“What does it mean to have a healthy relationship with pain and pleasure?”

Anna Lembke

“What does it mean to have a healthy relationship with pain and pleasure?”

Anna Lembke

Addiction psychiatrist & author

Anna Lembke is a professor of psychiatry at Stanford University School of Medicine. She is author of Drug Dealer: MD (2016) and Dopamine Nation (2021), as well as over a hundred peer reviewed papers and book chapters. She appeared in the Netflix documentary The Social Dilemma, where she discussed the damage that social media is doing to our lives.


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KP Hello Anna, thank you so much for joining me today. As you know, this podcast starts by asking for a question that we should be asking ourselves, so I wonder whether we can start there. From your insights and experience, what do you think it’s particularly important for us to be asking ourselves at this moment in time?

AL  Well thank you for inviting me, I’m delighted to be here and I’m a little nervous in the face of having to pose this type of question. But I’m going to try, and I guess I would say I think one of the most pressing questions for modern humans, because I think we all ask the same questions again and again through the generations but we have to reformulate them for our times, and different questions become more urgent at different times…As you can see I’m prevaricating, trying not to get to the point where I actually have to pose the question. But I think one of the most important questions, or a question that we could and should ask ourselves, is how is it that we as modern humans should be orienting on pain and pleasure. So what role do pain and pleasure have in our lives today, and how can understanding how we process pain and pleasure inform better choices.

KP That’s an excellent question. So how is it that pain and pleasure kind of affect and shape the way that we live today? You mentioned that this is relevant to the way we live in modern life, which is presumably slightly different or maybe drastically different from the way it has been in the past. So um, how do you think, if you can speak in general terms, we are orientating towards pain and pleasure in contemporary life?

AL Well as you point out, implicit in my question is the idea that somehow the world is fundamentally different today than it has been for most of human history. So let’s talk about that first, because I think that’s an important way to set the stage and, importantly, you know, for most of human existence we have lived in a world of scarcity and ever present danger, and our reflexive, innate evolutionary wiring to approach pleasure and avoid pain is what has allowed us to survive over the millennia. But scientific and technological innovation in all aspects of life have really transformed the world from a place of scarcity, to a place of overwhelming abundance. We need to now orient differently on how we approach pleasure and pain, and namely, I believe that we need to embrace a new kind of asceticism, and we need to actively invite the friction of pain and suffering into our lives as a way to just generally be physiologically healthier. But also to strive for the kind of contentment and serenity that I think all humans are wired to want and to strive for. So I think that this is a unique time where we have to think differently about our orientation to pleasure and pain, and specifically we have to go against our biology; we have to kind of actively and intentionally oppose millions of years of evolution if we want to survive frankly.


KP So maybe we could begin by unpacking what happens with pain and pleasure in the brain – your work is based on the neurotransmitters of pain and pleasure, and what that is doing to us – because it’s counterintuitive isn’t it to avoid pleasure.


AL Yes, exactly. So I use a simple metaphor to try to explain how our brains process pleasure and pain and I’ll share it here. First of all, one of the exciting findings in neuroscience is that pain and pleasure are co-located in the brain. So the same parts of the brain that process pleasure also process pain, and they work like opposite sides of a balance. So if you imagine that in your brain in your reward circuitry there’s like a teeter totter in a kid’s playground, and that represents how we process pleasure and pain. When we experience something pleasurable it tips one way, and pain tips it the other. But like all living organisms, one of the driving realities is the desire or the need for all physiologic systems to return to homeostasis, or a level balance that means without any deviation from neutrality, either in the direction of pain or pleasure. Our brains are going to work very hard to restore a level balance, and the way that our brains do that when it comes to pleasure and pain is first by tilting an equal and opposite amount to whatever the initial stimulus was. So to give an example, I really like chocolate, and when I eat chocolate I get the release of dopamine, our reward neurotransmitter and a specific circuit of our brain called the reward pathway. My balance tilts to the side of pleasure. But no sooner has that happened than my brain adapts to that increased dopamine by down-regulating dopamine receptors and dopamine transmission, not just to baseline levels but actually below baseline. I like to imagine that as these neuro-adaptation gremlins hopping on the pain side of the balance to bring it level again, but they like it on the balance so they stay on until it’s tilted an equal and opposite amount to the side of pain. That’s the come down, the hangover, the after effect, that moment of wanting one more piece of chocolate now. If I wait just a few seconds or minutes or hour minutes or hours, those gremlins hop off and homeostasis is restored, and that feeling passes. 


But if I live in a world of overwhelming overabundance, where at the touch of a finger I can have more of my drug, which again is not the world that humans evolved in, then all of a sudden I’m overwhelming my neurological system with these high dopamine rewards in order to compensate for that. My brain essentially has to continue to down regulate dopamine transmission as a way to restore homeostasis. You might imagine that as the gremlin’s multiply, getting bigger and stronger, eventually I’ve got enough gremlins on the pain side of my balance to fill this whole room. They’ve got their tents and barbecues in tow now they’re camped out there. And essentially what that means is that I’ve changed my hedonic set point, now I’m walking around with a pleasure pain balance semi-permanently tilted to the side of pain – that means now I need more of my drug in larger quantities, in more potent forms. Not even to get high, but just to level the balance and feel normal. And when I’m not using my drug of choice, I’m experiencing the universal symptoms of withdrawal from any addictive substance, which are anxiety, irritability, restlessness, insomnia, dysphoria and craving or intrusive thoughts of wanting to use. 


How this resonates, or is relevant on the meta level is that in the last 30 to 50 years, what we’ve seen is rising rates of anxiety depression and suicide all over the world, but especially in rich nations which is really this paradox of plenty. Why is it that living in the richest countries in the world with the access to everything we could ever desire and then some, we are more miserable than ever? I would argue it has to do with the mismatch between our ancient wiring and this modern ecosystem; we were not evolved for this world of plenty. We are evolved to be eternal strivers, never satisfied with what we have, always craving more. And this mismatch is leading to a kind of overwhelming population despair, essentially because from our first potent cup of Joe in the morning, and checking our smartphones, to our Netflix binge in the evening and everything in between – we’re overwhelming our reward pathways and our brains are reeling in an effort to compensate.


KP You got onto the more banal ways that we are addicted like Netflix, and I guess that was my next question because when people think about addiction, they think about people who have real problems with alcoholism or drugs or whatever. But you think this is significantly more widespread in the West, and in ways that we wouldn’t ordinarily call addiction, but you would like to use the word addiction for?


AL Yeah, thank you for emphasising the need for clarification there. When I say drugs, I’m not just talking about alcohol, and cannabis, and cocaine, and heroin, I’m talking about really anything that releases a lot of dopamine in our brain’s reward pathway quickly and and in large amounts. Dopamine is not the only neurotransmitter involved in pleasure reward and motivation, but it is the final common pathway for all reinforcing drugs and behaviours. And the more dopamine that’s released, and the quicker it’s released, the more likely that substance or behaviour is to be addictive. And what I’m arguing is that every aspect of human life has become druggified in some way, made more more reinforcing as it releases more dopamine, and is more accessible. 


One of the biggest risk factors for addiction is simply access to our drug. If you live in a neighbourhood where drugs are sold on the street corner, you’re more likely to use them and more likely to get addicted to them. Can you imagine somebody who had access to cocaine at the level that we have access to Tiktok? That would be a very serious cocaine problem, right? And then we talk about a potency – you know we have engineered ancient drugs like opioids to be a hundred times more potent than opium from the poppy plant, that is to say fentanyl, and we’ve also created drugs that didn’t exist before – video games, social media is in essence the drugification of human connection. We’ve got online pornography, you know pornography and and sex addiction probably always existed in some form, but it’s the access, quantity and potency made possible by the internet that completely changes the risk vulnerability diathesis. 


So that now you’ve got people who were innately vulnerable to addiction who are absolutely reeling. And then you’ve got a whole bunch of people who maybe aren’t innately that vulnerable to that problem two hundred years ago, but become vulnerable in the modern ecosystem, because the drugs are more potent, and again because we now have access to more drugs including, again, drugs that didn’t exist before. 


I’ll use myself as a case example. So I thought that I was immune to the problem of addiction –  when I drink alcohol I feel nothing but a headache, when I drink caffeine it unfortunately does not wake me up – I’ve tried many different times and versions. So I thought well, whatever this addiction gene is, I guess I don’t have it. But then you know in my early 40’s I discovered romance novels, for whatever reason I’d never read them before. I’d always been a reader but never happened on romance novels, and I was absolutely transported. And then I got a Kindle, which is part of the technology making that drug more accessible, and I was off and running. I became a chain reader. Twilight was my gateway drug, then I found other vampire romance novels, and then I went to the next level of like werewolf romance novels, and then you know not long thereafter that wasn’t enough, and I was reading frank erotica. And I know I wasn’t alone, because there were a lot of other middle aged women who were clearly hooked on Twilight and ended up at 50 Shades of Gray, which is essentially a socially sanctioned pornography for women. But it was very interesting for me not be able to observe the phenomenon as it was happening, which is exactly what my patients with addiction describe. It’s an insidious process that we don’t see happening as it’s happening – that is to say the process of becoming addicted. And it wasn’t until I had a kind of ah-ha moment where I had to relate my reading habits to another human being that it became real for me, which is of course the therapeutic function of going to see a mental health professional and having to tell your story all of a sudden. It’s like oh wow yeah – I really did that thing which is not necessarily observable until we put it into words. Anyway, I went a little far afield of your question.


KP No, I think you answered it really well, particularly this point about those things that we think of as innocuous that are socially acceptable and sanctioned, that there’s also, like very little friction between you and your drug of choice – be it a book, a kindle or whatever. Have you noticed in your clinical practice a rise in these kinds of problems that wouldn’t classically fit into your drug addiction and categories, but have misshapen lives because of the habits they have developed?


AL Yes, and I think this is really an important point. It’s not just my own experience, but it’s what I’ve observed in the past twenty years as a psychiatrist. And just to clarify, addiction is the continued compulsive use of a substance or behaviour, despite harm to self and/or others. So what we’re talking about here is a kind of engagement that leads to real harm, and what I have seen in just really ever growing volume in the past twenty years, but especially in the past ten years is, alarming numbers of ah people coming in with severe pornography and sex addiction a mostly occurring on the internet. And we’re talking devastating, life-threatening behaviours, people who are suicidal, who can’t do anything else, who have lost their families, lost their incomes for engaging in legal activity. Young people addicted to video games, people addicted to social media, or just the internet in general getting caught up in the spiral of being on their screens and then letting everything else go – their self-care, their obligations to others, reaching a kind of lethargy and nihilism and thoughts of suicide. So these are really devastating patterns of behaviour which are similar enough across different demographics and ethnic groups that they really can’t be Ignored. You know psychiatry is phenomenology. We based it on observed patterns of behaviour, and this is clearly an emerging problem. The other thing that I would add is that we have many patients who come to see us who are coming in for depression and anxiety,  and insomnia who don’t self identify as addicts, but have these behaviours – especially on the internet and screens causing or playing into their depression anxiety. 


But when we engage them in asking them to abstain from their tech behaviour for a period of time, usually on average about four weeks, what we find is that they initially feel more depressed and anxious. But by you know, the fourth week they’re feeling less depressed and anxious than they have in many years, and I say that because there’s a big question of causality versus correlation or causation. Because there’s lots of data now showing that people who spend more time on the internet are more likely to be depressed and anxious, is it because they’re depressed and anxious and they’re going on the internet, or is it because they’re on the internet and depressed and anxious? I would really argue that it’s the causal direction, where we’re priming our reward pathways with these highly reinforcing drugs and behaviours, and our brains are trying to compensate by down regulating – we go into the dopamine deficit state which is akin to depression. I argue that that’s the causal direction because when we ask our patients to abstain for four weeks, the vast majority feel much much better after having not been on their devices. So I think that’s really important to think about.


KP It’s huge in thinking about it as a parent, but also as someone who works in schools – it’s like this is a significant job, and it doesn’t feel like we figured out how to do it at all, and not not in the slightest. What you say reminds me slightly of Pinocchio, the Disney classic. You know when he goes to this hedonistic Island where he seeks pleasure and it’s turns out to be like some kind of a hell. It feels like a really clever way of kind of playing out the fruits of seeking pleasure for its own sake


AL Yeah, right.


KP And so we have this kind of reward and motivation chemical called dopamine. But when that becomes the goal in itself, that feeling it seems like that’s a very quick route to mischief, and so I suppose the one of the questions I’m failing to ask here is, if we shouldn’t be seeking pleasure which the world is screaming at us to pursue, what is the thing we should be pursuing beyond it, what’s the self talk there?


AL Yeah, so to me, it’s ah it’s a three part approach. The first is abstain, and you know that again is very difficult to do in the world that we live in now these drugs literally chase us down with push notifications and and other such technological advances. So. It’s very hard to do that. When we first do that, by definition we will experience pain because there’s the pain of withdrawal, but there’s also the pain of having to tolerate our own negative emotions without distracting ourselves, or escaping from them through these titillating behaviours and substances that are really everywhere we look. So because the world is kind of chasing us down with these pleasures, we really need to engage in what I call self-binding strategies. This is where we create both literal and meta cognitive barriers between ourselves and our drug of choice, so that we can press the pause button between desire and consumption. I talk about three general categories of self-binding: categorical, geographic and chronological.


So categorical is like we might tell ourselves and this may be true. Okay I can’t play League of Legends video game because it’s just too addictive, but maybe it’s okay for me to play some other video game. Or I can’t play with strangers, but maybe I can play with friends. Food is often – I can’t eat processed food and sugar, but I can eat other foods. So we kind of create these categories. 


Chronological self-binding is where we use time as a way to create these boundaries between ourselves and these drugs, which is absolutely necessary in the world today. I might say, okay I’m only going to use my drug on special occasions, or I’m only going to use two days a week for two hours a day, or I’m only going to use after I finish my exam, or I’m going to use at the end of this 30 day dopamine fast which is the initial intervention. 


Geographic is just exactly what you would imagine – not having the drug in the house, or not having the app on our phones, or maybe not even having a phone. So like, I personally own a smartphone, but 99% of the time it’s turned off in my backpack. So I don’t use it for texting and I don’t give out the number, so that’s a great barrier for me because I’m essentially not on the phone, I’m not giving and I’m not receiving through the phone. Obviously I’m on the internet and you know, I’m interacting in that space. But I do it from this relatively less portable laptop. 


So these people have to find out what works for them. So it’s first abstain, and then its use self binding to maintain, and then the third thing is seek out pain. And from a neuroscience point of view, this makes a lot of sense, that is to say if you go back to this pleasure pain balance those gremlins are essentially agnostic to whatever the initial stimulus is. So if we press on the pleasure side, they will try to rebalance by going on the pain side. But if we first intentionally press on the pain side, they will hop on the pleasure side as a way to restore homeostasis, and we will get our dopamine indirectly. Getting dopamine indirectly, for example through exercise, ice cold water immersion, focused concentration, cleaning out our closet, prayer meditation things that are effortful that are difficult to initiate, that are even physically painful – as long as they’re not too physically painful, these are all things that will ultimately change our hedonic set point to the side of pleasure, and that’s what we’re looking for right? We’re looking for a healthy resilient pleasure pain balance that responds to pleasure and pain. It’s not a matter of eliminating all pain and pleasure in our lives, we wouldn’t be human. But it’s a matter of not overdoing it in one direction or another, and because we live in this dopamine overloaded world, we have to with intention actually seek out pain, or kind of ah you know ascetic practices so that we stay in balance. So these are ideas that have been woven throughout theological and philosophical texts since the beginning of time, but with a slight twist. So for example, you know Buddha preached the middle way, right? Not asceticism, not indulgence – but somehow in the middle. But the problem is that you know in the modern world, the middle way is already tilted to the side of pleasure. So I think what we have to with intention is to tilt ourselves to the side of pain in order to stay balanced and in the middle.


KP So actually your page is on cold water immersion in Dopamine Nation was fascinating. I’ve been into that for a while, but since reading there the 200% increase in dopamine I’ve been much more religious about going in the sea and turning the shower cold and the payoff is good.


KP Good, I’m Glad.


AL It’s interesting that going towards pain, the things you mentioned they’re quite embodied-  exercise, cold water immersion, prayer, meditation etc, as opposed to and classic addiction were like you know porn, gaming, those kinds of things – they’re not embodied in the same way/ In fact, they’re kind of living a vicariously embodied life in some ways, I think you make a point to that and that effect in your book. So I guess my question is part of the problem that we have we’re very sedentary, and we have departed from the ways of our ancestors in feeling like embodied human beings, and we’re living vicariously for pleasure rather than having it as a payoff from the way that we naturally?


AL Yes I agree with you, and I would even take it a little bit further, and I would say that we first of all, we absolutely need and crave physical experiences, and in some ways drugs actually do that for us. So they give us a physical experience that otherwise we are not getting in our lives and that’s part of their appeal. I would argue that sex addiction, because it’s almost always associated with orgasm, is also a physical experience in a vacuum of physical experiences – and so again, very attractive, very appealing. And then the video games – you’re right there there we have our avatars – they run, they jump, they fly. They do all these physical things while we’re just sitting there, but the physicality of the video games is in large part their appeal, because we are so disembodied. So there’s a funny way in which these drugs sort of simulate an embodied experience, but actually are this real disconnection between our lives, and our minds, and our goals, and our values – and then this physical experience that that we’re having. I agree with you 100%, we are our bodies – I mean you know this idea that we had there’s some capacity to be a person not in your body, really don’t buy that – like we are our bodies, and our bodies are a huge part of our subjective experience in the world, and the way that we both ignore and mistreat our bodies because we have machines that do the work for us because we have a supply chain that delivers everything we need. You know we’re really suffering because of the disembodied nature of our lives.


KP I think I’ve heard your book described as science catching up with Grandma, you know this  lovely phrase to describe stuff that we know intuitively or from traditional wisdom, and and now you’re uncovering the kind of science behind it.


AL Ah, yeah, that’s right.


KP One question I have really is about something that you mentioned passingly, and now and again in the book, about the role of the spiritual, higher powers etc. At one point you say ‘I believe in believing’ when you’ve urged somebody to get on their knees and pray when they’re struggling with an addiction.And I guess my question is maybe slightly upstream of that. So over the last few decades as screens have proliferated and friction has been removed from all these ways we can find dopamine, and at the same time we’ve lost a kind of meaning-making narrative that religion offered. Would you would it be too much to suggest that perhaps as we’ve lost this sense of meaning and purpose, pleasure has has become the kind of the purpose of things? I mean would you make that association at all, if that makes sense as a question?


AL Well those those two things definitely go hand in hand. So you know I mean I think it’s fair to say that again for most of human existence people derived their meaning through the notion of being part of something larger than themselves, and some deistic you know, um, some kind of god right? And of course what’s happened with the enlightenment and science and scientism, because science is at the end of the day a religion in itself, is that we are really these disembodied, purposeless things that are just sort of floating around on this rock in space, and none of it means anything, and so I think you know with that comes a kind of nihilism on the order of ‘well if if if none of it means anything and and there’s no reason for my suffering, then who cares like you know and like, ‘just live for today and feel pleasure’ and I think also a big part of that. 


Many people don’t really necessarily even reflect in spiritual terms especially in our increasingly secular world. There’s just plain old capitalism, which is really the driving economic system even in so-called communist countries today.  And capitalism is sort of this incredible invention which optimizes human striving and innovation, but the ultimate end of which is to turn us all into addicts. You know the ultimate capitalist member of society, not necessarily the dominant members, but you know the vast hordes, is the ultimate consumer – somebody who just feeds the machine by continuing to look for an optimal product, and then ultimately becomes the product themselves. We talk the way that these digital products are really engineered to keep us hooked in, so I think it’s I think all of those things, all of those threads are related like the secular nature of our lives, the sort of underpinnings of capitalism, a kind of a nihilism. You know that that Nietzsche certainly predicted it, and that has really come to pass – and I say that because I see that in a lot of young people who come from loving families of privilege who have access to the best education, and who have friends and you name it, they could really do almost anything, and yet there’s this incredible lassitude. They can barely get out of bed in the morning, they see no reason for doing anything, and so they they lose themselves in in video games or pornography or what have you.


KP So you’ve got these fantastic, really practical tips on self-binding and so on. But you can’t impose a spiritual narrative on people, but do they at the same time have to re-enchant  the world so that it doesn’t seem as nihilistic, and you know that hedonism isn’t there and isn’t the guiding principle of life, like to move away from the Utilitarian and towards something a bit more transcendent?


AL Oh yes I mean I agree with that 100%, and that’s been also very true in my own life. But it’s really interesting in modern western medicine you know the probably the the four- letter word is is the three letter word of God. So we’re not supposed to talk about God and Spirituality. It’s crazy even in Psychiatry. It’s kind of a taboo subject, but I do – I mean I really encourage patients to talk about spirituality. I ask them whether they have a spiritual practice, whether they are a person of faith. So I tried to meet them where they are explore those aspects of their lives with them, and really encourage that The nice thing about being in the field of addiction medicine is that there’s a long tradition of getting into recovery from addiction through spiritual transformation. So it is let’s say ah a sort of area of of medicine where maybe spirituality talk is is still okay, but even then I would say most most physicians are really afraid to go there. I had a colleague recently who said to me ‘I had a patient who come came in, he was a lot of distress and you know he asked me if maybe he should start going back to synagogue or seek out his rabbi’ and she said you know and I’m Jewish and I wanted to tell him ‘yes, you definitely should’. But then I thought no, I shouldn’t do that because I’m a doctor, so a lot of these. Yeah.


KP It’s I mean it’s so interesting isn’t it. Lisa Miller who I interviewed for the series, her research suggests that you are with the spiritual practice 80% resilient against despair and suicide and presumably addiction comes into that too. And yet despite the evidence base, it’s kind of taboo – like in the UK you could be struck off because it it seems proselytizing or whatever. So it’s interesting, when we want to be scientific and you know there’s is data here, there is there’s something to be said.


AL Yeah yeah, yeah, that’s right, that’s right and when you know you look at, for example, we have data showing that participation in 12 step groups like alcoholics anonymous, which is really founded on this idea of a spiritual transformation or higher power. When people participate in that, they have good outcomes that are on par with seeing a psychologist, and maybe even better than seeing a psychologist for long-term recovery. And when you look at the mechanisms specifically that are at play in those organizations, the spiritual transformation or the higher power is a very important part of that. And yet I would argue that this is the age of scientism. Science is our new religion, and if you can’t quantify it, and you can’t do a controlled trial or whatever, or even if there are controlled trials, people are very resistant to these ideas.


KP I feel like I hope that the conversation is beginning to change. I mean maybe it’s just what I read, but there’s a certain kind of disenchantment with hard scientism and reductionism and utilitarianism and instrumentalism – and all these things these isms that seem to be governing the way we live in a dissatisfying way. So if our pursuit of pleasure is part of the problem, how should we think about pleasure, like what role should it have in our lives?


AL Yeah, I mean you know so my message is not ‘never imbibe intoxicants’. But my message is to use them infrequently, and in moderation, and try to avoid very potent forms. You know once we reset our reward pathways, even very simple, modest rewards can be highly rewarding. In other words, pain and pleasure are incredibly relative, and that’s what we have to recognize in that. If we’re always upping the ante, and using more and more of these reinforcing drugs and behaviors, they all exhaust themselves – nothing then is pleasurable and then things that are more modestly rewarding that used to be pleasurable, aren’t pleasurable either. So it’s really a matter of keeping a healthy and resilient pleasure pain balance, and we need to do that by generally avoiding intoxicants and using them in moderation when we do use them, and allowing enough time in between for those neuro-adaptation gremlins to hop off of the pain side of the balance and for homeostasis to be restored because what we don’t want to do is get into that situation where we’re getting into the addicted brain, which is those gremlins camped out on the pain side of the balance. 


There’s an interesting experiment done by George Koob, a neuroscientist and his colleagues, showing that if you expose rats to an unlimited amount of cocaine they will essentially accelerate their consumption by pressing a lever faster and faster over the course of subsequent days. But if you allow them to have access to cocaine only one hour a day, then the rate at which they press that lever stays steady over the course of many days, so there is something important about having enough time in between our usage to kind of restore this homeostatic step set point, so that we don’t start chasing more and more dopamine. So I think that’s really important. I do think it’s really important to recognize the ways in which so many things have become drugified, you know, even watching a Netflix show. We might not think of that as a drug, but I challenge people to think about how they feel when they’re watching a show and then how they feel right when the show ends and then what it means that when you come to the end of an episode, for example, that there’s a little button in the right hand corner that starts to go through and say next episode so you’ll automatically be given that next episode unless you do the work to stop that button which is I think a great metaphor for the world that we live in now. 


We have to actually prepare in advance for it, and do the work to avoid pleasure, because otherwise the world is set up to just keep that fire hose going. So I think that’s really important and then you know, inviting pain into our lives doing things that are physically hard. We have a whole narrative that pain is bad for you, that pain is not just painful in the moment, but kind of creates a kind of psychic scar for pain in the future. That is completely different from how people used to think of pain the role of pain in our lives. The people used to believe that not only were there spiritual gifts through suffering, but even surgeons you know in the mid eighteen hundreds when general anaesthesia was first invented did not did not want to use it, because they believed that their patients needed to experience pain during surgery in order to heal faster and have a better recovery. That sounds like barbaric to modern people, and yet fascinating studies are now showing that when when surgeons spare opioids during surgery, that is to say use fewer opioids or use no opioids, that patients heal faster from surgery. So there’s real scientific evidence to support that sort of instinctual reaction that surgeons had to general anaesthesia with opioids in the mid 1800’s.


KP That’s a super interesting finding, it reminds me of something I learned recently about trees that grow up in kind of greenhouses or biodomes, and they get to a certain height and they can’t support their own weight, so they collapse. The reason is that they’re never exposed to wind to resistance, which is what makes them grow strong, if they have resistance – the same with grass and football stadiums. They have fake wind so that it has some resistance to grow against, which seems like a lovely metaphor for character development, right?


AL Oh that’s fascinating. Yeah, yeah, right, right


KP I mean, you’re talking about something much bigger than chemicals here really, it’s how we live, how we oriente our lives. Something you say towards the end of your book is that you urge. your reader to embrace yourself fully in the life you’ve been given. I take it from this that the suggestion is that we run away from the life that we’ve been given, and into these kind of cul-de-sacs of pleasure. But perhaps you could explain a bit more what the intention behind that kind of challenge was to us?


AL Yeah, so I mean it the way that it comes to me visually that most of us spend most of our lives literally, like not literally but figuratively, mentally running away from the pain in our lives, whatever it may be. And that is a race we will never ever win, at some point we will be too exhausted to keep going and the terror of that moment, we can’t even fathom it. And yet you know there’s this incredible paradox that when we stop running away trying to escape with drugs and alcohol and Netflix and romance novels and you name it,  to sort of not feel our pain; when we actually then stop and turn and face that pain of our lives, whatever it may be – we imagine that we will be annihilated, but something really incredible happens in that moment, and we experience relief from our suffering. And I just find that absolutely fascinating. Especially I as a psychiatrist in the work that I do it’s really It’s really changed the way that I talk with patients. Because you know early in my career, because of where I was in my own life and and still running from pain and also the way that I was taught to prescribe pills for people to make them not feel pain. Then if I was going to be a good doctor then I would get them out of their pain. And now I don’t orient that way at all toward patients, instead I see their suffering as part of our communal suffering, I try to some extent to to normalize, to validate it, to just kind of bear witness and to also trust in their own ability to tolerate it, and to endure and to keep going, which is a very different thing than saying oh no, you’re you’re depressed here, let’s give you some pills and take that away, and are you less depressed now? No. Okay so here are some more pills. 


The other way that idea ,this different way of orienting on pain has really affected my practice which is at serious odds with the way that mental health care is delivered today, is this the way that people now orient on trauma. So. There’s this very, I would say like, overwhelming movement now in mental health treatment that if we’re unhappy or have dysfunction in our lives that what we need to do is go back into our past and find that moment or 2 or 10 of how we were traumatized typically by other people who then ah then get identified as the perpetrators of our suffering. And then once we’ve done that we will be completely illuminated as to why we’re so unhappy and then that will solve our unhappiness and first of all I don’t know that that is true. That’s the ancient Freudian idea that adult psychopathology is caused by these early childhood experiences, that then often enter some unconscious realm and maybe we don’t even remember them and once we. Bring them to the surface then we will solve our psychological problems and like I mean the longer I practice psychiatry the less true I think that is I think that we’re much more likely to be influenced by things like temperament. Ah the people that we surround ourselves with the the ecosystem and the culture that we live in the dominant narratives. But we we nonetheless tell ourselves and mental health care providers encourage this telling of a story, where you identify that moment of trauma and what happens to those people often is it doesn’t help them, it doesn’t move them into wellness or um, serenity or a better way of living it instead. It makes them feel like the perpetual victims. So this idea that the difficult things in our lives make us weaker is really problematic.


KP That’s really interesting. I’ve not heard much pushback against that before, so dominant this find the pain in your childhood and you bring it to the fore and then you, you’re going to yeah deal with it that way. 


One last thing I’d like to ask you about is truth and deception, which have some place in this whole story of addiction. Like what we do on screens is essentially secret, we can get away with things when we live in atomized communities. We’re far less relational than we were I think made to be. You have this observation that truth produces a sense of plenty or abundance, this kind of spaciousness; whereas deception or lies create scarcity –  I think it paraphrased you badly there, would you with your mind explaining the gist of it?


AL I think a good way to enter into this is to talk about the Stanford Marshmallow Experiment. So this was an experiment that was done many years ago where they put a child between the age of 4 and 6 in a room with nothing else in the room except for a table a chair a plate and one marshmallow on the plate. They said to the child ‘if you can wait 15 minutes here in this room by yourself without eating the marshmallow we will give you a second marshmallow and then you can have both of them’, and it was a way to kind of measure the ability to to delay gratification what they found was that it highly correlated with age. The older the child, the more able they were to not eat the marshmallow in order to get a second one 15 minutes later. The sort part of the marshmallow experiment that became very famous is that they then followed these children prospectively to show that you know the kids who could wait longer at a given age compared to the kids at the same age who couldn’t wait as long. The kids who could wait longer went on to college, had better jobs better test scores and more successful lives. But a little known variant to that experiment was where they divided the kids into two groups. They said the same thing ‘you wait 15 minutes you’ll get a second marshmallow, but you see this bell here. if you ring this bell anywhere in those 15 minutes the researcher will come back, so if for any reason you want to ring the bell and have the researcher come back,t hey’ll do that’ and what they did is that in half of that cohort. When the child rang the bell the researcher indeed came back. In the other half when the child rang the bell the researcher did not come back in. In other words, the researcher had lied to the child and said I’ll be there for you but then they weren’t and what they found was that in the cohort of children who were lied to they were much more likely. To eat that marshmallow and not be able to wait the full fifteen minutes and I as as as I interpret that um, what? what? I think that means is that when we live in a world where people tell the truth to each other then we have. Trust in ah, an unseen future and we feel we can rely on the world being an orderly and predictable place where people will do what they said they would do and when that happens then we can delay gratification because we can trust in other people. Ah, and trust in the world and that is a plenty mindset. Um as opposed to a scarcity mindset where ah people lie to us. We can’t rely on them. So I better take all I can get and eat that marshmallow right now because. Who knows if they didn’t come back at the bell they’re probably not going to give me a second marshmallow even if I wait the full fifteen minutes and I think this has to me really interesting implications for um, for the world that we live in now and for a conceptualisation of of addiction.


Addiction really is the ultimate scarcity mindset. It’s you’ve got a lot of your drug you wouldn’t be able to get addicted without having access to quite a bit of it and yet you have this continual feeling that there’s never enough, and you can’t wait and you can’t delay gratification. There’s lots of data and lots of studies showing that people who are addicted discount future rewards and opt for immediate rewards, and it’s like it’s ah it’s like a very nice. It makes a very nice indifference curve when you examine that. But the sort of corollary to that that is fascinating is that. Let’s not start with the addiction piece that often also and leads to lying. Let’s just start with the lying and we we aren’t we now live in a world like a post- truth world right? Where people can make up their entire identities and run for office on fake identities and then other people find out that it’s fake and then still vote for them. I mean it just like.. it’s like truth is sort of optional and I think that that very much contributes to this kind of addictive tendency that we then all gather this sense of well that the world is a. An unreliable place I can’t trust my politicians I can’t trust other people So I’m just going to eat myself silly so that that’s that’s how I understand that.


KP It’s a super helpful explanation, and particularly your interpretation of the marshmallow experiments a very telling. I think of it the way I bring up my kids, because I can be late for things I’ll say ‘I’ll be down in a minute’ and I think it’s innocuous is not actually.


AL Yes, that that’s right. And so and I’m always very interested in how these ideas can practically influence our choices and so I hope that that.


AL That you know anecdote and the explanation of it and encourage parents to be really truthful with their kids to admit their mistakes to to show up when they said they were going to show up. It’s all those little things. The accumulation of those little things that absolutely hugely impact. How people you know, perceive the world and the framework that they then apply to their choices. So I’m glad that you think about that a vis-a-vis your children I think that’s really important and I try not to lie to my children too. I’m often unsuccessful but then I try to make amends.


KP So if I can if I can kind of just a brief review of what I think and we’ve been talking about what particularly you’ve been saying and well yeah, well weve we’ve ramble that as for my curiosity but you’ve.


AL Great. Thank you! That’ll be good to write it down.


KP You’ve been fascinating to to hear in these questions and the that society needs a reset is absolutely clear but we cannot rely on society to to reset itself for our benefit, because it’s not happening. It’s too much in thrall to big tech and everything else. So what needs to happen on an individual level when you ask yourself this question of how do I orientate towards pain and pleasure is to step back and to think about how we need to reset in terms of what are we enthralled, to and how is this kind of misshaping the way we orientate to the world and those around us. And so one of my big takeaways from your book and from this conversation is, what would it mean to have a healthy relationship with pain and pleasure?

AL Yes, that’s wonderful. Yes, and that that’s a wonderful way to phrase it, I wish I had phrased that it that way in the beginning. What would it mean to have a healthy relationship with pain and pleasure – and again because I’m ultimately a very practical person and I feel that life is one grand experiment that we’re always tinkering with the variables to the recipe for a healthy relationship with pain and pleasure is really this 3 step recipe. First abstain, then use self binding to maintain, then seek out pain. And because it rhymes it will hopefully be easy to remember.


KP Well rhyming is a wonderful way to to work in the memory. Dr Lembke, it’s been such a pleasure to speak to you, I think your book is massively important and I frequently recommend it. 


AL Well thank you, It’s been really a pleasure and thank you for your thoughtful questions and your curious mind and also thank you for teaching young people I think that’s a really important job.


KP Oh thank you I appreciate that, and thank you so much for your time today – it’s been a privilege and a pleasure.


AL Oh you’re welcome. Thank you so much bye-bye.



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