock. I'll be there to get the kids. We're done.

We're good.

He's got all the information he needs. Okay. What's wrong with you? Why aren't you talking to me more? Come on, say, I know, you know. We're good. We have our pickup time now. Your heart's racing as this is happening. This is taking a physiological toll on you. If you're dealing with a narcissist. Sorry, but you know, but you know, it's the.

He's a lawyer.

He kind of just.

Yeah, right, exactly. So I'm not engaging him. Then the other mistake people do is they start explaining themselves. No, no, what really happened was this.

But you misheard.

And then I'm like, oh, man, you're screwed now. Like, you're not coming out of this one. Maybe there's a reason why sometimes narcissists are drawn to professions where arguing works, like being a lawyer, because they argue better than anyone, because they're able to lift a lot of the emotion out of situations, because they don't bring it in. So where we're often arguing from heart, they're arguing from logic, which anyone who's ever been in a relationship knows that doesn't work. Yeah, okay. So it's. Though I would say don't engage, don't defend, don't, don't explain and don't personalize. This is them. This is their madness. Leave it housed in them. So while they're like this, you just stay. I always say you. In fact, somebody, one of my clients put it beautifully. He said, I have a cone of protection I now have.

So he literally is like, I imagine.

A cone on me and it keeps me perfectly still. So while they're going off, I'm completely serene. And I really say, find that inner serenity. Meditate. Find some sort of mantra you can use while you're dealing with them. You're not even listening to them now. They're ah. And you're like, you know what? It's time to go. It was so good to see you. And you use calm voice. I call it a hostage negotiator voice. You know, it's very easy to inflame them. So you really have to keep evenly toned. And so there's that piece of it too. And also, don't make excuses. Excuses for them. The reason so many Narcissistic individuals get so deep into our hearts and get so deep into our careers is we give them a second chance, a fifth chance, a 55th chance. We make excuses. He had a tough start in life. I say those are two separate conversations. He had a tough start in life. And he's treating you like shit.

Right.

Okay. You don't need to be mean to him. He did have a tough start in life. He is treating you like shit. You need to get out of this relationship.

Yeah.

So it's about self preservation. Exactly. It's about self preservation.

The beauty of this, though, is, man, I've become so, so more aware of noticing this behavior in subtle ways that I never did before. It's almost like when you get really stung by one, then you start to see.

You do start to see it. And you also start to become, especially if you've really been hurt, you know, anyone who's been through a relationship or a really bad business dealing. And I've had it happen in three interesting spaces. In a family space, in a professional space. And it turned my career around permanently. Like, it was like, it was literally where my career should have gone. Left and ended up going right, much to my toll. And then it ended up exactly where I wanted it, and then once in a personal space. And I think that what does happen, though, is what you have to be able to endure, and I don't know if you've run into this, Jo, is that once you become the person who identifies that narcissistic individual, whether as colleague, whether as potential partner, friend, whatever, the first play is to distance and to distance quickly. You know, I hate to say it, and I've been criticized for this, but I'm just gonna put it out there. I called narcissism the secondhand smoke of mental illness. Because you're just being near them is probably gonna make you sick over time. And there was a recent situation I'd been in professionally. I'm part of an advisory board that convenes regularly in Washington, D.C. around mental health issues. There was one guy. I mean, like, if narcissism had a smell, it was coming off this guy. Very arrogant, lots of swagger. People who are charming and charismatic terrify me. Like, when I meet a charismatic person, I'm like, I gotta go. You know, all my friends, like, when I was trying to date, they were kind of like, he's charismatic. I'm like, oh, no, Absolutely not. And so I was looking, let's find someone awkward who's sitting in the corner. Doesn't have friends. That's my guy.

And so.

But you know what got interesting is.

That you should be a spokesperson for every non charismatic person that wants to date.

Oh, absolutely. Because the non charismatic people are where the magic happens. I mean, they're so sweet and kind and loving.

I think I understood what you said.

That psychopath and sociopath, there may be a CNS or a genetic component with.

Psychopath and then a environmentally created with sociopath. Do I understand that you're saying there may be. With narcissism, there could be a neuroplastic rewiring.

Is it something that we can reverse?

You mean in terms of treatment?

Yep.

And have you seen any connection with sensory integration disorder and narcissistic tendencies?

That's a great question. So to your first point, if you look at the research by Elsa Roningstam, and she's at Harvard Medical School, she has written some really neat, really great theoretical and empirically based stuff on narcissism. The biggest problem with narcissism research is it's based on very small sample sizes. So the generalizability of the findings is not so great because there's not a lot of good treatment work done. Because they don't come into treatment, they're 80% more likely to drop out of treatment. So it's hard to do that work. She does believe, though, that there's a potential with a narcissistic individual of what we call a corrective emotional experience, that they have an experience that engages in exactly the kind of rewiring you're talking about. Now here's where my role in this whole world gets interesting. Because I work more with survivors of narcissistic abuse than I work with the actual narcissist. A lot of people out there with stars in their eyes with Mr. Charisma that they met at the cocktail party, want to believe that they're going to be the corrective emotional experience. The odds of you being the corrective emotional experience is the odds of you winning your sort of your March Madness ticket. Like, you're not, it's not going to happen. You're not going to win in Vegas. You're not going to be the corrective emotional experience. The corrective emotional experience is actually something we as therapists can watch unfold. But even during my lunch period Today, I spent 15 minutes talking a narcissist off the ledge because he's 48, the girlfriend's 22, and he can't get his head around why she doesn't like spending time with him. And I Was like, give you a couple reasons, but I'm sorry you're hurt, you know, and so it's that entire, you know, I don't think. And this is the fourth time I've walked him through this rodeo with four different inappropriately young women. And so he's not getting it now. I hate to say it, but sadly, sometimes the corrective emotional experience can be a tragedy. It can be losing someone significant to you. We don't want to program that for. Well, once your kid dies, I'm sure everything's going to turn around for you. Like, we don't want that as an intervention. So it's the question of, does that happen every so often the stars line up. Going to prison can sometimes be that corrective emotional experience. I'd say for about 2 out of 10 narcissists that go to jail or prison, it ends up being a wake up call. Like, I don't want to do that again. And I've let everyone down. So I think that in a very small subset, because of the lack of self reflective capacity in narcissists, they don't have the ability. Empathy is equal parts out and in. The out part is me caring. Joe, are you okay? Did you eat enough lunch? Is he bored right now? Like, I'm worried about Joe. I'm worried about all of you. But the in part is, am I reflecting on my contribution to this? Like, am I aware of how I'm reacting? Am I aware of my stuff? They can't do either. They can't do the out, they can't do the in. But so there is some possibility for that in terms of sensory integration stuff. We could even argue this and extend it to people on the spectrum, right? There is a lot of argument, like people say to me, what's the difference between autism spectrum and narcissism? There's a big difference. Okay? People on the spectrum have a processing issue. They cannot uptake and process social interaction and other environmental stimuli the same way because of a central nervous system issue that we're still trying to fully unravel. That said, in a child or an adult with autism spectrum, when the empathic miss is pointed out to them, they do not become defensive, they do not become angry. They very quickly say, I didn't know, and sometimes will express very authentic emotion at the thought that they may have hurt someone. We see this all through the age span and immediately that's when we know. Because I have a lot of folks who come in, women who will say, I don't know if my Husband's on the spectrum. I don't know if he's narcissistic. So we'll try some stuff. I'll give them questions to try with him the next week. And we're pretty much able to unplug it. So that processing issue means that they can integrate new information and say, I'm so sorry I hurt you, I just didn't know. And so that's. And I think that would, that would also go to other sensory integration experiences. Yeah, that would be my guess. That's what I'm wondering about because I've.

Seen that the retraining of sensory integration disorder, but it's a minimum kind of, of a two year. You're really on the spectrum. And that survival mentality is number one.

It's a two year rewiring process before you kind of go, okay, we can hang out together a little. And it's the same in narcissism. Any published research shows people have been in therapy for 18 months to 24 months. Good luck finding an insurer that's going to pay for that and that. So you've got almost two years of multi time a week therapy and still only a subset of those clients improve. No one's got that kind of access. So on a population level, I'm not clear on how we're going to improve this.

What's the link between narcissism and addiction?

Oh, so strong. Think about it. This is a person at the core of it. Narcissism is about emptiness. I always say it's like a bucket with holes in the bottom. No matter how much water, no matter how much validation you put in it, it's always coming. And there's not enough times I can tell you you're wonderful and you're beautiful and you're smart and you're successful. There's not enough anything to keep it full, right? So when someone feels empty, what do they do? They fill the hole. And there ain't nothing that fills that hole like drugs. And so it is so common. And here's what I find when I work.

Or behaviors. Right.

Or behaviors. I find this when I work with rehab centers, addiction centers. And in fact, you know, Tim, you'll be able to speak to this too is I work with families who now are having a family member go into rehab, right. And their hope is, well, now they're clean, they're sober, they're home. This is gonna be great. Everything's gonna be great. And they come home and they're still an asshole. I'm like, oh, yeah, they couldn't get rid of the narcissism, sweetie. Now he's just not using coke anymore. Now he's a grumpy narcissist because he's not using coke anymore. So it's a. You know, I think that the two go together. And what happens is we do know that narcissistic traits make maintaining sobriety a thousand times more difficult. I would imagine. Again, I will defer to you that people who are narcissistic are much more likely to relapse because the first time they come up against a disappointment, it feels like the bottom has fallen out. Right. So the easiest way to get back, you know, to get that soothing is to turn to drugs and alcohol. So I really do think that they're highly, highly, highly correlated. I mean, I would say well over 50% of the narcissistic personalities I've worked with in therapy had comorbid or past addictions.

Wow. Hey, I hope you're enjoying this video. And I want to let you know that I have a new book that's come out and if you'd like to get it absolutely free, there's a link below in the description. Or you can wait till the end of this video or you can Simply go to joesfreebook.com and you can get a copy there. I was going to ask you about the forgiveness.

Yeah, that's a good note to end on.

Yeah.

Forgiveness is such a tough space because, you know, a lot of the psychological literature describes forgiveness as sort of a major mental illness antidote. Mental health antidote. Right. You can get. You will feel better if you forgive and you'll feel lighter and all kinds of peace and reconciliation work and all of that is written around forgiveness. Here's the rub. In the west, we like to put people on a schedule like, hurry up, forgive, forgive. Everything's going to be so much easier if you just forgive your dad. And can we just get over this? No, we cannot put these human processes on a schedule. To me, forgiveness is sort of a two part kind of a process. There's a letting go piece and there's forgiving. Forgiving is a much higher order concept because it involves no longer feeling resentful about what that person did to you. And you know what? Some people are never going to get there. I work with many, like I said, survivors of child sexual abuse, and they say to me, I don't want to forgive the person who did this to me. And they've gone from therapist to therapist that say, you need to Forgive. And I said, fuck them. You do not need to forgive the person who did this to you. I want you to let this go, go. Because you're carrying this weight. You're making that more of your heavy soul weight. Can we help you put it down and no longer take responsibility for what happened to you and let you move forward, but you don't have to forgive. Forgiveness is very much something we try to sell in the West. It's very much built into religion. But here's the problem with forgiveness. For a narcissist, forgiveness is permission. They're like, this is cool. I did, I cheated on you, and you're great. That's permission to do that again. Rarely, sadly, does a narcissist integrate forgiveness as someone doing the divine for them. If I did something bad and someone forgave me, I'd be like, oh, my God, thank you. And I mean, you would forever monitor never to make that misstep again, but for all the couples, especially couples. But I've also seen this happen in professional consultations I've done when the narcissist got forgiven, nine times out of ten, they went out and committed the same transgression again, thinking that she forgave me before he forgave me before he or she is going to forgive me again. And then what it does is it screws up your ability to forgive even in the healthy parts of your life. Because now that very. That incredibly, what I consider honestly divine space has been abused. So I think forgiveness is perfect. Personal, it doesn't always happen. And for me, the real goal is letting go. And if you can get to the letting go, which is really a sense of, I am no longer going to carry this burden around. But you know what? I do feel resentful because you changed my life in a permanent way. And I'm not okay with this change. I feel different and I don't want to feel this. And you made my fucking life a little more unsafe. So no, I don't forgive you. And I. My practice is very focused on giving people enough giving. Let some people come around. And sometimes the best I hope for is letting it go with indifference. They see the cheater on the street ten years later, or they even see the abuser on the street 10 years later. And like, you know what? I didn't feel a thing. And that's when they feel empowered. And then it doesn't even matter. Forgiveness becomes almost irrelevant.

So in your latest book, you know, one of the. One of the emphasis and focuses on helping the person heal not so much emphasis on the narcissist itself. Although the first beginning part lays the foundation and the groundwork. So for people that are out there, let's play a game. How do you spot a narcissist in a crowd?

You know, you know, it's funny, that's. This is the question everyone grapples with. How quickly can I find them? What are the red flags? How can I pick them out in a crowd? I mean, listen, it's a probability game, right? It's like picking a horse in a race. You're gonna. If you pick the odds on favorite, it's probably a good bet, but they still may not win the race in a crowd. If somebody said, all right, I'll give you 10 bucks, tell me who's most likely the most narcissist, narcissistic person here. I'm probably going to gravitate to either the most charming, charismatic, attention seeking person in the room or the most aggrieved, angry person in the room. Those are my two bets, right? They're different people. Sometimes that aggrieved, angry person isn't as socially skilled. They might be sort of victimized and sullen and petulant. And whereas that grandiose, charismatic, charming person is smooth as can be and is pulling old, you know, pulling chairs out for ladies to sit at the table, like all the manners and all of that. So you'll see these two different kinds of portrayals, but those are the two people I'd be looking for in a room. Unfortunately, we're drawn to that charming, charismatic person.

Yeah, no, totally, totally. So do narcissists usually develop relationships with non narcissists or do they often find each other together?

So you find you're asking such an interesting question and I've really been doing a deeper dive into this issue, so I'm so glad you asked it. One of the things that people struggle with is they say, am I a narcissist magnet? And one thing, thing I tell everyone who's ever gotten into a narcissistic relationship. I say to them, you know why the narcissist chose you? Not because you're the broken gazelle, not because you're damaged, not because you look like an easy mark. They chose you because you were attractive. They chose you because you're good supply and whatever. For every narcissist, supply is a little different, right? Narcissistic folks are heat seeking, status missiles. They want status. Right now status means different things to different people. For some people, it's looks and Appearance. For another person, it may be money. For another person, it might be position. For another person, it might be contacts. It depends on everyone, right? And for some people, it might be that they're absolutely beautiful, but, like, very malleable, right? But that supply is going to be different. So they chose you because you're a fantastic supply. And a narcissistic person isn't going to choose someone who makes them look bad. So I always say, folks, if they chose you, you got it going on. So let's not get into this place of you're somehow broken. And so for that reason, a narcissistic person could end up with any number of people in a relationship, including another narcissistic person, because another narcissistic person could be quite charming and charismatic and grandiose and attractive themselves. And you can imagine that's an extraordinarily volatile relationship. And we're talking a lot about intimate relationships in a way, in sort of how we're framing it. This can happen in families. This can happen in business relationships. You and I have talked about that a lot. You can imagine if you're in business and you're looking for someone to be like this great business partner, someone who's really visionary and charming and energetic and charismatic, that might be who you're drawn to. And then before you know it, the whole business goes poof because you've got this narcissistic business partner.

Okay? So that's really great. I want to have you go elaborate a little more on narcissistic supply, because in your book, you just define. Because that's what they want.

They want.

Like, what is that actually mean? And let me frame it from this standpoint. So we all go into relationships because we want something, right? I always say this all the time. You know, it's like, what do people want? We're going to want to eat lunch later, right? Everybody wants something. People are coming to this event today because they want to do trauma healing. So everyone wants something. People go into relationships because they want companionship, maybe they want intimacy, they want sex, they want whatever. So the narcissist, what are they actually seeking? Because I think it's. You really help people understand what they're looking for. And if they don't get it, they can get really ugly. They can get very violent. They can destroy their. Your life.

Right?

And I'm going to. I'm going to push back on you a little. Joe here is that it's that everyone's wanting something in a relationship, because I also think that even more primal to us is an attachment seeking element. And that's less of a want, but a drive and a need. Right. Human beings are wired for attachment. And when a human being is not attachment oriented, it's actually a bit pathologic. Right. We're a tribal species, we live in small social groups. We need each other. We have babies that take a long time to get to maturity. So that means you need multiple people on the job. Right. So evolutionarily we are attachment seeking creatures. Right. So it means that most people are seeking attachment, connection, reciprocity, mutuality, compassion. They want to, you know, there's caring and being cared for. Right, Right. The narcissistic person though isn't coming at that from a different angle. Not saying the narcissistic people don't want attachment though. They tend to be more anxiously and avoidantly attached. So they're either not, there's a lack of capacity for intimacy or there's like a lot of a push, pull in, out, in, out kind of thing. But that supply seeking is almost a higher order motivation for them. Right. Because that feels feeds that insecurity. There's an empty beast in them that's always needing more, more and more and more. And so that supply is something that not only makes the transaction of the relationship make sense to them. Right. Because a relationship isn't for that, just that attachment need for them. It's they're getting something from this. Right. Whatever getting something means. And it's usually some form of social status. Right. But supply gets stale. Right. At some point that very attractive partner gets older and is not as attractive or they're not a novelty anymore. And narcissists, narcissistic folks are very reward sensitive. That's why we see a high overlap with narcissism and addiction. That same kind of dopaminergic orientation of reward, reward, reward, whatever that looks like gambling, drugs, alcohol, sex, pick your poison, shopping. You know, there is also that kind of compulsion we see. So that supply is really kind of an offset to the insecurity and the shame. And it bolsters those external defenses like entitlement that allows the narcissistic person to sort of feel anodyne, in control and able to dominate, so that it's a constant sort of feeding energy to do that.

Gotcha.

Does that make sense?

Totally. No. In the other flip side, which I didn't finish on, like we all want something, I tend to look at it from the standpoint of if you want something from somebody, make sure that your give is equal to a greater want. So you're not a taker and narcissists seem to be the ultimate taker. Yeah, they just take like it's not a given if it is a give, it's like fake.

Well, it's a performative give. At that point, the give is still also a source of supply. That's where we talk about communal narcissism. Those narcissistic folks who it's there, they sort of trick people because unlike the grandiose narcissist who's very extroverted and it's sort of look at me and sort of shiny and handsome and all this other stuff, or the vulnerable narcissist who plays victim and everyone gives them supply by trying to like save them or give them supply in some other way. The communal narcissist gets their supply by playing at humanitarian and rescuer. And I am the great savior. And so that's why at the most extreme end of the communal continuum, we would see a cult leader, but at the more mild ends, we'd see the person who seems to be organizing things to save every vulnerable group in the world. But behind closed doors, they're screaming at their spouse, they're screaming at their staff. So they're a terrible person. But to the world they seem like a humanitarian. You know what I'm talking about.

I. Absolutely. You're the, you're the. When I first, you first shared that term with me about, I don't know, four years ago, we were talking and won't they names very famous person, men and women that give to charity let the whole world know they're doing it. Social media posts, television, you name it. And they're donating to everything, they're contributing everything. But absolutely, it's all a status seeking. Look at me, I'm so wonderful, I'm so great.

And Joe, the wellness world is also fraught with this too. I mean, I have worked with many people in yoga communities, things like that. They'll say I went in with my heart open, wanting to learn from this teacher, from this healer. And by the time they were done in this space, I went into vulnerable. A very narcissistic person was at the top of that food chain and advantaging people and sort of is quite extreme distortion. It, it was humiliating. And, and that to me is heartbreaking because it's hard enough for a person to get to vulnerability, but then to get pulled into a community where once again they're caught in a toxic transaction that, that's communal narcissism.

Totally. What is the. I. I've got a few questions I've written down I wanted to ask you. So what's the single most surprising thing narcissists do that people never expect until it's too late?

I think the thing that throws people off about narcissistic folks is they're looking for almost a psychopathic lack of empathy. Does that make sense? So we keep hearing lack of empathy, lack of empathy. So they're expecting to meet someone cold and remote and distant who doesn't cry at movies and who doesn't like babies and doesn't like puppies and all of that stuff. Right. So when they meet a narcissistic person who actually can seem quite gregarious and warm and cry at the movie and be emotional at times, that's what throws people off. And I think this is why we've got to get away from this idea of the narcissistic person having, like, a forked tongue and, you know, like horns on their. On their head. That's not that people fall in love with these folks because there's a moment in time, in many moments in time, when they can show up with what feels like empathy. But it's often what we call cognitive empathy. Narcissistic people understand this idea of empathy. They understand emotion. They could say, I understand why you feel that way. It feels very analytic. But that's not emotional empathy, which is somebody's entire demeanor changing, somebody not screaming at you on a bad day because it's inconvenient. Right. But that cognitive empathy, I have to say, is the thing that throws a lot of people off because they'll see someone who looks and it like, looks empathic. And so they're saying, well, maybe they're not narcissistic because they were really nice to my aunt when she came to visit, or they really cried at that person's funeral. Like, they seem to show this emotion. And I think that the key is to sort of understand this idea of cognitive empathy, but also consistency and how they show up on your bad days.

Hey, I hope you're enjoying this video. And I want to let you know that I have a new book that's come out, and if you'd like to get it absolutely free, there's a link below in the description. Or you can wait till the end of this video, or you can simply go to Joe's freebook.com and you can get a copy there. Gotcha. No, Great, Great. So why do so many people stay emotionally trauma bonded even when they know the narcissist is toxic.

So there's, there's a couple ways I want to go with this is. One is the con. The, the. The idea of trauma bonding is really based on a. What feels like, almost like a physiologically unbreakable connection you have with someone that's created by that alternation between good and bad or not so bad and better or whatever it may be. But it's an alternation, right? If we think of it in its most primal way for how a trauma bonded relationship is created for a child. The child needs the caregiver. There's no alternative here. So the child has to go through all of these mental accommodations to maintain that relationship narratives they create, blaming themselves, anything to make it so they can maintain that relationship. And there's a lot of justifications, there's a lot of excuses. There's a lot of almost metaphysical thinking about the relationship to keep it in place. Because the idea of losing that relationship for a child is a complete attachment for fracture that the child simply couldn't tolerate and survive. Now, fast forward to adulthood where we don't have those same survival needs, but still that alternation with someone we feel attached to, connected to, that we love because there are some good days. Again, that pattern of rationalization and justification and having the same arguments and never quite resolving them and making excuses for the relationship. And one of the things that also happens is people become isolated in these relationships so they don't get that sort of alternate point of view. Right. And that's. There's something almost deliberate about that. People won't be able to articulate in an adult manner what they like about this person. Again, I always call it my trauma bond hack when I'm working with a client is they'll say, I love them, I love them. It's clearly a dysfunctional relationship. I'll say, what do you love about them? And the client will always pause and they'll say, okay, Dr. Ramani. I. Well, okay, so I love. I. I can't put it into work. That's when I know I'm like, this is trauma bonding. Because when you really love someone and it's healthy, you'll say, this is my friend, my companion. I love being with them. I look forward to seeing them. I. We share so much. Like they're articulating a coherent model of the relationship versus a trauma bonded relationship. There's no coherent schema because it's all based on this sort of physiological panic model. Does that make sense? And so the idea, and the person Will say the idea of ending this relationship fills them with panic. Even as they intellectually at a, at almost like a, a cerebral cortex level, they know this is not a healthy relationship. Like, I know they cheat on me, I know they like, I know, I know. But what's happening is much more, it's much more primal, right? It's much more an attachment oriented where there is a sense of panic, of what if I'm always alone? What if they find someone better? What if it's me? That's not enough. And that panicky system is what sort of kicks in for someone. And undoing that is no small task therapeutically. A lot of folks really benefit from trauma oriented work. And where did this, where did the schema, where did this model define schema? So a schema is a mental model, right? And we can think of this in terms of again what I was using the term, a coherent narrative. A coherent narrative is being able to look at something holistically. Great example would be a childhood, right? A childhood where a person could say, I was abused by one parent or I was abandoned by the parent. And since then I keep looking for people who reject me, but when a kind person comes along, I reject them. The person is able to see everything in a very coherent, consistent, stable way. So the more stable the schema, usually, the healthier it is because it almost becomes like a little mental gps, like I know how to navigate the situation. And schemas are driven by experience, or they're driven by temperament, they're driven by culture and they're driven by personality, right? So, and having that model, when it's coherent and healthy, then a person's also even able to say, oh, I see what I'm doing here in this relationship. But I often see in the more trauma bonded relationships, there's no coherence in that schema, in that narrative.

Not super helpful. So how, how do we set ourselves up for being able to develop healthy, connected relationships? Because you've heard this a thousand times where someone's like, why'd I keep picking this bad person? What's wrong with me? Like there's something their pickers messed up. And, and maybe it is, maybe the, and when I say it, I mean they've been in damaging relationships and they're scared, they're gunshot, they don't know what to do. They're, they're, you know, they've, they've been burned, they don't want to get hurt again. So therefore they don't play to win, they play not to lose. And if you play not to lose you, you tend to lose.

So I want, I want to connect this back to our trauma bond. Our trauma bond question too. When we think of this narcissistic relationships, we often make the knee jerk assumption that this is a trauma bonded relationship. Not necessarily so too. There are plenty of people in narcissistic relationships who aren't trauma bonded who but can't get out. So it's very, and I work with a lot of folks who are in narcissistic relationships and not trauma bonded. They're like, if this fool walked out the door tomorrow, as long as I could keep my kids or keep the house, I would be fine. So there's, there's external structures, practical issues, minor children, finances, family court, a whole host of other things, family traditions, whatever it may be. So those folks are like, I see this 100% clearly, but there's no clear path out for, for me right now. To your point about how do we talk with people and create these healthier models of relationships? First of all, we need to create healthier models of relationships. We don't talk to people about this. Right. For all the things we talk about, we don't really have those straight up informed by psychological science conversations of what makes a healthy relationship. And I keep using these terms mutuality, reciprocity, respect, compassion, and above all else, Joe, psychological safety. That a person feels like they can come into a relationship and show up as they are, farts and all, and not feel that they are going to be rejected on that. And, and I say that jokingly, but I always say like there's the fart test in the relationship. That first time you pass gas in front of someone, you're like, oh my God. I'm like, what did you, did you really think you were going to be married to someone in 50 years and not pass gas in front of them? And, and I'm like, and look, they're still here. Maybe they'll, they'll laugh a little. And I'm like, if they get up and leave because you had beans for.

Dinner, I don't know that this was the keeper.

But I think that that kind of model of I have to be perfect, I have to show up as this idealized version of myself. I can't be authentic. And I do think it takes us to that conversation about authenticity. Another really overused word these days. But that has so much power and in creating healthy relationships because it's, that requires us, even before the relationship to do a deep dive in who am I? What do I stand for how do I show up? And people are afraid of that because they were told, maybe in childhood I show up as my true self. I'm going to be raged at, I'm going to be told I'm selfish, I'm going to be told I'm ungrateful. They go into a relationship, the first time they show up as a true self, they're rejected. And so that can really squelch that authentic self. Right. But that's what a healthy relationship is. That capacity to feel like you're in something that's not only psychologically safe, but balance. We are very much so still. And I think social media made this worse in the era of the check, the check mark relationship, you know, if for. I think we still have very gendered anticipations around that. Whether it's around money or appearance or youth or, or whatever it may be, intelligence, anything. And instead of these very, very sorts of healthy barometers. And I don't know about you, Joe, but I have a handful of friends who are in fantastic long term relationships and marriages. And when I look at all of their relationships and these are people you can of every age, ethnicity, these are straight couples, these are queer couples, These are couples with money, without money. And you feel that you're in the presence of, of two people who get each other, who, who have each other's backs. It doesn't feel lovey dovey. I don't feel like I'm in some sort of, you know, sort of fairy tale. I feel like I'm with two people where it's just like a big cozy blanket and I just want to stay in their house forever and that, and that kind of alchemy. There was often two healthy people that entered that relationship.

That's really great. Yeah. And that, that feels really good. And there are. And I'll tell you, I think it's important to have models of relationships because if everyone you hang around with is completely dysfunctional and talking shit about each other, you know, it's just. Yeah, it doesn't help you at all. We need. And look, I think in a lot of ways you are providing models. Like we have one interview that we did that has over a million views and I have at least 100 times when someone has sent me a message because I have genius recovery. So I'm talking to people that are struggling with addiction all the time. It's just kind of weird how I've. My own recovery has led to all these other things I do. And I. Will you utilize your interviews? I Will say, you need to watch this. And so it's not just an interview. It's. It's literally a toolkit. It's helping people work through their. Their lives. So what is if you could wave a magic wand? There's so much you've learned. You've had so many of these conversations. You. You ever get sick of talking about this stuff?

I don't, because Joe, one with the beauties of being sort of a former academic is you never stop the work. Like, it's all your. Your head's in the journal articles. You're always reading the new science. You're again, even. Here we are today at this beautiful seminar on trauma. I get to learn from Gabor all day. I get to learn from Kimberly all day. I get to learn from folks like you about addiction. So it's. It's not just getting your head in the clouds with all the minutiae of the science, but talking to people who've walked the walk. And so every day as a teacher, and it's like this gigantic sculpture. You're always adding more clay to it. You're always flexible and willing to sort of see things in a new way. So I never get tired of it because I have the real privilege of always getting to learn, pushing myself to learn, always reading books and always talking to survivors.

Yeah.

Yeah. And so. So you've learned so much that, like, what have you discovered over the last year or so that you're like, oh, this is really valuable, that I think people need to be aware of this. They need to. I'd love to have you share some of those things because you're. You're always on the cutting edge of all of this. I mean, you. You. You in. I mean, I really admire just how much work and what you deal with is pretty heavy. I mean, you deal with some very difficult situations that I don't know very many people that could unravel. Some of the stuff that you. You. You. You work with.

Well, I really appreciate that. But again, it feels like a real privilege. You know, I've lived experience, experience in all of this. So I get it. I feel it, and I know how important it is for people to feel seen and not shamed. I think that the piece in this year that has really been illuminating for me, and I was reading in all these sort of complex models, but the simple part of it is anyone who's in a narcissistic relationship, I don't care how mild or severe it is, it is a relational trauma, and it is a betrayal Trauma. And the only way to treat relational trauma is in relationship that we, that you are now, basically you are fixing that broken schema of a relationship. And even whether it's in the therapeutic room where you're teaching someone, people show up, people care that this can be a healthy space, that the therapist can show up authentically. And then it's about helping that person heal in community. And we have a monthly membership. And what I've seen now, we've had it for over two years. And that you need that much time to sort of see changes in trend. What's been remarkable watching that healing community is watching people who all came in, not everyone didn't come at the same time, like some people come, drop out, whatever, but is watching people evolve from feeling that they couldn't even get out of bed to becoming the healers themselves. They healed relationally. You see this in the addiction community all the time. We heal relationally. Right, right. That idea that somebody can go off with a book or, or a podcast and do this themselves is never going to happen. Or even I, I still don't even think therapy is sufficient. There has to be community. We heal in community. And I think that helping people understand that they're not alone. And I have, you know, listen, I have worked with folks who've been in 30, 40, 50 year marriages with narcissistic folks, right. So that raise kids in it, the whole nine yards. And they said, you know what, Dr. Ramany? If I had five years, eight years into this marriage, even before we had kids, one or two years in, had I read this, I would have gotten out. There was just simply no framework. We had no language. Right. And so, and that applies in the world of addiction. Think of how long there was no language. We didn't understand this as a disease. We didn't understand how people heal. We didn't understand the intersection of trauma and addiction. Right. When those, each of those layers of the onion got peeled away. We have had more compassionate conversations. People are getting better treatment. Well, narcissism is about 20 years behind that right now in terms of understanding how that shows up in relationships. And now that people are getting these schemas, they're willing to clock these patterns earlier. And that plus the relational understanding, I think we're actually going to start seeing people being more discerning in their relationships, maybe sort of capture these things as patterns and start disengaging earlier, giving themselves even permission, not just in intimate relationships, but even in workplace relationships, family relationships, saying, no, this, this isn't okay. This is, this is one sided, this is asymmetric. This doesn't make sense. So. But I think the needle is moving. But as all arcs are, they move quite slowly. And so those are the things I've really learned in the last year. So I really am focusing on the community piece of this.

Yeah, no, so, so critical. And I always go back to the saying, you're sick of your secrets. And so having people to talk to, silent battles, the hardest battles to fight to try to do this on your. And it's so difficult. So I absolutely agree. I mean I would have never had recovery with addiction without.

I don't think anyone would.

Yeah, yeah. And I always say to people, you know, like, even when they talk about 12 steps, it's not an attendance program. No, it's a step program. You go, you go meet other people, you do the steps, that sort of thing. I've read comments where I'm so curious because I've never asked you this. Where someone, probably a narcissist on the other side, where you, you know, you are really describing someone, they'll say like, she's a narcissist. They call you a narcissist. Yeah. So how do, like what, what is, what is, what is that about? How do you interpret it?

I, I mean, listen, if somebody sees themselves in the content, first of all, I applaud them for willing to do that. I think that's an incredibly vulnerable thing to do. However, that vulnerability activated the shame, activated the rage. And they're gonna. Look, Joe, I'm gonna be very. I'm, I'm, I am willing to be completely self efficient facing in that they see a person who makes her living putting herself in a public forum to teach people about this. And in some level it's paying the bills. Right. You know, I'll give them that. Right. And, and many. I get that and it hurts my feelings. I'll be, I'm very. I do not read my comments. I would be in a psychiatric hospital if I read my comments. I'm still a very, very sort of. I have my, like, I understand my own neurotic personality structure and my fearfulness and all the things. Right. And so I really would dig in in my own therapy, say, do I have empathy? And she's like, why, why are we having this conversation? You have deep empathy, you know, and so it's like I'm thinking I will even stand in a line when I don't need to stand in line because I don't want anyone to think like she's ever taking advantage. So I know I'm not those, I'm very. Because entitlement is the, the, the, the, the sort of. The trunk of the tree. And so I don't, I never. And so, so I'm pretty confident that I'm not. In fact, I think if I was narcissistic, my business would have been so much better and so much bigger. But I, I, but you, you do come against that. And I do think that more than anything is that people are being made uncomfortable about this conversation, and so it's activating shame in them. I also think that it's the nature of, of online spaces, and so people are on the attack. I'm sure you get all this stuff all the time. And so any of us in this space too.

Yeah.

No, you just, like, what, Just hearing you say that makes me realize, why the heck are we so sensitive? Where I could read like a book review where, you know, there's like, one, there was one that I read recently that was a negative review, and right before and right after is like, this is the best book I've ever read. And I'm like, how is it, you know, but why do I get so bothered by that? Why do we get so, but why are we so sensitive to it and how do we not be bothered by it? Or maybe that's part of just being a really cool human. Like, yeah, you're sensitive. You know, you want, you don't want people to call you something that you don't, that you're not, or you don't feel that you're not. I mean, I, you know, how, I guess, how do we become less bothered by it?

I don't know that we do become less bothered by it. In fact, maybe we don't. I don't know that we do. I think that part of the burden of empathy is that that also would, would sensitize us to that kind of discourse. And it will. And I'm going to be frank with you. I think that anyone who's had a history of trauma and anyone who's had, or a history of these kinds of narcissistic, betraying relationships, there is such, again, a core schema of what's wrong with me? What did I do wrong? Do I deserve this? Am I the bad one? Right. Since that's such a central schema, that kind of commentary is going to bounce off of that. And instead of like, I'm absolutely not. That is that there's a plausibility to it, and then it causes this, this sort of Grappling. And I don't think grappling is ever a bad thing. That that creates the core of accountability, which is another core element of a healthy relationship. But I don't need to be sitting there all day. And I'm very much. I again, one of the things, the way I opened up this book was a story of me as a child with a purple dress and not willing to sort of put myself out there more than anything. Cause I didn't want to be made fun of. That was the driver that day. I did not want people to see me and make fun of me. And even to this day, I still think, what the hell are you doing?

But I.

Because there was no way to do this anonymously, right? I could have tried. And then people like, what the heck is this? So I, I do. In academia, in some ways you can be very anonymous. So for decades of my career, you really are. You sort of. In fact, the way our work is reviewed in academia is it's done. It is done anonymously. They remove our names from the manuscript. So there's no bias in the peer review process. So there's almost a built in anonymity in the scholarly process. And so if people say it, they say it. And I'm thinking if they. Again, I'm not reading the comments, so I'm not seeing it. But if it did lead the person to grapple with, well, maybe I am the narcissistic one, maybe then the content was worth it.

Lots of exciting work in the neuroscience of pleasure and pain the last 75 to 100 years. And one of the first and most exciting discoveries is that we have a dedicated reward circuit in our brains. It consists broadly of the prefrontal cortex, which is that large gray matter area right behind our foreheads that's so important for future planning, delayed gratification, and also autobiographical narratives and storytelling. And we have these deep limbic structures or emotion brain areas, the nucleus accumbens and the ventral tegmental area, that are rich in dopamine releasing neurons. When it comes to the problem of compulsive overconsumption or addiction, we have a problem either in the prefrontal cortex, which is kind of like a problem in the brakes on the car, the control centers, or a problem in those limbic structures which are kind of like the accelerator on the car. So another very exciting discovery just in the last 75 years is the discovery of dopamine as a human brain neurotransmitter. Now, dopamine was known long before then as an Animal neurotransmitter, but it was only discovered in the 1950s as a human brain neurotransmitter. And for those of you who may not be exactly familiar with what a neurotransmitter is, neurotransmitters are chemicals that we make in our brain that bridge the gap between neurons. Neurons are these long, spindly cells that conduct the electrical circuits that make up who we are, but they do not touch end to end. There's a gap between them called the synapse. That synapse is bridged by molecules called neurotransmitters. Those neurotransmitters allow for fine tuning of that electrical circuit. Dopamine has been discovered as one of the most important neurotransmitters for the experience of pleasure, reward, and motivation. Now, it's not the only neurotransmitter involved in that process, but it is the final common pathway for all reinforcing substances and behaviors. This image represents a series of experiments done in rats and mice where a probe was placed in the nucleus accumbens to measure dopamine firing. We're always releasing dopamine at a kind of baseline tonic level in our brain. When we do something that's pleasurable, rewarding for reinforcing, or simply that. Our brains tell us that this is important for your survival, so you should pay attention to it. We increase dopamine firing temporarily above baseline, and this shows in rats and mice anyway, how much we increase those dopamine levels. For chocolate, it's 55% above baseline. Sex is 100%, nicotine 150, cocaine 225, and amphetamine 1000. Now, the very high amount of dopamine released by amphetamine is somewhat artifactual in the sense that the mechanism of action of amphetamine is to release dopamine directly into the synapse, whereas these other kinds of reinforcers have their own unique chemical cascade, and dopamine is their final common pathway. So it's not necessarily that amphetamine is so much more addictive than these other things, although in rats it may actually, because, in fact, rats will press a lever for cocaine or amphetamine until exhaustion or death. What this also doesn't quite represent is that although we are very similar to rats in terms of this very basic, evolutionarily conserved part of our brain, we're also very different because we have these large gray matter cortices that are overlay these deep limbic structures that we can use to modulate it. And, for example, we're also just different from rats in the sense that it's very hard to get a rat addicted to alcohol. But for human beings, it's very simple to get addicted to alcohol. You can actually make genetic strains of rats that get addicted to alcohol, but it's just hard to do. This also doesn't take into account the very important point of inter individual variability. So what releases a lot of dopamine in one person's reward pathway may not release a lot of dopamine in another person's reward pathway and vice versa. And from an evolutionary point of view, that makes sense. If you've got a tribe of people trying to survive in a world of scarcity, you wouldn't want everyone going for the same reward. You would want some people interested in finding mates, other people interested in meat, other people interested in berries. And this drug of choice concept becomes particularly important when we think about the ecology and the world that we live in now, where we have so many different types of drugs, including many drugs that didn't exist before. Dopamine is also very important for movement. And it's probably no coincidence that the same neurotransmitter that's essential for pleasure, reward and motivation is also important for movement. Even the most primitive nematode will release dopamine in response to food in its environment. And that dopamine allows it to locomote to toward the food. One of the big problems today is that we don't actually have to move our bodies in order to get the things we want. So there's this big disconnect between the function of dopamine as something that has us engage in movement in order to get our reward, and the actual getting of the reward, which is of course partially what makes things addictive. Right. What is the difference between cocaine and broccoli? It's the amount of dopamine that's released and how fast it's released in the reward pathway. But the other thing that's different about what's addictive and what isn't is the relationship between how hard we had to work to get the dopamine and how much dopamine is released. Because really we are physiologically designed for so called natural rewards. Food, clothing, shelter. But really what that means is that we're physiologically designed to, to go into some kind of physiologic deficit that then drives us to want to do the work, to get the reward, to survive. Whereas today we don't actually need to do that work to survive. And we have all this amazing, highly Potent stuff that's handed directly to us. That makes our brain very confused in a way that I'm going to talk about now. So to me, the most exciting finding about processing pleasure and pain in the last 75 years is the finding that pleasure and pain are actually co located in the brain. The same parts of the brain that process pleasure also process pain. And they work like opposite sides of a balance. Imagine that deep in your nucleus accumbens you've got this teeter totter, like in a kid's playground, that represents how we process pleasure and pain. It's an obvious oversimplification, but it gets at a very fundamental aspect of what happens in our brain as we become addicted. So when we experience something pleasurable, the balance tips one way. When we experience pain, it tips the other. But there are certain rules governing this balance. And the first and most important rule is that the balance wants to remain level, or what neuroscientists call homeostasis, so that with any deviation from neutrality or, our brains will work very hard to restore a level balance. How do our brains do that? First, by tilting an equal and opposite amount to whatever the initial stimulus was. And 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 it's tilted an equal and opposite amount to the side of pain. That's the comedown, the hangover, the blue Monday. Or maybe even just that moment of wanting to eat one more piece of chocolate, watch one more TikTok video. It can be even outside of conscious awareness. Now, if we wait long enough, those gremlins get the memo that there's no more dopamine incoming. They get off the balance and homeostasis is restored, and we kind of go on our way. But until that happens, while the gremlins are on the pain side of the balance, we are in a state of physiologic craving and wanting. We want to restore homeostasis. And by the way, the work of restoring homeostasis also triggers our adrenaline or our innate stress response, so that it is stressful and it is work inducing in order to bring that balance level again. But what if we don't wait? What if we continue to consume our drug of choice? Over days, to weeks, to months, to years, those gremlins start to multiply, and pretty soon we've got enough gremlins to fill this whole room. And now they're camped out on the pain side of the balance, tents and barbecues in tow. And now we're entering addicted brain, right? And essentially, this means we are changing our hedonic or joy set point such that we need more of our drug and in more potent forms, not to get high or feel feel good, but just to level the balance and feel normal. And even more importantly, when we're not using our drug of choice, we're walking around with a balance that's tilted to the side of pain, experiencing the universal symptoms of withdrawal from any addictive substance, which are anxiety, irritability, insomnia, depression, and craving. And this is why people with severe addiction will relapse even after they can see that when they're not using, their lives are better. It's because their brains aren't better. They're walking around in this state of physiologic pain. This is also why it's so difficult to stop addictive substances and behaviors when we're chasing dopamine, because we're experiencing that craving that comes from having that pleasure pain balance tilted to the side of pain. Now, with enough neuroplasticity and enough sustained abstinence from our drug of choice, and I'll get into how long that needs to be in just a little bit, those gremlins eventually get the memo, they hop off and homeostasis is restored. Just to represent this graphically, at the simplest level, what we're really talking about is dopamine firing. That initial exposure to anything that's reinforcing or rewarding increases dopamine firing above baseline, followed then by neuroadapt adaptation, which is dopamine freefall, not just to baseline, but below baseline, into a dopamine deficit state, where we're in a state of craving, which if we then just wait long enough, we go back to the level balance homeostasis, or a neutral baseline level of dopamine firing. So in other words, initial exposure to reinforcing substances and behaviors brings our dopamine levels up, and we feel good. But with repeated exposures over time to the same or similar reinforcing substance and behaviors, and maybe in one person it takes two weeks for this to happen. For another person, it could take 10 years. But eventually our brains will adapt such that that initial upward deflection of dopamine gets weaker and shorter in duration, but that after response, that dopamine deficit state gets stronger and longer, and we eventually settle out at a new set point. And again, now we're in addicted brain. This is a neuroimaging study done by Nora Volkoff and her colleagues. This is now human brains, not rat brains. What you see here is the nucleus accumbens, which is the area that's lighting up in the middle. And red represents dopamine transmission, healthy, robust dopamine transmission. And what you'll see on the left hand side is that in the nucleus accumbens of these healthy control subjects, there's plenty of red, so plenty of dopamine transmission. On the right hand side, you have images of people who have been using cocaine, methamphetamine, alcohol and heroin in an addictive way for a longish period of time. And you can see that there's very little red in their nucleus accumbens. In other words, they have subthreshold or below normal levels of dopamine transmission. And what I find incredibly powerful about this is that on the right hand side, the images of those individuals who were using these addictive substances were taken two weeks after they stopped using. What that tells us is this dopamine deficit state. Those gremlins don't hop off the balance right away. It takes a while for them to get the memo and hop off. And it is also possible that in some individuals, perhaps they've lost the plasticity to ever reset their reward pathway and that they're in a chronic dopamine deficit to state for life. And that's why, for example, for some patients with severe opioid addiction, we will actually use opioids to treat their opioid addiction. Things like methadone maintenance or buprenorphine, not to help them get high, but just to level the balance, restore homeostasis, and give them a fighting chance of engaging in recovery. The second rule of the balance is that the balance remembers. So once those gremlins are created, even if they hop off the pain side of the balance and they never entirely go away, they're hiding in the wings, eager to hop on again. Which is why we can see people relapse even after a single exposure to their drug of choice, even after decades of absence, perhaps you've all seen that in someone that you know. We certainly see it in clinical care all the time. So since those gremlins are already created and waiting in the wings, what we know from that is that we have a kind of permanent or latent activity echo, a permanent change to the brain, even once people get into recovery. One of my favorite rat experiments is where they took rats. They gave them an injection of cocaine daily for seven days. And what they found was that with each successive injection of cocaine, the same amount on every day, the rats went from hiding out in the shadows of the cage to being in a running frenzy all around the middle of the cage on day seven. Then they stopped giving those rats injections, and they waited a year. And a year is about a rat lifetime. And then they re injected those rats with cocaine, and they were immediately in a running frenzy, exactly as they had been on day seven. Which tells us that even after a sustained period of not being exposed to our drug of choice, there's a kind of latent echo. Now, this should not be a cause for feeling hopeless or despairing, because we see people get into recovery all the time. And my colleague Edie Sullivan at Stanford has shown that what happens in the brain of someone who's getting into recovery is probably not so much that they repair those damaged neural networks, but that they form new neural networks that go around those damaged areas. All right, so let's focus on this graphic here. This is from a series of experiments looking at dopamine levels in the brains of rats and mice when you give them an injection of cocaine that they have to work for, so they have to press a lever for it. But these are rats and mice who have basically been taught or trained to know that they'll only get cocaine if they first see a light and then press the lever. If they go up and just press the lever on any old occasion, they're not going to get cocaine. So, in other words, this is what we call a cue induced learning. This is classic Pavlovian learning. They know when they see the light, they can go get cocaine if they press the lever. But look at what happens to dopamine levels during this process. Now, if you go all the way to the right side of this graphic, you'll see that when the rat receives cocaine, dopamine levels go up. That's what's happened, at least within those initial bouts of exposure. But look at what happens when the rat sees the light. Just seeing the light and knowing that cocaine is on its way increases dopamine firing a little bit above baseline. So we get a little bit high, just anticipating our drug of choice. But look what happens right after that. Upward deflection. Dopamine levels don't go just back down to baseline. They go a little bit below baseline. So there's a mini dopamine deficit state, which sets up the craving that makes us then want to do the work to go get our drug of choice. Because, remember, we want to restore homeostasis this is why it's so important when people are trying to change a habit of compulsive overconsumption, or people are trying to get into recovery from severe addiction, that they insulate themselves not just from their drug of choice, but also from the triggers or reminders that will set them up for this craving cycle that will make them want to go get that drug of choice. What happens when we have learned to anticipate a certain reward and we don't get that reward? So here you see the graphic. The rat has been trained to think that when it sees a light, it presses the lever. It gets cocaine. It sees, sees the light, it presses the lever. No. Cocaine dopamine levels go way below baseline. This, to me, is really, really interesting because there are a lot of inferences you can make from this. First of all, what it says is that as people get into their addiction, their drug of choice essentially stops working and can even turn on them and do the opposite of what they hope for. We see this all the time, for example, with cannabis, right? I use cannabis to help my pain. I use cannabis to go to sleep. I use cannabis to go relax. Now my cannabis makes me anxious, makes me paranoid. Drug turns on them through the process of neuroadaptation. If we are addicted to our drug of choice, we do not learn from that experience. Instead, what we do is we try harder to get more, to bring those dopamine levels back up to baseline or even get them above baseline. I also think, more broadly speaking, in the process of learning, generally what we're doing is we're kind of making mental maps of the world, and then we're testing them on the world. When those mental maps work out and we've got it right, we get a little hit of dopamine. And when those mental maps don't work out, meaning we got it wrong, we probably go into a dopamine deficit state. And then we can either fight that awareness or we can change our mental maps. This is just to speak broadly about the importance of childhood and adolescence as a very influential time in terms of the development of the brain. What you see here is a series of brains from about age 5 to about age 20. And Red here represents the number of neurons that we have in our brain as well as the number of neuronal synapses. So synapses, again, are where those neurons connect. And when we are five years old, we have 50% more neurons and neuronal synapses than we will have for the rest of our lives. We are totipotent cells, we're sponges, right? We can learn anything between about age 5 and age 25. We cut back on or prune, as neuroscientists call it. Other neurons we're not using and we myelinate and make more efficient with blue here, the neurons that we use most often. So you can see in this graphic, we have a lot of red for neurons at age 5 and a lot of blue for myelin at age 20. And essentially at age 20 or 25, we have the neuronal scaffolding that we'll be left with for the rest of our lives. So a very important time to make sure that we are creating really good and healthy coping strategies for ourselves, for our kids, et cetera. All right, I want to widen the lens now and extrapolate from the neuroscience, really exciting advances in neuroscience of pleasure and pain and addiction to talk about what I call the plenty paradox. The plenty paradox is essentially the mismatch between our primitive wiring for processing pleasure and pain and the world that we find ourselves in today. You might reasonably ask, why on earth would mother Nature create a pleasure pain processing system consisting of this balance? It seems especially cruel because it means anything that we find pleasurable will eventually become less pleasurable over time and might even be a source of pain for us. Why do that? Well, in a world of scarcity and ever present danger, this is actually a great mechanism because it means we are the ultimate seekers, never satisfied with what we have, always looking for more. It's exactly what's going to keep us alive. But in today's world, a world in which most of our basic survival needs are met, a world of overwhelming overabundance, this actually becomes a liability. And I would go even so far as to say that almost every aspect of our lives has become drugified in some way, made more potent in reinforcing, that is to say, releases more dopamine very quickly and and the reward pathway been made more accessible. Our phones are basically 24. Seven hypodermic syringes delivering digital dopamine made more novel. Novelty is one way to overcome addiction, right? Overcome tolerance. We combine two drugs together to make a third new drug and we overcome tolerance. And then just sheer quantity. Quantity matters when it comes to highly reinforcing substances and behaviors. The more we use and the more often we use, the more we change our brain. TikTok never runs out. This is an example of the types of things that people can get addicted to. I'll just let you sort of, oh, can you see it there oh, here it is. The print is a little small. I'll read kind of the general categories. So we have our traditional drugs, alcohol, nicotine, cannabis, et cetera. We have medications. These are the things that doctors prescribe, described to us mostly with good intentions. We've got media, Internet, technology. I'm personally very vulnerable there. We can get addicted to other people, right? We can get addicted to our own bodies. One of the most common types of addictions we're seeing now is addiction to sex, pornography, compulsive masturbation, love, sex and pornography. This is certainly my own category of vulnerability as well, which I talk about in my book. In my early 40s, I got addicted to romance novels, which I actually think is socially sanctioned pornography for women, which is all good in moderation. But what happened to me as I went from reading the Twilight Saga, which, for those of you who don't know, is teenage vampire romance novels, to reading about butt plugs at three o' clock in the morning while reading about 50 Shades of Gray? Reading all the time, got a Kindle. People didn't know what I was reading. I could read anonymously on the bus at work, spending less time with my kids, with my husband, even taking romance novels to work and reading in the 10 minutes between patients. But probably the biggest and most impactful part of it that I really didn't see till later was that I got progressively more depressed and unhappy with my circumstance, even though I. I had a lot to be grateful for and I had this kind of narrowing of focus where the only thing that I really wanted to be doing was reading romance novels or to be in this escape world. And the ways in which continued engagement in our highly reinforcing substances and behaviors ends up with those gremlins on the pain side of the balance means that we can no longer take pleasure in modest rewards or things that used to give us pleasure. Because we've narrowed our focus on this one thing and it's the only thing that has salience for us. I would also just emphasize that our food supply in general has become highly drugified, as was mentioned earlier, with the addition of salt, fat and sugar. Sugar is incredibly addictive. We have lots of good data that it lights up the nucleus accumbens. It's very hard to stop. If you've ever tried to give up sugar, it's very, very difficult. And then of course, for this audience, work achievement, money. I thought Tommy said it really well. Go get money, but just don't love money. So again, how do we define addiction very broadly? It's the continued compulsive use of a substance or behavior despite harm to self and or others. This is not to trivialize addiction, severe addiction, or even to say that anything can be addictive. But really, it's when a passion or a hobby crosses over into being harmful to self or harmful to. To others, and recognizing that, we may be the last person to recognize it. So this is really important. When we're chasing dopamine, we often lose a sense of causality. Mark did a really nice job this morning talking about the importance of because statements. Why are because statements so powerful? Because we all want to understand causality, right? We're trying to figure out what leads to what. But just be aware that when we're in our addiction cycle, we don't see causality necessarily. And so we might have to either take some action or go on blind faith when someone else is telling us that this substance or behavior is causing harm to our lives or to the people who love us. So one of the hypotheses that I would just like to put out there Is that our mental health crisis has many different causes, of course. But I would hypothesize that one of the causes may in fact be the. That we are both at an individual and a sort of national collective level in a dopamine deficit state, which may be contributing to the rising rates of depression and anxiety. And this is really important because if that's true, then that means the intervention is quite different from the typical things that you will find recommended or prescribed from a psychologist or a psychiatrist or mental healthcare provider. One of the interesting paradoxes is that, in general, if you look at happiness surveys and wealth, the wealthier people become, the happier they become. If you look at this from an epidemiologic perspective, as nations get wealthier, especially as they're moving out of poverty, when you do happiness surveys nationally, those populations will endorse getting happier. Something changed about 20 years ago, and the wealthiest nations in the world started reporting that they were less happy than they had been before. Not only that, the richest nations are now showing the highest rates of reported depression, anxiety, and also suicide. And I'll get to that in a second. So you could say, well, you know, maybe the culture's changing. It stimulated reporting. Now everybody talks about their disorder. I would absolutely agree with you that that's part of the phenomenon. But I don't think that's the whole phenomenon. I actually think people are less happy, and I think the reason they're less happy is because overabundance itself is a physiological and psychological stressor. We were wired to strive. In the absence of anything to strive for, we are not thriving. And if you had to question on any space around stimulated reporting, I think suicides will tell you that that's no longer just a reporting phenomenon. People are ending their lives more often in the wealthiest nations of the world. You can see here that second bar graph is both men, women and both. And you'll see that people in high income countries now kill themselves at rates far higher than in the lowest income countries. And this is unprecedented, at least in the time that we've been documenting these data. And finally, in terms of the epidemiology, it is probably the poorest people living in the richest countries who are the most unhappy and vulnerable to the problems of addiction and other forms of mental health. Why? Because they are surrounded by all of these cheap pleasures, have easy access to them without the same kind of access to the kinds of healthy and rewarding sources of dopamine that we really need to thrive. Deaths of despair. You may have heard of it before. How many folks have heard of the term deaths of despair? Okay, so not very many. This is the work of Anne Case and Angus Deaton. These are two Princeton economists that have shown that for the first time in many generations, people, white Americans who are not graduating from high school are dying younger than their parents and grandparents. Okay, so for 200, 300 years, we've all had increased longevity, right? The average person in 1800, 17, 50 used to live to about age 30. Now, on average, especially in wealthy nations, we're living older and older, more centenarians than ever before. But in this generation, for the first time, we saw people who were dying younger. Top three causes of death in this cohort were alcohol related liver disease, drug overdose, and suicide. And they've called these deaths of despair. And all of this is probably on some level tied to the Internet. In 2021, adults in the US spent on average 8 hours and 5 minutes with digital media day. This is not digital media for work, okay? This is digital media for entertainment. I don't think in the early 2000s, when the smartphone first came out, anybody would have predicted that we would be spending this much time on digital media. Digital media, digital devices, they're a powerful tool and they're also a very potent drug. They light up the same nucleus accumbens, the same reward pathway. We're seeing more and more people getting addicted to social media, video games, YouTube, and just sort of indiscriminate Internet addictions. All right? And sort of ending this brief talk today, I want to tell you what are some of the somewhat novel but really quite simple things that we're doing about this in our clinical work, which are just a lot different than what we were doing 20 years ago. So 20 years ago, if a patient came in to see me with anxiety, depression, inattention, insomnia, the first thing I would have done was prescribe an antidepressant and or recommend them for some form of psychotherapy. Today, the first thing that I do is actually screen them for their consumption of highly reinforcing drugs and behaviors. And if I'm finding a pattern of repeated use of caffeine, alcohol, cannabis, pornography, video games, social media, shopping, romance novels, one of the first things that I might do is to recommend a dopamine fast. And the reason I do that is because when patients are willing and able to engage in a dopamine fast, which is essentially giving up their drug of choice for four weeks. And I'll tell you a little bit more about the four weeks. What we find is that they will often return feeling less depressed, less anxious, better able to sleep with our without our having to do any other intervention. And even if they don't feel better, we still have a lot of information from that. Because if they don't feel better even after they've given up their drug of choice, then we know that there's something else going on. So what we tell patients is we'd like you to abstain from your drug of choice long enough for those neuroadaptation gremlins to hop off the pain side of the balance so that homeostasis can be restored, so that you can have a supple pleasure pain balance that can respond to cues in your environment of both pleasure and pain. And you can restore your joy in everyday rewards like things as simple as a sunset. We asked for four weeks because we know from Nora Volkov's work and from clinical practice that two weeks is not enough. Remember that image of the brain? We're still in a dopamine deficit state at two weeks. That tracks exactly to what we see in clinical care. Those first 10 to 14 days are hell, no matter what your drug of choice is. Now, it's true that some drugs of choice, that withdrawal period can be life threatening. Those would be opioids, benzos and alcohol. In which case, if you are physically dependent and at risk of a life threatening withdrawal, you need to go into the hospital for medically monitored detox. But the vast majority of people addicted to those drugs and other Drugs can actually stop cold turkey if they are able to. Not everybody is able to. That's why we have rehabs. I'm very grateful for rehabs. They get a bad rap. I'm really glad they exist. Some people need to go into a rehab in order to be at enough distance from their drug of choice to be successful. But essentially what we find is that those first 10 to 14 days are really, really bad. Your gremlins are not off the pain side of the balance and we warn people that that will be the case. And this is the most important thing that we say to people because if we don't say it, people feel like the pain that they experience in early withdrawal is the pain that they're going to be left with the rest of their lives. And since that is so intolerable, they go back to using their drug of choice. People when they. People with a severe addiction, when they come in, they see only two possibilities. I use drugs and I'm miserable. I don't use drugs and I'm miserable. What we have to teach them is there is a third way in which you don't use drugs or you use an extreme moderation and you're not miserable. The way to get there is to abstain for long enough to reset reward pathways, return to homeostasis, and then decide what your next steps are. So we recommend four weeks and we warn people they're going to feel worse before they feel better. We recommend self binding strategies. So what is self binding strategies? That's an acknowledgement that willpower is a limited resource and that if we're relying alone on willpower, we will not be successful. Successful. Therefore, we have to create literal and metacognitive barriers between ourselves and our drug of choice so that we can leverage our willpower and meet our goal of abstention for four weeks. General categories. These are just some general categories. You can make any up any categories, but space is a category. So this is both literal barriers between ourselves and our drug of choice. Get the sugar out of the house, get the alcohol out of the house. Throw your bong away. Run water over your cigarettes and put them in a garbage can far away so you can't go fishing them out again. Delete the app. Unsubscribe yourself from that sports betting website. These are the literal kinds of. You just create that little pause, right? That little pause that allows us to kind of take a breath and say, okay, I don't want to do this. And if there's a little bit of a break, maybe I'll be more successful. Time is a really interesting kind of self binding strategy. So the dopamine and fast itself is really a form of using time as a self binding strategy. But also later, after the dopamine fast, we talk about, well, what do you want to do now? Do you want to continue to abstain or do you want to go back to using in moderation? The vast majority of our patients want to go back to using in moderation. And even if I think they're not a good candidate for that, they often have to learn that for themselves. This is like a PhD, their own little PhD in neuroscience. So what we say is, okay, that's your goal. What is moderation going to look like? And here we really drill down on details. When are you going to use how much, how often? Who are you going to use with? What are going to be your red flags for when you're using more than you said you were going to use or in a way you didn't want to. So part of that could be scheduling specific times for scrolling meaning. So this is really, I think, very helpful looking at sort of what's the, the larger meaning behind my wanting to abstain. When people report feeling better, which most of them do after the dopamine fast, we have them do a pros and cons list. What was better about not using and what was bad about not using. When people talk about what was better, they'll talk about things like, I was more present in my life, less anxious, less depressed, better able to sleep, able to pay attention. The top of the list of what was bad about not using. Couldn't hang out with my friends because all my friends use whatever that drug may be. Right? Number two was bored. Really bored. Had a whole bunch of time that I didn't know what to do with. Boredom is a really powerful and scary emotion and we really in the modern world don't have to deal with it very much and we don't really know what to do with it because boredom brings up all kinds of existential issues like, wow, if I don't know what I'm doing with myself right now, what am I supposed to be doing? I'm betting that many people in this room don't deal with a lot of boredom because you guys are way too busy. But I bet also that boredom would be pretty scary to deal with people is a great way to engage in self binding. So doing the dopamine fast with somebody else, doing it together as a family, engaging in a 12 step community or other mutual help community when we co regulate our behaviors with other people, we are much more likely to be successful. Whereas if we live alone and we have to manage these consumptive behaviors alone, super hard. And then finally, there are a lot of interesting medications. Not a lot, but I would say there are more coming down the pike. For example, we have a medication called naltrexone, which is an opioid receptor blocker that we use to help people quit using opioids. The mechanism there is obvious. If you're blocking the opioid receptor, the opioid that you're ingesting cannot bind and stimulate that receptor. But we also use naltrexone to treat alcohol use disorder. And not just for people who want to stop drinking, also for people who want to reduce their use. Because it turns out that the chemical cascade for alcohol, it works on the gaba, or inhibitory neurotransmitter system, but it also works on our endogenous opioid system. So when we're blocking the opioid receptors with naltrexone, basically what my patients tell me is when I'm on naltrexone and I drink a beer, I really don't want another one. I'm kind of good with one, whereas normally I would want to drink the whole six pack. Also, interestingly, remember that reminder mechanism, how when we're reminded of our drug of choice, we get a little boost in dopamine. Naltrexone actually helps decrease craving because probably when people are reminded or triggered, they don't get that same dopamine boost because the chemical cascade is blocked by the naltrexone, so they don't get triggered in the same way. Too. We have other medicines. WeGovy or Ozempic is being used now to treat binge eating and obesity. And we're also finding that it's helpful for alcohol use disorder. Alcohol, because it's caloric, works on the same appetitive mechanisms as food. This is a really old but very powerful study. This was a cohort of adult males who, who met criteria for major depressive episode and also alcohol use disorder or alcohol addiction. They were put into a psych unit where they received no treatment for their depression, but they also did not have any access to alcohol for four weeks. At the end of those four weeks, 80% of those individuals no longer met criteria for major depression. So what's very powerful there is again, just by, by intervening around the consumptive addictive behaviors, symptoms of depression and anxiety get better. Finally, this pleasure pain balance works Both ways, those gremlins are agnostic to whatever the initial stimulus is. If we press on the pleasure side of the balance, they hop on the pain side of the balance. If we press on the pain side of the balance, they will actually hop over onto the pleasure side of the balance and we will get dopamine indirectly by paying for it up front. The classic and evidence based examples of this are exercise, ice cold water baths, fasting, meditation, and prayer. I put on here. You wouldn't necessarily think of meditation and prayer as doing what's painful, but for most people it's effortful. And anything that requires a kind of sustained and effortful engagement tends to be difficult. And when we do that, and we know that all of these things increase dopamine, but the way that they do it is different from the way that intoxicants do it. You remember intoxicants, you get that burst of dopamine followed by dopamine free fall. Here you get something very different. You get the initiation of the activity with a slow increase in dopamine over the latter half of that activity. Then that dotted line represents when the activity stops. You see here, dopamine levels remain elevated for hours afterwards before going back down to the baseline position. You never go into that dopamine deficit state that drives the craving. So this is a wonderful way to get your dopamine. However, it's not without its own pitfalls. So anything that gives us dopamine has the potential to be addictive. Most personality types will not be drawn to the kinds of addiction to pain. But I'm guessing that a disproportionate number of people in this room probably have the personality type that could get addicted to pain. And you see that, you know, with workaholism or exercise addiction and the intervention really is the same where we ask for people to take a break from that activity or the exercise or whatever it might be for a period of time to reset reward pathways and then a plan for re engagement. I also forgot to say that when we, we think about addictions that it's not possible to completely eliminate. Like a food addiction, you can't just stop eating for four weeks, or a workaholism addiction, you know, you can't just stop running your business for four weeks. What we ask people to do is think of a bullseye and to really drill down what is the specific activity that's problematic, what is the specific food that's problematic, and put that in the center of their bull's eye and have that represent their drug of choice, the thing that they're going to abstain from. So for work, it might be a certain way of engaging with digital media after hours or, I don't know, you guys could probably tell me better. For food, it's something like sugar, right? Giving up sugar. Then that second ring of the bullseye represents the trigger behaviors. So these are things that are not the drug itself, but the thing that trigger us to use our drugs. So it might be something like going by a bakery where there's a lot of sweets. And then that outer circle is the things that are healthy sources of dopamine, Things we want to do more of, kind of approach behaviors. These are examples. Hormesis is a branch of science that is interested in looking at the ways that exposing ourselves to mild to moderate doses of toxic stimuli actually makes us more resilient. Hormesis is Greek to set in motion. And basically what's happening is when we expose our bodies to mild to moderate doses of noxious stimuli, our body senses injury and then essentially upregulates feel good neurotransmitters like serotonin, norepinephrine. These are examples of activities that my patients have told me are hermetic. For them, you'll see many of them are quite ordinary activities, but they're doing them unplugged. We are living in a time when we're constantly stimulated. Simply sitting quietly and not being stimulated for a period of time gives our brains time to rest and recover. I've talked a little bit about dealing with boredom and other painful emotions, and also slightly mentioned getting addicted to pain. Believe it or not, we used to think that rats on a running wheel just simply measured locomotion or physical activity. But then it became apparent that certain strains of rats will actually get addicted to running wheels. And they will run on ever smaller running wheels until their little rats or their little tails are curved up in the shape of a running wheel. Some of those rats will in fact run to death. And then I love this experiment that was done in the Netherlands. They took running wheels and they put them in nature and they said, surely in God's great wonderful nature, nothing's going to go into a running wheel. Not true. Rats, slugs, squirrels, all kinds of animals were intrigued by moving through three dimensional space against gravity in a novel way, which maybe explains roller coasters and Ferris wheels and things like that. Finally, this is my last slide. I've really emphasized sort of what we can do at an individual level to cope with our drugified addictogenic ecosystem. But it's Obviously not just an individual problem. This is also a problem that needs to be solved at the both the community level, the level of governance. This is a meme somebody sent me. Are you 18? Because otherwise you can't go into this porn site. And as you can see, it's pretty easy to access. And we're now seeing legislation that's happening in certain states that makes it, for example, harder for people under the age of 21 or under the age of 18 to access certain states sites. I think this is really important. We need to have these guard rails. When I think about community, I really think about schools. You know, we were really led to believe that one child, one laptop would solve all of our education problems. Now what we have is one child, one inattentive child who's not learning. So I think that smartphones should essentially be banned from the top down during school hours. There are schools that are doing this now, and there are different ways to accomplish it. For example, there are these pouches that kids put their phone in the pouch, they lock the pouch, it can't transmit or receive, and then they unlock it at the end of the day. That way the school doesn't have to deal with holding onto the phones. Whatever it takes, let's get the smartphones out of the schools so teachers can teach and kids can learn. Yeah, especially like K through 12. I mean, it's just so obvious that we need to do that. And then in terms of governance, I mean, so we're seeing, you know, the Facebook meta lawsuit. We'll see if that goes anywhere. There's legislation all over the country. In China, the government actually said that kids can't play video games except for two days a week, two hours a day, and that the corporations that make the video games are responsible for creating the facial recognition software to police it. And I know that that could never happen in the United States, but boy, parents in China were jumping for joy when they. When they came up with that. And I really do think that we need some kind of government legislation and guardrails to protect our kids.

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