Dopamine Nation by Anna Lambke
Juan Carlos Zambrano
Gerente de Finanzas @ Tecnofarma Bolivia | Coaching ontologico
INTRODUCTION - The Problem
Feelin’ good, feelin’ good, all the money in the world spent on feelin’ good. —LEVON HELM
This book is about pleasure. It’s also about pain. Most important, it’s about the relationship between pleasure and pain, and how understanding that relationship has become essential for a life well lived.
Why?
Because we’ve transformed the world from a place of scarcity to a place of overwhelming abundance: Drugs, food, news, gambling, shopping, gaming, texting, sexting, Facebooking, Instagramming, YouTubing, tweeting?.?.?. the increased numbers, variety, and potency of highly rewarding stimuli today is staggering. The smartphone is the modern-day hypodermic needle, delivering digital dopamine 24/7 for a wired generation. If you haven’t met your drug of choice yet, it’s coming soon to a website near you.
Scientists rely on dopamine as a kind of universal currency for measuring the addictive potential of any experience. The more dopamine in the brain’s reward pathway, the more addictive the experience.
In addition to the discovery of dopamine, one of the most remarkable neuroscientific findings in the past century is that the brain processes pleasure and pain in the same place. Further, pleasure and pain work like opposite sides of a balance.
We’ve all experienced that moment of craving a second piece of chocolate, or wanting a good book, movie, or video game to last forever. That moment of wanting is the brain’s pleasure balance tipped to the side of pain.
This book aims to unpack the neuroscience of reward and, in so doing, enable us to find a better, healthier balance between pleasure and pain. But neuroscience is not enough. We also need the lived experience of human beings. Who better to teach us how to overcome compulsive overconsumption than those most vulnerable to it: people with addiction.
Whether it’s sugar or shopping, voyeuring or vaping, social media posts or The Washington Post, we all engage in behaviors we wish we didn’t, or to an extent we regret. This book offers practical solutions for how to manage compulsive overconsumption in a world where consumption has become the all-encompassing motive of our lives.
In essence, the secret to finding balance is combining the science of desire with the wisdom of recovery.
PART I - The Pursuit of Pleasure
CHAPTER 1 - Our ** Machines
Addiction broadly defined is the continued and compulsive consumption of a substance or behavior (gambling, gaming, sex) despite its harm to self and/or others.
One of the biggest risk factors for getting addicted to any drug is easy access to that drug. When it’s easier to get a drug, we’re more likely to try it. In trying it, we’re more likely to get addicted to it
To be sure, increased access is not the only risk for addiction. The risk increases if we have a biological parent or grandparent with addiction, even when we’re raised outside the addicted home. Mental illness is a risk factor, although the relationship between the two is unclear: Does the mental illness lead to drug use, does drug use cause or unmask mental illness, or is it somewhere in between?
Trauma, social upheaval, and poverty contribute to addiction risk, as drugs become a means of coping and lead to epigenetic changes—heritable changes to the strands of DNA outside of inherited base pairs—affecting gene expression in both an individual and their offspring.
These risk factors notwithstanding, increased access to addictive substances may be the most important risk factor facing modern people. Supply has created demand as we all fall prey to the vortex of compulsive overuse.
Our dopamine economy, or what historian David Courtwright has called “limbic capitalism,” is driving this change, aided by transformational technology that has increased not just access but also drug numbers, variety, and potency.
The world now offers a full complement of digital drugs that didn’t exist before, or if they did exist, they now exist on digital platforms that have exponentially increased their potency and availability. These include online pornography, gambling, and video games, to name a few.
Furthermore, the technology itself is addictive, with its flashing lights, musical fanfare, bottomless bowls, and the promise, with ongoing engagement, of ever-greater rewards
The Internet and Social Contagion
The Internet promotes compulsive overconsumption not merely by providing increased access to drugs old and new, but also by suggesting behaviors that otherwise may never have occurred to us. Videos don’t just “go viral.” They’re literally contagious, hence the advent of the meme.
Human beings are social animals. When we see others behaving in a certain way online, those behaviors seem “normal” because other people are doing them. “Twitter” is an apt name for the social media messaging platform favored by pundits and presidents alike. We are like flocks of birds. No sooner has one of us raised a wing in flight than the entire flock of us is rising into the air.
Seventy percent of world global deaths are attributable to modifiable behavioral risk factors like smoking, physical inactivity, and diet. The leading global risks for mortality are high blood pressure (13 percent), tobacco use (9 percent), high blood sugar (6 percent), physical inactivity (6 percent), and obesity (5 percent). In 2013, an estimated 2.1 billion adults were overweight, compared with 857 million in 1980. There are now more people worldwide, except in parts of sub-Saharan Africa and Asia, who are obese than who are underweight.
Rates of addiction are rising the world over. The disease burden attributed to alcohol and illicit drug addiction is 1.5 percent globally, and more than 5 percent in the United States. These data exclude tobacco consumption. Drug of choice varies by country. The US is dominated by illicit drugs, Russia and Eastern Europe by alcohol addiction.
Global deaths from addiction have risen in all age groups between 1990 and 2017, with more than half the deaths occurring in people younger than fifty years of age.
The poor and undereducated, especially those living in rich nations, are most susceptible to the problem of compulsive overconsumption. They have easy access to high-reward, high-potency, high-novelty drugs at the same time that they lack access to meaningful work, safe housing, quality education, affordable health care, and race and class equality before the law. This creates a dangerous nexus of addiction risk.
Princeton economists Anne Case and Angus Deaton have shown that middle-aged white Americans without a college degree are dying younger than their parents, grandparents, and great-grandparents. The top three leading causes of death in this group are drug overdoses, alcohol-related liver disease, and suicides. Case and Deaton have aptly called this phenomenon “deaths of despair.”
Our compulsive overconsumption risks not just our demise but also that of our planet. The world’s natural resources are rapidly diminishing. Economists estimate that in 2040 the world’s natural capital (land, forests, fisheries, fuels) will be 21 percent less in high-income countries and 17 percent less in poorer countries than today. Meanwhile, carbon emissions will grow by 7 percent in high-income countries and 44 percent in the rest of the world.
We are devouring ourselves.
CHAPTER 2 - Running from Pain
In 2016, I gave a presentation on drug and alcohol problems to faculty and staff at the Stanford student mental health clinic. It had been some months since I’d been to that part of campus. I arrived early and, while I waited in the front lobby to meet my contact, my attention was drawn to a wall of brochures for the taking.
There were four brochures in all, each with some variation of the word happiness in the title: The Habit of Happiness, Sleep Your Way to Happiness, Happiness Within Reach, and 7 Days to a Happier You. Inside each brochure were prescriptions for achieving happiness: “List 50 things that make you happy,” “Look at yourself in the mirror [and] list things you love about yourself in your journal,” and “Produce a stream of positive emotions.
Perhaps most telling of all: “Optimize timing and variety of happiness strategies. Be intentional about when and how often. For acts of kindness: Self-experiment to determine whether performing many good deeds in one day or one act each day is most effective for you.
These brochures illustrate how the pursuit of personal happiness has become a modern maxim, crowding out other definitions of the “good life.” Even acts of kindness toward others are framed as a strategy for personal happiness. Altruism, no longer merely a good in itself, has become a vehicle for our own “well-being.”
The practice of medicine has likewise been transformed by our striving for a pain-free world.
By contrast, doctors today are expected to eliminate all pain lest they fail in their role as compassionate healers. Pain in any form is considered dangerous, not just because it hurts but also because it’s thought to kindle the brain for future pain by leaving a neurological wound that never heals.
The paradigm shift around pain has translated into massive prescribing of feel-good pills. Today, more than one in four American adults—and more than one in twenty American children—takes a psychiatric drug on a daily basis.
The use of antidepressants like Paxil, Prozac, and Celexa is rising in countries all over the world, with the United States topping the list. Greater than one in ten Americans (110 people per 1,000) takes an antidepressant, followed by Iceland (106/1,000), Australia (89/1,000), Canada (86/1,000), Denmark (85/1,000), Sweden (79/1,000), and Portugal (78/1,000). Among twenty-five countries, South Korea was last (13/1,000).
Beyond extreme examples of running from pain, we’ve lost the ability to tolerate even minor forms of discomfort. We’re constantly seeking to distract ourselves from the present moment, to be entertained.
Lack of Self-Care or Mental Illness?
We’re all running from pain. Some of us take pills. Some of us couch surf while binge-watching Netflix. Some of us read romance novels. We’ll do almost anything to distract ourselves from ourselves. Yet all this trying to insulate ourselves from pain seems only to have made our pain worse.
According to the World Happiness Report, which ranks 156 countries by how happy their citizens perceive themselves to be, people living in the United States reported being less happy in 2018 than they were in 2008. Other countries with similar measures of wealth, social support, and life expectancy saw similar decreases in self-reported happiness scores, including Belgium, Canada, Denmark, France, Japan, New Zealand, and Italy.
Researchers interviewed nearly 150,000 people in twenty-six countries to determine the prevalence of generalized anxiety disorder, defined as excessive and uncontrollable worry that adversely affected their life. They found that richer countries had higher rates of anxiety than poor ones. The authors wrote, “The disorder is significantly more prevalent and impairing in high-income countries than in low- or middle-income countries.
The number of new cases of depression worldwide increased 50 percent between 1990 and 2017. The highest increases in new cases were seen in regions with the highest sociodemographic index (income), especially North America.
Physical pain too is increasing. Over the course of my career, I have seen more patients, including otherwise healthy young people, presenting with full body pain despite the absence of any identifiable disease or tissue injury. The numbers and types of unexplained physical pain syndromes have grown: complex regional pain syndrome, fibromyalgia, interstitial cystitis, myofascial pain syndrome, pelvic pain syndrome, and so on.
When researchers asked the following question to people in thirty countries around the world—“During the past four weeks, how often have you had bodily aches or pains? Never; seldom; sometimes; often; or very often?”—they found that Americans reported more pain than any other country.
Thirty-four percent of Americans said they felt pain “often” or “very often,” compared to 19 percent of people living in China, 18 percent of people living in Japan, 13 percent of people living in Switzerland, and 11 percent of people living in South Africa.
The question is: Why, in a time of unprecedented wealth, freedom, technological progress, and medical advancement, do we appear to be unhappier and in more pain than ever?
The reason we’re all so miserable may be because we’re working so hard to avoid being miserable.
CHAPTER 3 - The Pleasure-Pain Balance
Neuroscientific advances in the last fifty to one hundred years, including advances in biochemistry, new imaging techniques, and the emergence of computational biology, shed light on fundamental reward processes. By better understanding the mechanisms that govern pain and pleasure, we can gain new insight into why and how too much pleasure leads to pain.
Dopamine
The main functional cells of the brain are called neurons. They communicate with each other at synapses via electrical signals and neurotransmitters.
Neurotransmitters are like baseballs. The pitcher is the presynaptic neuron. The catcher is the postsynaptic neuron. The space between pitcher and catcher is the synaptic cleft. Just as the ball is thrown between pitcher and catcher, neurotransmitters bridge the distance between neurons: chemical messengers regulating electrical signals in the brain. There are many important neurotransmitters, but let’s focus on dopamine.
NEUROTRANSMITTER
Dopamine is not the only neurotransmitter involved in reward processing, but most neuroscientists agree it is among the most important. Dopamine may play a bigger role in the motivation to get a reward than the pleasure of the reward itself. Wanting more than liking. Genetically engineered mice unable to make dopamine will not seek out food, and will starve to death even when food is placed just inches from their mouth. Yet if food is put directly into their mouth, they will chew and eat the food, and seem to enjoy it.
Debates about differences between motivation and pleasure notwithstanding, dopamine is used to measure the addictive potential of any behavior or drug. The more dopamine a drug releases in the brain’s reward pathway (a brain circuit that links the ventral tegmental area, the nucleus accumbens, and the prefrontal cortex), and the faster it releases dopamine, the more addictive the drug.
DOPAMINE REWARD PATHWAYS IN THE BRAIN
This is not to say that high-dopamine substances literally contain dopamine. Rather, they trigger the release of dopamine in our brain’s reward pathway.
For a rat in a box, chocolate increases the basal output of dopamine in the brain by 55 percent, sex by 100 percent, nicotine by 150 percent, and cocaine by 225 percent. Amphetamine, the active ingredient in the street drugs “speed,” “ice,” and “shabu” as well as in medications like Adderall that are used to treat attention deficit disorder, increases the release of dopamine by 1,000 percent. By this accounting, one hit off a meth pipe is equal to ten orgasms.
REWARDS AND DOPAMINE RELEASE
Pleasure and Pain Are Co-Located
In addition to the discovery of dopamine, neuroscientists have determined that pleasure and pain are processed in overlapping brain regions and work via an opponent-process mechanism. Another way to say this is that pleasure and pain work like a balance.
Imagine our brains contain a balance—a scale with a fulcrum in the center. When nothing is on the balance, it’s level with the ground. When we experience pleasure, dopamine is released in our reward pathway and the balance tips to the side of pleasure. The more our balance tips, and the faster it tips, the more pleasure we feel.
But here’s the important thing about the balance: It wants to remain level, that is, in equilibrium. It does not want to be tipped for very long to one side or another. Hence, every time the balance tips toward pleasure, powerful self-regulating mechanisms kick into action to bring it level again. These self-regulating mechanisms do not require conscious thought or an act of will. They just happen, like a reflex.
I tend to imagine this self-regulating system as little gremlins hopping on the pain side of the balance to counteract the weight on the pleasure side. The gremlins represent the work of homeostasis: the tendency of any living system to maintain physiologic equilibrium.
Once the balance is level, it keeps going, tipping an equal and opposite amount to the side of pain.
Tolerance (Neuroadaptation)
We’ve all experienced craving in the aftermath of pleasure. Whether it’s reaching for a second potato chip or clicking the link for another round of video games, it’s natural to want to re-create those good feelings or try not to let them fade away. The simple solution is to keep eating, or playing, or watching, or reading. But there’s a problem with that.
With repeated exposure to the same or similar pleasure stimulus, the initial deviation to the side of pleasure gets weaker and shorter and the after-response to the side of pain gets stronger and longer, a process scientists call neuroadaptation. That is, with repetition, our gremlins get bigger, faster, and more numerous, and we need more of our drug of choice to get the same effect.
Needing more of a substance to feel pleasure, or experiencing less pleasure at a given dose, is called tolerance. Tolerance is an important factor in the development of addiction.
This phenomenon, widely observed and verified by animal studies, has come to be called opioid-induced hyperalgesia. Algesia, from the Greek word algesis, means sensitivity to pain. What’s more, when these patients tapered off opioids, many of them experienced improvements in pain.
The paradox is that hedonism, the pursuit of pleasure for its own sake, leads to anhedonia, which is the inability to enjoy pleasure of any kind
The neuroscientist George Koob calls this phenomenon “dysphoria driven relapse,” wherein a return to using is driven not by the search for pleasure but by the desire to alleviate physical and psychological suffering of protracted withdrawal.
Here’s the good news. If we wait long enough, our brains (usually) readapt to the absence of the drug and we reestablish our baseline homeostasis: a level balance. Once our balance is level, we are again able to take pleasure in everyday, simple rewards. Going for a walk. Watching the sun rise. Enjoying a meal with friends.
People, Places, and Things
The pleasure-pain balance is triggered not only by reexposure to the drug itself but also by exposure to cues associated with drug use. In Alcoholics Anonymous, the catchphrase to describe this phenomenon is people, places, and things. In the world of neuroscience, this is called cue-dependent learning, also known as classical (Pavlovian) conditioning.
Ivan Pavlov, who won the Nobel Prize in Physiology or Medicine in 1904, demonstrated that dogs reflexively salivate when presented with a slab of meat. When the presentation of meat is consistently paired with the sound of a buzzer, the dogs salivate when they hear the buzzer, even if no meat is immediately forthcoming. The interpretation is that the dogs have learned to associate the slab of meat, a natural reward, with the buzzer, a conditioned cue. What’s happening in the brain?
By inserting a detection probe into a rat’s brain, neuroscientists can demonstrate that dopamine is released in the brain in response to the conditioned cue (e.g., a buzzer, metronome, light) well before the reward itself is ingested (e.g., cocaine injection). The pre-reward dopamine spike in response to the conditioned cue explains the anticipatory pleasure we experience when we know good things are coming.
Right after the conditioned cue, brain dopamine firing decreases not just to baseline levels (the brain has a tonic level of dopamine firing even in the absence of rewards), but below baseline levels. This transient dopamine mini-deficit state is what motivates us to seek out our reward. Dopamine levels below baseline drive craving. Craving translates into purposeful activity to obtain the drug
My colleague Rob Malenka, an esteemed neuroscientist, once said to me that “the measure of how addicted a laboratory animal is comes down to how hard that animal is willing to work to obtain its drug—by pressing a lever, navigating a maze, climbing up a chute.” I’ve found the same to be true for humans. Not to mention that the entire cycle of anticipation and craving can occur outside the threshold of conscious awareness.
Once we get the anticipated reward, brain dopamine firing increases well above tonic baseline. But if the reward we anticipated doesn’t materialize, dopamine levels fall well below baseline. Which is to say, if we get the expected reward, we get an even bigger spike. If we don’t get the expected reward, we experience an even bigger plunge.
Learning also increases dopamine firing in the brain. Female rats housed for three months in a diverse, novel, and stimulating environment show a proliferation of dopamine-rich synapses in the brain’s reward pathway compared to rats housed in standard laboratory cages. The brain changes that occur in response to a stimulating and novel environment are similar to those seen with high-dopamine (addictive) drugs.
But if the same rats are pretreated with a stimulant such as methamphetamine, a highly addictive drug, before entering the enriched environment, they fail to show the synaptic changes seen previously with exposure to the enriched environment. These findings suggest that methamphetamine limits a rat’s ability to learn.”
The Balance Is Only a Metaphor
In real life, pleasure and pain are more complex than the workings of a balance.
What’s pleasurable for one person may not be for another. Each person has their “drug of choice.”
Pleasure and pain can occur simultaneously. For example, we can experience both pleasure and pain when eating spicy food.
Not everyone starts out with a level balance: Those with depression, anxiety, and chronic pain start with a balance tipped to the side of pain, which may explain why people with psychiatric disorders are more vulnerable to addiction.
Our sensory perception of pain (and pleasure) is heavily influenced by the meaning we ascribe to it.
Science teaches us that every pleasure exacts a price, and the pain that follows is longer lasting and more intense than the pleasure that gave rise to it.
With prolonged and repeated exposure to pleasurable stimuli, our capacity to tolerate pain decreases, and our threshold for experiencing pleasure increases.
By imprinting instant and permanent memory, we are unable to forget the lessons of pleasure and pain even when we want to: hippocampal tattoos to last a lifetime.
The phylogenetically uber-ancient neurological machinery for processing pleasure and pain has remained largely intact throughout evolution and across species. It is perfectly adapted for a world of scarcity. Without pleasure we wouldn’t eat, drink, or reproduce. Without pain we wouldn’t protect ourselves from injury and death. By raising our neural set point with repeated pleasures, we become endless strivers, never satisfied with what we have, always looking for more.
But herein lies the problem. Human beings, the ultimate seekers, have responded too well to the challenge of pursuing pleasure and avoiding pain. As a result, we’ve transformed the world from a place of scarcity to a place of overwhelming abundance.
Our brains are not evolved for this world of plenty. As Dr. Tom Finucane, who studies diabetes in the setting of chronic sedentary feeding, said, “We are cacti in the rain forest.” And like cacti adapted to an arid climate, we are drowning in dopamine.
The net effect is that we now need more reward to feel pleasure, and less injury to feel pain. This recalibration is occurring not just at the level of the individual but also at the level of nations. Which invites the question: How do we survive and thrive in this new ecosystem? How do we raise our children? What new ways of thinking and acting will be required of us as denizens of the twenty-first century?
Who better to teach us how to avoid compulsive overconsumption than those most vulnerable to it: those struggling with addiction. Shunned for millennia across cultures as reprobates, parasites, pariahs, and purveyors of moral turpitude, people with addiction have evolved a wisdom perfectly suited to the age we live in now.
What follows are lessons of recovery for a reward-weary world.
PART II - Self-Binding
CHAPTER 4 - Dopamine Fasting
D Stands for Data
This framework is easily remembered by the acronym DOPAMINE, which applies not just to conventional drugs like alcohol and nicotine but also to any high-dopamine substance or behavior we ingest too much of for too long, or simply wish we had a slightly less tortured relationship with. Although originally developed for my professional practice, I’ve also applied it to myself and my own maladaptive habits of consumption
The d in DOPAMINE stands for data. I begin by gathering the simple facts of consumption. I explored what she was using, how much, and how often.
O Stands for Objectives
What does smoking do for you?
The o in DOPAMINE stands for objectives for using. Even seemingly irrational behavior is rooted in some personal logic. People use high-dopamine substances and behaviors for all kinds of reasons: to have fun, to fit in, to relieve boredom, to manage fear, anger, anxiety, insomnia, depression, inattention, pain, social phobia?.?.?. the list goes on
P Stands for Problems
Any downsides from smoking?
The p in DOPAMINE stands for problems related to use.
High-dopamine drugs always lead to problems. Health problems. Relationship problems. Moral problems. If not right away, then eventually. That Delilah could not see downsides—except the mounting conflict between her and her parents—is typical for teenagers?.?.?. and not just teenagers. This disconnect occurs for a number of reasons.
First, most of us are unable to see the full extent of the consequences of our drug use while we’re still using. High-dopamine substances and behaviors cloud our ability to accurately assess cause and effect.
A Stands for Abstinence
I do have an idea about what might help you, but it will require you to do something really hard.
The a in DOPAMINE stands for abstinence. Abstinence is necessary to restore homeostasis, and with it our ability to get pleasure from less potent rewards, as well as see the true cause and effect between our substance use and the way we’re feeling. To put it in terms of the pleasure-pain balance, fasting from dopamine allows sufficient time for the gremlins to hop off the balance and for the balance to go back to the level position.
The question is: How long do people need to abstain in order to experience the brain benefits of stopping?
At two weeks, patients are usually still experiencing withdrawal. They are still in a dopamine deficit state.
On the other hand, four weeks is often sufficient. Marc Schuckit and his colleagues studied a group of men who were drinking alcohol daily in large quantities and also met criteria for clinical depression, or what is called major depressive disorder.
Which brings us to an important caveat: I never suggest a dopamine fast to individuals who might be at risk to suffer life-threatening withdrawal if they were to quit all of a sudden, as in cases of severe alcohol, benzodiazepine (Xanax, Valium, or Klonopin), or opioid dependence and withdrawal. For those patients, medically monitored tapering is necessary.
Any reward that is potent enough to overcome the gremlins and tip the balance toward pleasure can itself be addictive, thereby resulting in trading one addiction for another (cross addiction). Any reward that is not potent enough won’t feel like a reward, which is why when we’re consuming high-dopamine rewards, we lose the ability to take joy in ordinary pleasures
A minority of patients (about 20 percent) don’t feel better after the dopamine fast. That’s important data too, because it tells me that the drug wasn’t the main driver of the psychiatric symptom and that the patient likely has a co-occurring psychiatric disorder that will require its own treatment.
M Stands for Mindfulness
I want you to be prepared, for feeling worse before you feel better.
The m of DOPAMINE stands for mindfulness.
Mindfulness is a term that is tossed around so often now, it has lost some of its meaning. Evolved from the Buddhist spiritual tradition of meditation, it has been adopted and adapted by the West as a wellness practice across many different disciplines. It has so fully penetrated Western consciousness that it’s now routinely taught in American elementary schools. But what actually is mindfulness?
Mindfulness is simply the ability to observe what our brain is doing while it’s doing it, without judgment. This is trickier than it sounds. The organ we use to observe the brain is the brain itself. Weird, right?
Mindfulness practices are especially important in the early days of abstinence. Many of us use high-dopamine substances and behaviors to distract ourselves from our own thoughts. When we first stop using dopamine to escape, those painful thoughts, emotions, and sensations come crashing down on us.
The trick is to stop running away from painful emotions, and instead allow ourselves to tolerate them. When we’re able to do this, our experience takes on a new and unexpectedly rich texture. The pain is still there, but somehow transformed, seeming to encompass a vast landscape of communal suffering, rather than being wholly our own.
I Stands for Insight
Why would that motivate you?
The i of DOPAMINE stands for insight.
I have seen again and again in clinical care, and in my own life, how the simple exercise of abstaining from our drug of choice for at least four weeks gives clarifying insight into our behaviors. Insight that simply is not possible while we continue to use
N Stands for Next Steps
So what do you think? Do you want to continue to abstain for the next month, or do you want to return to using?
The n of DOPAMINE stands for next steps.
This is where I ask my patients what they want to do after their month of abstinence. The vast majority of my patients who are able to abstain for a month and experience the benefits of abstinence nonetheless want to go back to using their drug. But they want to use differently than they were using before. The overarching theme is that they want to use less.
An ongoing controversy in the field of addiction medicine is whether people who have been using drugs in an addictive way can return to moderate, nonrisky use.
E Stands for Experiment
The e and final letter of DOPAMINE stands for experiment.
This is where patients go back out into the world armed with a new dopamine set point (a level pleasure-pain balance) and a plan for how to maintain it. Whether the goal is continued abstinence or moderation, we strategize together for how to achieve it. Through a gradual process of trial and error, we figure out what works and what doesn’t.
But how about patients addicted to food? Or smartphones? Drugs that can’t be stopped altogether?
The question of how to moderate is becoming an increasingly important one in modern-day life, because of the sheer ubiquity of high-dopamine goods, making us all more vulnerable to compulsive overconsumption, even when not meeting clinical criteria for addiction.
领英推荐
Further, as digital drugs like smartphones have become embedded into so many aspects of our lives, figuring out how to moderate their consumption, for ourselves and our children, has become a matter of urgency. To that end, I now introduce a taxonomy of self-binding strategies.
But before we talk about self-binding, let’s review the steps of the dopamine fast, the ultimate goal of which is to restore a level balance (homeostasis) and renew our capacity to experience pleasure in many different forms.
CHAPTER 5 - Space, Time, and Meaning
I ask my patients, “What kinds of barriers can you put into place to make it harder for you to get easy access to your drug of choice?” I have even used self-binding in my own life to manage problems of compulsive overconsumption.
Self-binding can be organized into three broad categories: physical strategies (space), chronological strategies (time), and categorical strategies (meaning).
As you will see in what follows, self-binding is not fail-safe, particularly for those with severe addictions. It too can fall prey to self-deception, bad faith, and faulty science.
But it is a good and necessary place to start.
Physical Self-Binding
Physical self-binding is now available from your local apothecary. Instead of locking our drugs away in a file cabinet, we have the option of imposing locks at the cellular level.
The medication naltrexone is used to treat alcohol and opioid addiction, and is being used for a variety of other addictions as well, from gambling to overeating to shopping. Naltrexone blocks the opioid receptor, which in turn diminishes the reinforcing effects of different types of rewarding behavior.
I’ve had patients report a near or complete cessation of alcohol craving with naltrexone. For patients who have struggled for decades with this problem, the ability to not drink at all, or to drink in moderation like “normal people,” comes as a revelation.
Because naltrexone blocks our endogenous opioid system, people have reasonably wondered if it might induce depression.
Other modern forms of physical self-binding involve anatomical changes to our bodies; for example, weight-loss surgeries such as gastric banding, sleeve gastrectomy, and gastric bypass
We can and should celebrate a medical intervention that can improve the health of so many people. But the fact that we must resort to removing and reshaping internal organs to accommodate our food supply marks a turning point in the history of human consumption
From lockboxes that limit our access, to medications that block our opioid receptors, to surgeries that shrink our stomachs, physical self-binding is everywhere in modern life, illustrating our growing need to put the brakes on dopamine
Chronological Self-Binding
Another form of self-binding is the use of time limits and finish lines.
By restricting consumption to certain times of the day, week, month, or year, we narrow our window of consumption and thereby limit our use
Sometimes, rather than time per se, we bind ourselves based on milestones or accomplishments. We’ll wait till our birthday, or as soon as we complete an assignment, or after we get our degree
This study suggests that by restricting drug consumption to a narrow window of time, we may be able to moderate our use and avoid the compulsive and escalating consumption that comes with unlimited access.
Another variable contributing to the problem of compulsive overconsumption is the growing amount of leisure time we have today, and with it the ensuing boredom.
The mechanization of agriculture, manufacturing, domestic chores, and many other previously time-consuming, labor-intensive jobs has reduced the number of hours per day people spend working, leaving more time for leisure.
Dopamine consumption is not just a way to fill the hours not spent working. It has also become a reason why people are not participating in the workforce
Categorical Self-Binding
Not thinking about myself and my problems was a good change. I also stop shaming myself. Mine is a sad story, but I can do something about it.
Categorical self-binding limits consumption by sorting dopamine into different categories: those subtypes we allow ourselves to consume, and those we do not.
This method helps us to avoid not only our drug of choice but also the triggers that lead to craving for our drug. This strategy is especially useful for substances we can’t eliminate altogether but that we’re trying to consume in a healthier way, like food, sex, and smartphones.
Categorical self-binding fails when we inadvertently include a trigger in our list of acceptable activities. We can correct mistakes like these with a mental sifting process based on experience. But what about when the category itself changes?
Deifying the demonized is another form of categorical self-binding
The hope is that by limiting access to these drugs, and by making psychiatrists gatekeepers, the mystical properties of these chemicals—a sense of oneness, transcendence of time, positive mood, and reverence—can be leveraged without leading to misuse, overuse, and addictive use.
CHAPTER 6 - A Broken Balance?
Medications to Restore a Level Balance?
Whether the problem was in Chris’s brain or in the world, whether it was caused by prolonged drug use or a problem he was born with, here are some of the things I worry about in using medications to press on the pleasure side of the balance.
First, any drug that presses on the pleasure side has the potential to be addictive.
Second, what if these drugs don’t actually work the way they’re supposed to, or worse yet, make psychiatric symptoms worse in the long run? Although buprenorphine was working for Chris, the evidence for psychotropic medications more generally is not robust, especially when taken long term.
Despite substantial increases in funding in four high-resourced countries (Australia, Canada, England, and the US) for psychiatric medications like antidepressants (Prozac), anxiolytics (Xanax), and hypnotics (Ambien), the prevalence of mood and anxiety symptoms in these countries has not decreased (1990 to 2015). These findings persist even when controlling for increases in risk factors for mental illness, such as poverty and trauma, and even when studying severe mental illness, such as schizophrenia.
In medicating ourselves to adapt to the world, what kind of world are we settling for? Under the guise of treating pain and mental illness, are we rendering large segments of the population biochemically indifferent to intolerable circumstance? Worse yet, have psychotropic medications become a means of social control, especially of the poor, unemployed, and disenfranchised?
Psychiatric drugs are prescribed more often and in larger amounts to poor people, especially poor children.
According to the 2011 data from the National Health Interview Survey of the CDC’s National Center for Health Statistics, 7.5 percent of American children between the ages of six and seventeen took a prescribed medication for “emotional and behavioral difficulties.” Poor children were more likely to take psychiatric medications than those not living in poverty (9.2 percent versus 6.6 percent). Boys were more likely than girls to be medicated. Non-Hispanic whites were more likely than people of color to be medicated.
This phenomenon is not limited to the United States.
A nationwide study in Sweden analyzed rates of prescribing for different psychiatric drugs, based on indices of what they called “neighborhood deprivation” (index of education, income, unemployment, and welfare assistance). For each class of psychiatric medication, they found prescribing of psychiatric medications increased as the socioeconomic status of the neighborhood fell. Their conclusion: “These findings suggest that neighborhood deprivation is associated with psychiatric medication prescription.
Opioids too are disproportionately prescribed to the poor.
Please don’t misunderstand me. These medications can be lifesaving tools and I’m grateful to have them in clinical practice. But there is a cost to medicating away every type of human suffering, and as we shall see, there is an alternative path that might work better: embracing pain.
PART III - The Pursuit of Pain
CHAPTER 7 - Pressing on the Pain Side
Pain leads to pleasure by triggering the body’s own regulating homeostatic mechanisms. In this case, the initial pain stimulus is followed by gremlins hopping on the pleasure side of the balance.
This idea is not new. Ancient philosophers observed a similar phenomenon. Socrates (as recorded by Plato in “Socrates’ Reasons for Not Fearing Death”) mused on the relationship between pain and pleasure more than two thousand years ago:
“How strange would appear to be this thing that men call pleasure! And how curiously it is related to what is thought to be its opposite, pain! The two will never be found together in a man, and yet if you seek the one and obtain it, you are almost bound always to get the other as well, just as though they were both attached to one and the same head.?.?.?. Wherever the one is found, the other follows up behind. So, in my case, since I had pain in my leg as a result of the fetters, pleasure seems to have come to follow it up”
We’ve all experienced some version of pain giving way to pleasure. Perhaps like Socrates, you’ve noticed an improved mood after a period of being ill, or felt a runner’s high after exercise, or took inexplicable pleasure in a scary movie. Just as pain is the price we pay for pleasure, so too is pleasure our reward for pain
The Science of Hormesis
Hormesis is a branch of science that studies the beneficial effects of administering small to moderate doses of noxious and/or painful stimuli, such as cold, heat, gravitational changes, radiation, food restriction, and exercise. Hormesis comes from the ancient Greek hormáein: to set in motion, impel, urge on
The authors theorized that “low-dose stimulation of DNA damage repair, the removal of aberrant cells via stimulated apoptosis [cell death], and elimination of cancer cells via stimulated anticancer immunity” are at the heart of the beneficial effects of radiation hormesis.
Note that these findings are controversial, and a follow-up paper published in the prestigious Lancet disputed them.
What about exercise?
Exercise is immediately toxic to cells, leading to increased temperatures, noxious oxidants, and oxygen and glucose deprivation. Yet the evidence is overwhelming that exercise is health-promoting, and the absence of exercise, especially combined with chronic sedentary feeding—eating too much all day long—is deadly.
Exercise increases many of the neurotransmitters involved in positive mood regulation: dopamine, serotonin, norepinephrine, epinephrine, endocannabinoids, and endogenous opioid peptides (endorphins). Exercise contributes to the birth of new neurons and supporting glial cells. Exercise even reduces the likelihood of using and getting addicted to drugs.
In humans, high levels of physical activity in junior high, high school, and early adulthood predict lower levels of drug use. Exercise has also been shown to help those already addicted to stop or cut back
But pursuing pain is harder than pursuing pleasure. It goes against our innate reflex to avoid pain and pursue pleasure. It adds to our cognitive load: We have to remember that we will feel pleasure after pain, and we’re remarkably amnestic about this sort of thing. I know I have to relearn the lessons of pain every morning as I force myself to get out of bed and go exercise.
Pursuing pain instead of pleasure is also countercultural, going against all the feel-good messages that pervade so many aspects of modern life. Buddha taught finding the Middle Way between pain and pleasure, but even the Middle Way has been adulterated by the “tyranny of convenience.”
Hence we must seek out pain and invite it into our lives.
Pain to Treat Pain
The intentional application of pain to treat pain has been around since at least Hippocrates, who wrote in his Aphorisms in 400 BC: “Of two pains occurring together, not in the same part of the body, the stronger weakens the other.”
The history of medicine is replete with examples of using painful or noxious stimuli to treat painful disease states. Sometimes called “heroic therapies”
As the philosopher Friedrich Nietzsche famously said, a sentiment echoed by many before and after through the ages, “What doesn’t kill me makes me stronger.
Alex Honnold, now world-famous for climbing the face of Yosemite’s El Capitan without ropes, was found to have below-normal amygdala activation during brain imaging. For most of us, the amygdala is an area of the brain that lights up in an fMRI machine when we look at scary pictures.
The researchers who studied Honnold’s brain speculated that he was born with less innate fear than others, which in turn allowed him, they hypothesized, to accomplish superhuman climbing feats.
But Honnold himself disagreed with their interpretation: “I’ve done so much soloing, and worked on my climbing skills so much that my comfort zone is quite large. So these things that I’m doing that look pretty outrageous, to me they seem normal”
The most likely explanation for Honnold’s brain differences is the development of tolerance to fear through neuroadaptation.
Addicted to Pain
Extreme sports—skydiving, kitesurfing, hang gliding, bobsledding, downhill skiing/snowboarding, waterfall kayaking, ice climbing, mountain biking, canyon swinging, bungee jumping, base jumping, wingsuit flying—slam down hard and fast on the pain side of the pleasure-pain balance. Intense pain/fear plus a shot of adrenaline creates a potent drug.
Scientists have shown that stress alone can increase the release of dopamine in the brain’s reward pathway, leading to the same brain changes seen with addictive drugs like cocaine and methamphetamine.
Just as we become tolerant to pleasure stimuli with repeated exposure, so too can we become tolerant to painful stimuli, resetting our brains to the side of pain.
Technology has allowed us to push the limits of human pain
Too much pain, or in too potent a form, can increase the risk of becoming addicted to pain, something I’ve witnessed in clinical practice. A patient of mine ran so much she developed fractures in her leg bones and even then didn’t stop running. Another patient cut her inner forearms and thighs with a razor blade to feel a rush and to calm the constant ruminations of her mind. She couldn’t stop cutting even at the risk of severe scarring and infection.
When I conceptualized their behaviors as addictions and treated them as I would any patient with addiction, they got better.
Addicted to Work
The “workaholic” is a celebrated member of society. Nowhere is that perhaps more true than here in Silicon Valley, where 100-hour workweeks and 24/7 availability are the norm.
I find it difficult at times to stop myself from working once I’ve begun. The “flow” of deep concentration is a drug in itself, releasing dopamine and creating its own high. This kind of single-minded focus, although heavily rewarded in modern rich nations, can be a trap when it keeps us from the intimate connections with friends and family in the rest of our lives
The Verdict on Pain
If we consume too much pain, or in too potent a form, we run the risk of compulsive, destructive overconsumption.
But if we consume just the right amount, “inhibiting great pain with little pain,” we discover the path to hormetic healing, and maybe even the occasional “fit of joy”
CHAPTER 8 - Radical Honesty
Every major religion and code of ethics has included honesty as essential to its moral teachings. All my patients who have achieved long-term recovery have relied on truth-telling as critical for sustained mental and physical health. I too have become convinced that radical honesty is not just helpful for limiting compulsive overconsumption but also at the core of a life well lived.
The question is, how does telling the truth improve our lives?
Let’s first establish that telling the truth is painful. We’re wired from the earliest ages to lie, and we all do it, whether or not we care to admit it.
Lies arguably have some adaptive advantage when it comes to competing for scarce resources.But lying in a world of plenty risks isolation, craving, and pathological overconsumption
The Lying Habit is remarkably easy to fall into. We all engage in regular lying, most of the time without realizing it. Our lies are so small and imperceptible that we convince ourselves we’re telling the truth. Or that it doesn’t matter, even if we know we’re lying.
Radical honesty—telling the truth about things large and small, especially when doing so exposes our foibles and entails consequences—is essential not just to recovery from addiction but for all of us trying to live a more balanced life in our reward-saturated ecosystem. It works on many levels.
First, radical honesty promotes awareness of our actions. Second, it fosters intimate human connections. Third, it leads to a truthful autobiography, which holds us accountable not just to our present but also to our future selves. Further, telling the truth is contagious, and might even prevent the development of future addiction
Awareness
Earlier I described the Greek myth of Odysseus to illustrate physical self-binding. There’s a little-known epilogue to this myth that is relevant here.
You’ll remember that Odysseus asked his crew to tie him to the mast of his sailing ship to avoid the lure of the Sirens. But if you think about it, he could simply have put beeswax in his ears like he commanded the rest of his crew to do and saved himself a lot of grief. Odysseus wasn’t a glutton for punishment. The Sirens could be killed only if whoever heard them could live to tell the story afterward. Odysseus vanquished the Sirens by narrating his near-death voyage after the fact. The slaying was in the telling.
The Odysseus myth highlights a key feature of behavior change: Recounting our experiences gives us mastery over them. Whether in the context of psychotherapy, talking to an AA sponsor, confessing to a priest, confiding in a friend, or writing in a journal, our honest disclosure brings our behavior into relief, allowing us in some cases to see it for the first time. This is especially true for behaviors that involve a level of automaticity outside of conscious awareness.
Honesty Promotes Intimate Human Connections
Telling the truth draws people in, especially when we’re willing to expose our own vulnerabilities. This is counterintuitive because we assume that unmasking the less desirable aspects of ourselves will drive people away. It logically makes sense that people would distance themselves when they learn about our character flaws and transgressions.
In fact, the opposite happens. People come closer. They see in our brokenness their own vulnerability and humanity. They are reassured that they are not alone in their doubts, fears, and weaknesses.
Truthful Autobiographies Create Accountability
Single, simple truths about our day-to-day lives are like links in a chain that translate into truthful autobiographical narratives. Autobiographical narratives are an essential measure of lived time. The stories we narrate about our lives not only serve as a measure of our past but can also shape future behavior.
In more than twenty years as a psychiatrist listening to tens of thousands of patient stories, I have become convinced that the way we tell our personal stories is a marker and predictor of mental health.
Patients who tell stories in which they are frequently the victim, seldom bearing responsibility for bad outcomes, are often unwell and remain unwell. They are too busy blaming others to get down to the business of their own recovery. By contrast, when my patients start telling stories that accurately portray their responsibility, I know they’re getting better.
The victim narrative reflects a wider societal trend in which we’re all prone to seeing ourselves as the victims of circumstance and deserving of compensation or reward for our suffering. Even when people have been victimized, if the narrative never moves beyond victimhood, it’s difficult for healing to occur.
One of the jobs of good psychotherapy is to help people tell healing stories. If autobiographical narrative is a river, psychotherapy is the means by which that river is mapped and in some cases rerouted.
Healing stories adhere closely to real-life events. Seeking and finding the truth, or the closest approximation possible with the data at hand, affords us the opportunity for real insight and understanding, which in turn allows us to make informed choices.
Truth-telling Is Contagious?.?.?. and So Is Lying
In my clinical practice, I often see one member of a family get into recovery from addiction, followed quickly by another member of the family doing the same. I’ve seen husbands who stop drinking followed by wives who stop having affairs. I’ve seen parents who stop smoking pot followed by children who do the same
In 2012, researchers at the University of Rochester altered the 1968 Stanford marshmallow experiment in one crucial way. One group of children experienced a broken promise before the marshmallow test was conducted: The researchers left the room and said they would return when the child rang the bell, but then didn’t. The other group of children were told the same, but when they rang the bell, the researcher returned.
The children in the latter group, where the researcher came back, were willing to wait up to four times longer (twelve minutes) for a second marshmallow than the children in the broken-promise group
Truth-telling as Prevention
My patients have taught me that honesty enhances awareness, creates more satisfying relationships, holds us accountable to a more authentic narrative, and strengthens our ability to delay gratification. It may even prevent the future development of addiction.
For me, honesty is a daily struggle. There’s always a part of me that wants to embellish the story just the slightest bit, to make myself look better, or to make an excuse for bad behavior. Now I try hard to fight that urge.
Although difficult in practice, this handy little tool—telling the truth—is amazingly within our reach. Anyone can wake up on any given day and decide, “Today I won’t lie about anything.” And in doing so, not just change their individual lives for the better, but maybe even change the world.
CHAPTER 9 - Prosocial Shame
When it comes to compulsive overconsumption, shame is an inherently tricky concept. It can be the vehicle for perpetuating the behavior as well as the impetus for stopping it. So how do we reconcile this paradox?
First, let’s talk about what shame is.
The psychological literature today identifies shame as an emotion distinct from guilt. The thinking goes like this: Shame makes us feel bad about ourselves as people, whereas guilt makes us feel bad about our actions while preserving a positive sense of self. Shame is a maladaptive emotion. Guilt is an adaptive emotion
Yet the shame-guilt dichotomy is tapping into something real. I believe the difference is not how we experience the emotion, but how others respond to our transgression.
If others respond by rejecting, condemning, or shunning us, we enter the cycle of what I call destructive shame. Destructive shame deepens the emotional experience of shame and sets us up to perpetuate the behavior that led to feeling shame in the first place. If others respond by holding us closer and providing clear guidance for redemption/recovery, we enter the cycle of prosocial shame. Prosocial shame mitigates the emotional experience of shame and helps us stop or reduce the shameful behavior.
With that in mind, let’s start by talking about when shame goes wrong (i.e., destructive shame) as a prelude to talking about when shame goes right (i.e., prosocial shame).
Destructive Shame
Studies show that people who are actively involved in religious organizations on average have lower rates of drug and alcohol misuse. But when faith-based organizations end up on the wrong side of the shame equation, by shunning transgressors and/or encouraging a web of secrecy and lies, they contribute to the cycle of destructive shame.
Destructive shame looks like this: Overconsumption leads to shame, which leads to shunning by the group or lying to the group to avoid shunning, both of which result in further isolation, contributing to ongoing consumption as the cycle is perpetuated.
The antidote to destructive shame is prosocial shame. Let’s see how that might work
AA as a Model for Prosocial Shame
Prosocial shame is further predicated on the idea that we are all flawed, capable of making mistakes, and in need of forgiveness. The key to encouraging adherence to group norms, without casting out every person who strays, is to have a post-shame “to-do” list that provides specific steps for making amends. This is what AA does with its 12 Steps.
The prosocial shame cycle goes like this: Overconsumption leads to shame, which demands radical honesty and leads not to shunning, as we saw with destructive shame, but to acceptance and empathy, coupled with a set of required actions to make amends. The result is increased belonging and decreased consumption.
My patient Todd, a young surgeon in recovery from alcohol addiction, told me how AA “was the first safe place to express vulnerability.” At his first AA meeting he cried so hard he wasn’t able to say his name.
“Afterward, everyone came up, gave me their numbers, told me to call. It was that community I always wanted but never had. I could never have opened up like that with my rock-climbing friends or with other surgeons.”
After five years in sustained recovery, Todd shared with me that the most important step of the 12 Steps for him was Step 10 (“Continued to take personal inventory and when we were wrong promptly admitted it”).
Alcoholics Anonymous is a model organization for prosocial shame. Prosocial shame in AA leverages adherence to group norms. There is no shame about being an “alcoholic,” consistent with the saying “AA is a no-shame zone;” but there is shame about the half-hearted pursuit of “sobriety.” Patients have told me that the anticipated shame of having to admit to the group they’ve relapsed works as a major deterrent against relapse, and promotes further adherence to group norms
Prosocial Shame and Parenting
As a parent who is worried about her children’s well-being in a world flooded with dopamine, I’ve tried to incorporate the principles of prosocial shame into our family life.
First, we’ve established radical honesty as a core family value. I try hard, not always with success, to model radical honesty in my own behavior. Sometimes as parents we think that by hiding our mistakes and imperfections and only revealing our best selves, we’ll teach our children what is right. But this can have the opposite effect, leading children to feel they must be perfect to be lovable.
Instead, if we are open and honest with our children about our struggles, we create a space for them to be open and honest about their own. As such, we must also be ready and willing to admit when we’ve been wrong in our interactions with them and with others. We must embrace our own shame and be willing to make amends.
Like my patient Todd, when we engage in an active and honest reappraisal of ourselves, we’re more able and willing to give other people honest feedback, in the spirit of helping them understand their own strengths and shortcomings
This type of radical honesty without shaming is also important to teach children their strengths and weaknesses.
Through sacrifice and stigma, my husband and I have attempted to strengthen our family’s club goods
Many of these rules seem excessive and gratuitous, but when viewed through the lens of utility-maximizing principles to strengthen participation, reduce free riding, and augment club goods, they make sense. And kids flock to this team in particular, seeming to love the strictness, even as they complain about it.
We tend to think of shame as a negative, especially at a time when shaming—fat shaming, slut shaming, body shaming, and so on—is such a loaded word and is (rightly) associated with bullying. In our increasingly digital world, social media shaming and its correlate “cancel culture” have become a new form of shunning, a modern twist on the most destructive aspects of shame
CONCLUSION - Lessons of the Balance
We all desire a respite from the world—a break from the impossible standards we often set for ourselves and others. It’s natural that we would seek a reprieve from our own relentless ruminations: Why did I do that? Why can’t I do this? Look what they did to me. How could I do that to them?
So we’re drawn to any of the pleasurable forms of escape that are now available to us: trendy cocktails, the echo chamber of social media, binge-watching reality shows, an evening of Internet porn, potato chips and fast food, immersive video games, second-rate vampire novels?.?.?. The list really is endless. Addictive drugs and behaviors provide that respite but add to our problems in the long run.
What if, instead of seeking oblivion by escaping from the world, we turn toward it? What if instead of leaving the world behind, we immerse ourselves in it?
I urge you to find a way to immerse yourself fully in the life that you’ve been given. To stop running from whatever you’re trying to escape, and instead to stop, and turn, and face whatever it is.
Then I dare you to walk toward it. In this way, the world may reveal itself to you as something magical and awe-inspiring that does not require escape. Instead, the world may become something worth paying attention to.
The rewards of finding and maintaining balance are neither immediate nor permanent. They require patience and maintenance. We must be willing to move forward despite being uncertain of what lies ahead. We must have faith that actions today that seem to have no impact in the present moment are in fact accumulating in a positive direction, which will be revealed to us only at some unknown time in the future. Healthy practices happen day by day.
My patient Maria said to me, “Recovery is like that scene in Harry Potter when Dumbledore walks down a darkened alley lighting lampposts along the way. Only when he gets to the end of the alley and stops to look back does he see the whole alley illuminated, the light of his progress.
Here we are at the end, but it could be just the beginning of a new way of approaching the hypermedicated, overstimulated, pleasure-saturated world of today. Practice the lessons of the balance, so that you too can look back at the light of your progress
Lessons of the Balance