Talking To Teens: Expert Tips for Parenting Teenagers

Andy:
I just finished reading your book here, Dopamine Nation. And you have a lot of stories in here about different kinds of addictions and compulsive behaviors and a lot of research around that. How did you get so interested in this topic and what inspired you to turn it into a book?

Dr. Lembke:
Well, I'm a psychiatrist I've been practicing psychiatry for going on 25 years. And in the first decade of the 2000s, I started to specialize in addiction problems and I started seeing more and more people coming in with addiction, not just to drugs, but also to various behaviors. What we sometimes call process addictions, things like pornography, shopping, gambling, and then more recently tech addictions, social media, video games, and other activities on the smartphone. So I wrote my book as a way to communicate the basic neuroscience of addiction. What's happening in our brains as well as to provide a roadmap for how the rest of us can navigate a world in which we've really all become vulnerable to the problem of addiction because of the almost infinite and overwhelming supply of feel good drugs and behaviors.

Andy:
You write that prescriptions for sedative medications are on the rise. Between 1996 and 2013 in the United States the number of adults who filled a benzodiazepine prescription increased by 67%. What's going on with that?

Dr. Lembke:
Well, as write about in this book, as well as my prior book, we do have a problem. I believe of overprescribing, psychotropic medications and opioids in this country without fully appreciating the risks. Benzodiazepines things like Xanax, Valium, Ativan are just one example. They're prescribed for minor conditions. They're prescribed long term, even though there's no evidence to support their use, no reliable evidence to support their long term use and what happens is, although in the short term, they can solve a problem like anxiety or insomnia, long term they tend to stop working. People develop tolerance and then it can be very difficult to get off of them because people have become physiologically dependent. And in some cases, people can become addicted. So there's an under recognition of the risks of these drugs and an over-emphasis on potential benefits that really are not long term benefits.

Andy:
You say there's a similar thing with antidepressant use. Rose 46% in Germany in just four years. It seems to be on the rise as well in China, Spain, Portugal, all over the world.

Dr. Lembke:
Yeah. So one of the fascinating things about the rise in antidepressant prescribing is that in all of these countries where antidepressants have become more available, rates of depression and anxiety have actually increased. So it doesn't seem to be working at least on a national scale. I will say that I'm grateful to have these tools. And of course in certain individuals they have been beneficial and in some cases, even life saving. So it would not be my message that these kinds of medications have no utility. In fact, I believe they have utility with the right patients at the right time, especially when used at low doses and short term. But I do think again, we're using them at very high doses for very long periods of time and for very subtle indications without appreciating the potential risks.

Andy:
Well, because this is something that I found so interesting is you talk about how the number of cases of depression worldwide increased 50% between 1990 and 2017, but even physical pain too is increasing and you have some data in here that the numbers and types of unexplained physical pain syndromes have grown. So we're taking more antidepressants and more painkillers than ever before, but yet we still have more pain and more depression. How's that possible?

Dr. Lembke:
Yeah. It's such a great question. I think the implication is number one, that the interventions that we're using are not really working. That's the obvious first implication. And then the other question that it begs is why are we seeing increased rates of depression, anxiety, physical pain, and one of the major hypotheses in Dopamine Nation is that actually that we're getting too much dopamine. That all of these reinforcing feel good drugs and behaviors in our hyper convenient world are in fact making us more depressed and anxious. And I talk about the neuroscience of pleasure and pain and why that is.

Andy:
Yeah. You say that it's in essence seems to work like a seesaw.

Dr. Lembke:
Yeah. Well, pleasure and pain are co-located in the brain, the same parts of the brain that process pleasure also process pain. And they work like opposite sides of a balance. When we do something that's pleasurable, our balance tips one way, we release dopamine, the pleasure or reward neurotransmitter in a part of our brain called the reward pathway. But no sooner has that happen, than the brain adapts to that pleasurable feeling by counterbalancing to the opposite side or the pain side and that's the come down, that's the dopamine levels being decreased, not just to baseline level, but below baseline level before homeostasis is restored. So the point is that the way that the brain restores a level balance or homeostasis or baseline dopamine levels is to tilt it first to the side of pain, to put us in a dopamine deficit state before going back to baseline.

Dr. Lembke:
And there are very significant implications of that. It means that for every pleasure, there's a price and that price is a pain and it may be subtle and barely outside of awareness for mild pleasures, for significant pleasures, like getting intoxicated. There's the hangover a much more obvious come down, but really for every pleasure we're likely pay being a small price. And that the cumulative pleasures over days to weeks is that we ultimately end up with our balance stuck on the pain side. I imagine that as these neuro adaptation gremlins camping out on the pain side of the balance.

Andy:
Weighing it down.

Dr. Lembke:
Yeah. We can actually over time reset our hedonic set point and get our pleasure pain balance stuck on the pain side if we're constantly bombarding the pleasure side with these feel good drugs and behaviors. And the implication of that is that then we need to continue to use our drug not to get high, but just to feel normal. And when we're not constantly distracting ourselves with these feel good drugs and behaviors, we are experiencing the universal symptoms of withdrawal from any addictive substance, which are anxiety, irritability, insomnia, depression, and intrusive thoughts of wanting to use otherwise known as craving. So the antidote or treatment for that condition is to abstain from feel good substances and behaviors for long enough for those gremlins to hop off and for our bodies to start to up-regulate our own endogenous production of feel good hormones and neurotransmitters like dopamine, like serotonin, like our endo opioid system and our endo cannabinoid system.

Andy:
Yeah. So I love this visual and I think it's really a helpful to picture this way. And it's like the more we try to pound down that pleasure side and put more weight on there, the more our body naturally counterbalances by putting more weight on the pain side over there so that we have to do more and more to just keep the pleasure side from going totally in the other direction.

Dr. Lembke:
Yes.

Andy:
You have a great line in here talking about how well human beings, the ultimate pleasure 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. We are cacti in the rainforest. So in some ways we almost have too much of an abundance of activities that stack up on the pleasure side, which then gets our whole seesaw out of whack a little bit.

Dr. Lembke:
Yeah, exactly. That our primitive wiring is mismatched for our modern ecosystem and the reason that we have a balance that works like this, where we have to tilt to pain before going to level is because in a world of scarcity, that's a great system that keeps us relentlessly looking for something more, never satisfied with what we have. But it's a system that is not well suited to this world of easy access over abundance. So then the question really becomes, okay, how do we live in the modern world if our brains were designed for scarcity, and we live in a world of over abundance. What can we do about that? And I really hold up again, people in recovery, from severe addictions as models for how to navigate this dopamine overloaded world.

Andy:
Yeah. So one interesting caveat with all of this is that it's difficult to see the extent of the consequences of a lot of these addictive behaviors while we're still using them. High dopamine substances and behaviors, you write, cloud our ability to accurately assess cause and effect. So why is that?

Dr. Lembke:
Yeah, it's a great question. It's not well understood why it is, but it's very clear that when we're chasing dopamine, we struggle to see the true in impact of its pursuit on our health and our lives and our behavior, which is why one of the main recommendations I make is to abstain from our drug of choice for long enough, for the brain to readapt, to the absence of that drug for those gremlins, to hop off the pain side of the balance for a level balance to be restored. And the purpose of that is because in restoring a level balance, we feel better. We're more able to get joy out of more modest, natural rewards, but also importantly, we get more clarity. We're able to look back and see the true impact of our drug seeking behavior on our lives in a way that we really don't have access to when we're in it.

Dr. Lembke:
And anybody who's struggled with addiction will tell you that there are all kinds of ways in which the brain will rationalize our physiology. We're very good storytellers and the stories really are instantly created, instantly to explain why it is that I'm reaching for this substance. Even though I didn't plan to, even though I said I wouldn't today, there I am. And the stories are elaborate and they're well formed and they're convincing, and our brains do that as well as all kinds of stories as to why the negative impacts are not that bad.

Andy:
Not that big a deal.

Dr. Lembke:
Yeah. It's not that big a deal. And the positive effects are much better than they actually are.

Andy:
A lot of these behaviors really have, and especially when we're young talking about teenagers and you, write that your teenage patients this is a thing because in AA they say I'm sick and tired of being sick and tired, but you write my teenage patients by contrast are neither sick nor tired. And so it's like, "Hey, here I am. I feel great, physically. I'm in my prime. I can eat donuts and no big deal. I can smoke pot and I don't really see the consequences of that." And a lot of people look back and say, wow, I don't know how I drank as much as I drank in college because now when I try to do that, I feel terrible. But when we're young, it's even harder to see those consequences just because we're so young and healthy.

Dr. Lembke:
Yeah and yet the consequences, they're there even when we're young and often I'll have patients come in, in middle age or their late twenties even not middle age, definitely later. And they have a lot of regret about their teenage years because now they can look back and see the impact.

Dr. Lembke:
So the trick is how do we get teenagers who are having those impacts in real time, get them to see it and that's really a challenge, but again, one of the ways to do it is to have them abstain for long enough to be able to gather data themselves and say, "Oh wow. I actually, a month after not smoking pot, I am feeling much better. And I don't want to go back to smoking the way that I was smoking before. I'd like to preserve my autonomous choice to smoke or not smoke. I'd like to preserve this good feeling in my lungs. I'd like to preserve the fact that I've been much more productive in this month that I haven't been using." So that's the trick because I could try all day to persuade my patient, but it's not until they've gathered the data for themselves and done the experiment that they're really persuaded. So all I have to do then is persuade them to take the 30 day trial of absence. That's hard enough.

Andy:
Easy.

Dr. Lembke:
But once they're willing to do that and then able to do that, it can be revelatory for people.

Andy:
Yeah. And you have a great story in here about a teenage girl who is smoking a lot of pot and is having social anxiety, I think, and really feeling like the pot is necessary for the anxiety and once she takes the 30 days of not smoking, she starts to realize how actually a lot of that was being caused by withdrawal symptoms from not smoking and needing to smoke. And that once she reset her dopamine system a little bit, that those feelings went away. You'd never really have been able to convince her of that because she was really convinced that not having anxiety, this helps me.

Dr. Lembke:
Yeah. And I've seen that so many times in countless patients over the years. Patients who are just absolutely convinced that their drug of choice is the only thing that alleviates their anxiety, their sleep problems, their depression. And when they do that abstinence trial, they can see for the first time that the drug actually drives and creates the anxiety, the depression, the insomnia in a way that's very difficult to perceive in the moment because when we use it in the moment, it's relieving withdrawal, it's temporarily writing the balance. We feel better and so it's hard to imagine that it's the thing that's making us feel bad in the first place.

Andy:
Right. Does not compute. How do you go about trying to introduce the possibility of taking some time off and working towards one of these 30 day abstinence periods?

Dr. Lembke:
Well, a couple ways, if patients are presenting with a chief complaint, something they want help with like anxiety or depression or insomnia, what I will say to them is doing this 30 day fast from your drug of choice may in and of itself, be enough to cure your psychiatric problem. In which case we don't need to prescribe medicines or do much of anything at else. Of course they're quite disbelieving that this is the case.

Andy:
Oh yeah, sure enough. Yeah.

Dr. Lembke:
But I say to them, I just really lean on the neuroscience and I explain to them the pleasure pain balance and how it works. And that usually makes sense to people as well as just leaning on my clinical experience. Like I've done this experiment with countless patients and the vast majority feel better after a month of absence. So that's one way to do it. The other way is to really try to get them, especially young people to look at the long arc of their life and suggest to them as I did in the case of Delilah in the book saying, "Well, do you want to be smoking like this 10 years from now?" "No, I'm not going to be smoking like this." "Then how about five years from now?" "No." "How about a year from now?" And eventually bring it back to, "Well, if you don't want to be smoking like this a year from now, why not try quitting right now?"

Dr. Lembke:
Why wait to do that experiment? And that can be really helpful because one thing that most people are sensitive to, but especially young people is their future trajectory and everybody has as their hopes and dreams of what they want to accomplish. There is this appreciation of I'm young and my life is still full of possibility. Yeah. So they're trying to use that, leverage that like, okay, you are still young. So at which point are doors going to close for you. You think you're getting a free pass now because you're 18, but okay. Are you going to still be doing this when you're 45? Oh no way. 30, 25. How far in the future are you willing to look continue this kind of behavior, this state of living and then that wakes them up a little bit.

Andy:
Yeah, yeah, yeah. I like that. That's really smart. And because you write about delay discounting and how we tend to just put off things. It's going to happen in the future and it doesn't have as much impact. Just shrinking the timeline down, I thought that was really smart.

Dr. Lembke:
That's right and having people actually focus on the future because as you said, delayed discounting is this phenomenon where we're all more likely, whether addicted or not to overvalue immediate or short term rewards. Over rewards that we have to wait for. The vast majority of us would rather get a candy bar today than get a candy bar a month from now. But interestingly, if you look at people who are doing things like smoking cigarettes or using other drugs, they are much more likely to overvalue short term rewards and much more likely to discount or undervalue delayed rewards.

Dr. Lembke:
Because there is some phenomenon that happens when we're using feel good drugs and behaviors in an addictive way that we really begin to not pay attention to the future. And we become very narrowly focused on what we can get right now today to change the way we feel. And so opening that up a little bit and having people more expansively think about themselves in the world over longer periods of time. Knocking on that door can get people to shift their perspective. And sometimes that shift in perspective is just enough to get to agree to the abstinence trial.

Andy:
So then what about even just talking about this stuff at all sometimes it's really hard as a parent to even get your kid to feel like they can tell you about their behavior or they feel embarrassed about it or don't want to be open or honest. You write about shame in here and sure that there's a lot of that going on. Even to get to the point where you could suggest an abstinence trial. And there's some groundwork that you have to lay in terms of just gathering information or getting them to open up and talk about what's going on and what they're doing. Is there anything that we could think about as parents to facilitate that or make that easier?

Dr. Lembke:
Yeah. I think one thing is of course, as parents we love our children and we're worried about them when we see them doing behaviors that we can see are not good for them, but perhaps they don't see it. And so we bring our own motion dysregulation and a sense of urgency to those conversations and that inevitably poisons the interaction. So what I recommend is that we really focus on having these conversations at a time and place when we're not dysregulated. And when we are able to mitigate the sense of urgency that we have around it, so that we're in a calmer space that's more receptive to our child being able to openly share. It's very hard to do, but if you can do it by scheduling the time to have the conversation.

Dr. Lembke:
So you can say each other, I'd really like to have a conversation with you. I'd like to schedule a time when we're both relaxed. Could we do that at 2:00 PM on a Saturday. A time where you know that maybe you're going to be in a good head space and when they are potentially going to be in a good head space and have time. And then you can sit down and just share what you observe and what your concerns are. What I always say to parents is you don't have to come to the conversation with the solutions. Like you don't have to have figured it out. It's just really coming to the conversation with like, this is what I see and this is why it concerns me. All bracketed by, and I love you and that's why I want to have this conversation because I love you.

Dr. Lembke:
And I care about you. In terms of treatment providers, I do use this dopamine acronym as a frame for how to talk to patients about substance abuse problems. And the D stands for data. That's where we ask folks just, what are you doing? What are you using? How much, how often. The O stands for objectives, why do you use for every person who uses a substance or behavior to change the way they feel, they have a good reason. It's either to have fun or to solve a problem. And those problems can be infinite problems from boredom to insomnia, depression, anxiety, concentration, whatever it is.

Dr. Lembke:
And then the P of the dopamine acronym stands for problems related to use. So that's where we delve into, well, do you see any downsides from using, is it interfering? Is it maybe not working anymore? That's a common downside. It used to do X for me. Now it doesn't do that anymore because of tolerance in the gremlins. And then the A, of dopamine stands for abstinence and that's where we then ask them to engage in this experiment. It's really an experiment based on a hypothesis that has to do with the reward pathways and the dopamine balance an abstinence trial of 30 days to see what comes out of it.