Anna Lembke, M.D.
New York: Dutton, 2021
291pp., $28.00 (hardback)
Ebook and audio version are available
https://www.annalembke.com/
Anna Lembke’s website tells us that “she is professor of psychiatry at Stanford University School of Medicine and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. A clinician scholar, she has published more than a hundred peer-reviewed papers, book chapters, and commentaries. She sits on the board of several state and national addiction-focused organizations, has testified before various committees in the United States House of Representatives and Senate, keeps an active speaking calendar, and maintains a thriving clinical practice.” We also learn that she published Drug Dealer, MD – How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop (Johns Hopkins University Press, 2016), which was highlighted in the New York Times as one of the top five books to read to understand the opioid epidemic (Zuger, 2018)” and that she has “appeared on the Netflix documentary The Social Dilemma, an unvarnished look at the impact of social media on our lives.”
This is a complex book, but it was a quick read for me. As I read, I made lists of what I liked about the book and learned from it, what I’m struggling with in the book, the many paradoxes that Dr. Lembke presented readers with, and the points that I either disagree with or take issue with. I will use that format in discussing the book.
The Cleveland Clinic website gives us a working definition of dopamine:
Dopamine is a neurotransmitter made in your brain. It plays a role as a “reward center” and in many body functions, including memory, movement, motivation, mood, attention and more. High or low dopamine levels are associated with diseases including Parkinson’s disease, restless legs syndrome and attention deficit hyperactivity disorder (ADHD).
Dr. Lembke’s definition is somewhat more technical and is illustrated with some helpful drawings that emphasize the pleasure-pain balances (or imbalances) that we carry around with us, the effects of addiction on dopamine receptors, and dopamine levels and anticipation and craving. I struggled with the science that the author presented, but this is not a technical book. If I can understand the gist of what is being said, you can also.
What’s good in this book
The book begins and ends with discussion of the spiritual dimensions that we should consider as we think about how we balance pleasure and pain. Dr. Lembke takes a quote from the progressive Christian ethicist Kent Dunnington early on in the book that nails why thinking about pleasure, pain, and addiction in light of our shared social experience matters. Dunnington is quoted as saying “Persons with severe addictions are among the contemporary prophets that we ignore to our own demise, for they show us who we truly are.” This is an excellent starting point that touches the conscience. It seems that the most pressing conversations about dopamine and pleasure and pain balances are, or become, conversations about addiction and (dis)ability.
On the positive side, I think that Lembke is helping people take on mental and physical health conditions that are largely the products of a latter-day form of advanced capitalism, and I appreciate that she’s using science to help make her case. I don’t know that the science that is being used always used scientific methods, but this book is fact-based. She makes a statement somewhere in the book that I think is supported by science that says in effect that the human search for belonging and decreasing consumption can work together for a necessary social good. The science that Lembke is using helps her support anti-racism and oppose classism. A number of types or kinds of addictions are covered.
It's good to read someone saying “I urge you to find a way to immerse yourself fully in the life that you’ve been given. To stop running away from whatever you’re trying to escape, and instead to stop, and turn, and face whatever it is.” Lembke gets what I think are some of the actions and thinking that go with this. There is much talk in the book about the social good of having inclusive and exclusive organizations (pp. 219-220). The author understands that engagement with the world is a necessary part of finding a pleasure-pin balance and beating or controlling addictions (p. 231). She understands that derealization and depersonalization and the false self that so many of us live within terrify us and can lead to suicide (p. 192). People in the U.S. no longer talk to one another as much as we once did. Neil Postman is quoted as saying “Americans no longer talk to each other, they entertain each other. They do not exchange ideas, they exchange images. They do not argue with propositions; they argue with good looks, celebrities, and commercials.” (p. 40) We report experiencing more pain than people in other countries do, and our pain is increasing. (p. 45). There is an environmental cost to why and how we suffer, but a portion of our population---and I’m in this demographic---is increasingly prone to “deaths of despair” (p. 30). Working-class people will understand this last point. One of the addictions mentioned is the addiction to work, with the related fact of blue-collar alienation. Lembke makes the point that “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” (p. 106). People on the Left have been naming these facts of life as indicating advanced stages of alienation.
And Lembke takes some deep dives. She talks about “radical honesty” and taking a rigorous self-inventory, points that will be familiar to anyone who has gone through recovery. She has much to say about Alcoholics Anonymous (AA) and its internal culture. In this regard, there is much in the book about “prosocial shame” and the good that it does in certain groups, particularly recovery groups. This is not destructive shame, with its shunning and bullying. Rather, this is the how radical honesty works out when it comes to people in recovery holding one another accountable, AA’s 12 Steps program, empathy, and making amends. I was not familiar with the term “self-binding,” or the intentional acts of creating barriers between ourselves and our drugs of choice and the steps and paths that take us to them. Whether we struggle with addiction or not, most of us need some kind of self-binding to avoid the traps that capitalism and consumerism lay for us. The culture of doing this work with others, something that is made necessary given the ready supply of legal and illegal high-dopamine goods that are readily available, involves “club goods,” or the culture and benefits of working out our sobriety and refusal to partake with others who share our situation. Club goods are about who and how many people are participating with us, the energy they bring along, and the way they communicate support or disapproval. Social goods, or preserving them, is also about who comes along for the ride but doesn’t help others and becomes a stumbling block to others.
When Lembke says that “Abstinence resets the brain’s reward pathway and with it our capacity to take joy in simpler pleasures” (p. 234) she’s stating a scientific fact and sending a message of hope, but she is also inviting a potentially revolutionary response. If oppressed and exploited people are radically honest and boycott what traps us in capitalist society and hold real conversations with one another and build organizations that express this honesty and “simpler pleasures” it will create crises for the system.
Go to Part Two
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