 All right, coming up next, Sally Satel is going to do a presentation. She is the resident scholar at the American Enterprise Institute. Her talk is 50 Shades of Grey Matter, Healthy Skepticism and the Illuminated Brain. Here is her limerick. Sally will speak about the brain, an organ that helps us stay sane. Until it sees Chopra being interviewed by Oprah, then oh my dear, the pain, the pain. Please welcome to the stage Sally Satel. Thank you. I've never had a limerick dedicated to me. Why is the neuroscience so seductive? Or more precisely, brain images, brain scanning. That's really what I'm focusing on now. Brain scanning, in a sense, is a perfect storm of seduction. Think about it. For one thing, it's technology and technology at its most remarkable. This is truly a staggeringly fascinating technology that promises great objectivity and something truly we've never seen before. And I emphasize seen because the second dimension of why brain images are so amazing is that they're visual and we are highly visual creatures. In a sense, brain imaging, you could argue, has that more compelling factor over, let's say, genetics. Can't see genes. You can see a brain image. And then, of course, it's about the brain, the most fascinating, complex item in science, a masterwork of nature, the organ of the self. Nothing could be more compelling than the brain. And lastly, it promises a tidy narrative, a tidy brain to behavior narrative. And if we see something in the brain, if we see enhanced activation here or there, then the behavior that correlates with it, sometimes problematically said the behavior that is caused by that brain activation, but the behavior that seems to flow from that brain activation is inevitable. It's involuntary. Look, it's in the brain. The person couldn't have helped himself but to perform that act that supposedly flowed from the activity in the brain. You can see just from that formulation alone why brain images are becoming so popular in the courtroom. Listen, Your Honor, my client, it wasn't him, it was his brain. And I know you've heard that before. But the truth is at this time, and much of what I say has to be underscored with by saying at this time because we are discovering enormous amounts, we have eons longer to go in terms of our discovery trajectory. But right now, we cannot look at brain-derived data and tell whether an impulse is irresistible or it simply is one that hasn't been resisted. Nevertheless, the impulse or I should say the intuition is powerful. And that intuition being that if something is in the brain, then we have diminished expectations of agency. In other words, that person couldn't have been that responsible because again, we see something in the brain. And nowhere has, to my mind, nowhere is that sort of conceit more powerful and more used than when it comes to addiction. Actually, that's my area. I am a psychiatrist and I specialize in addiction and I work in a methadone clinic when I'm not at the American Enterprise Institute. We're on the staff psychiatrist. No, where I also work. And there's a lot of confused thinking when it comes to neuroscience and addiction because addiction, I'm going to say, has fundamental elements of being a voluntary behavior. And I will define exactly what I mean by voluntary. I don't mean it's easy to give up a crack pipe. It's not easy to quit smoking. These are very hard things, but there are voluntary dimensions to it. And I'm going to talk about that. But first, I want to describe that experiment. Those are two brains. One belongs to a non-drug user. One belongs to a drug user, cocaine user. When a cocaine user is put in an FMRI, this is a very, very, very common and much replicated experimental paradigm, put in an FMRI machine and shown videos of people using cocaine, people manipulating cocaine paraphernalia, preparing to use, enjoying the effects. There will be, these are PET scans, but there will be increased activation. That's funny. So you got them? Okay. So the slide of the cocaine user in this PET scan, that is increased activation, increased dopaminergic activation as the cocaine user observes these images of people using slides. He or she will report a subjective sense of craving and that will manifest as increased activity in the structures that are related to, that are part of the limbic system. Makes perfect sense. This is the so-called reward system. It's where expectation is mediated. And that's how it's manifest. And it's really a pretty remarkable portrayal of this phenomena that we see in the brain. It's well controlled. You show the non-drug user these pictures, you get no similar activation. Conversely, if you show a drug user two sets of slides, again, or two sets of images, one about people using drugs and enjoying them, you see the activation. You show the drug user slides of a natural habitat, a forest scene, something tranquil. You don't get the similar levels of activation. So it's a well done experiment. The problem is that too often that particular image and that particular description of the experiment is taken to mean that the person, the cocaine addict, because of this dopaminergic activity has then lost control over his or her ability. And the drug use itself has become involuntary. And you hear words, you will, this is an image of the limbic system that I mentioned. And just one path where the dopaminergic, there are others involved. There's serotonin, there's GAVA, there's glutamate, others. But everyone talks about dopamine and it's true. That is a major transmitter on the reward pathway. And here we see the reward pathway. And we hear words like drugs have hijacked the brain. That's a very common metaphor. Brains have hijacked the reward system. The person had no choice. It's an all or nothing phenomenon. You also hear, for example, that drug use addiction changes the brain forever. Well, in one sense, yes, heavy alcoholism, of course, can lead to organic changes. And we all know that. But the kinds of changes that we're talking about, for example, with a heroin abuse, heroin dependence addiction, even nicotine, are changes in the memory structures. And that's really no surprise. You get two types of changes. You get changes involved with conditioned memory so that you get a kind of almost Pavlovian-like craving, for example, when people are exposed to the classic places people and things that remind them of their use. This unbidden rush of craving, that's true. And you also have an explicit memory of using. Like, gee, I used to like using this drug. I did this for me. I enjoyed it. Those are two kinds of memory. And you can't have desire without memory. That makes perfect sense. If you do have desire without memory, you're basically talking about a drive. So there's nothing particularly menacing or toxic about having your brain changed forever because you've used a drug, because that's the nature of experience. Nevertheless, this notion of brains being changed has led to a kind of formula of referring to addiction, very popular in the National Institutes of Health, such that addiction is a brain disease. Now, why is it a brain disease, you might ask? And the reason is because, you will be told, well, the reason is it changes the brain. So it's a brain disease. Well, that doesn't quite work because learning a language changes the brain. But clearly, learning Italian is not the same as a quiner crack habit. So there are differences there. Well, what about Alzheimer's disease? And I've also frequently heard people make analogies to addiction is a brain disease just like Alzheimer's. And they really have to say, well, wait a minute now. There are very, very important differences between the kinds of brain changes that occur in addiction, and they do. There's no question about that. If you think that's sufficient enough to call it a brain disease, and that's how you defined it, then I suppose it is a brain disease. But I don't feel that those, I obviously don't feel that it is. I think it's much, much, much more complicated. But as far as the brain changes themselves, the brain changes of Alzheimer's are such that the course of that condition, which is to say the dementing process, cannot be reversed through incentives or sanctions, or even a person's desire to get better. So if a person has Alzheimer's, for example, you can't say, I will give you a million dollars if your memory doesn't deteriorate, or I will choo-choo if it does. It won't matter. The kinds of brain changes of Alzheimer's render that person impervious to contingencies. But when you say that to someone with an addiction, when you offer them sanctions and incentives, they can be extremely responsive. I'm going to talk about that a little bit later. And in fact, if we focus too much at the level of the brain, which is an important level, but not the only level, if we focus too much at that level, we will miss that very, very important element. And that's what I meant by the essence of voluntariness, defined in a behavioral sense as a behavior whose course can be altered through the application of sanctions or incentives. That's my definition of voluntariness. Now, the problem is when you focus on the brain too much, you find yourself in the realm of neurocentrism. This is a term that Scott William Feld and I have invented for this purpose. And it refers to the notion that the brain is inevitably the best level at which to explain behavior. That somehow explaining the behavior, complex human behavior at the level of the brain is somehow more authentic, more true, has greater predictive value. Now, for some conditions, that's true. In fact, for Alzheimer's disease, that is true. But for others, it is not. And addiction is one of them. It's a problem. Neurocentrism is a problem for several, several reasons. First, it implies that the solution to addiction is a medical one. And what I mean by that, I mean medical in a narrow sense in that it involves medication. Now, remember, I said, I work in a methadone clinic. So I have absolutely no ideological problems with medication for addiction. I'm a radical pragmatist. If it works, I'll use it. And methadone does work to some extent, but methadone treats withdrawal. If it treated addiction, I wouldn't have patients continuing to use other drugs and their lives would be much less chaotic. But unfortunately, that's not the case. We have some medications we use for addiction for alcoholism. We certainly use naloxone. People have heard about that for overdose. That's different. But in terms of treating behavior, some of our medications help around the margins. But there's no silver bullet. And medication has rarely been the focus of a successful treatment for a patient. So too much emphasis on the brain suggests a medication type of solution. It also suggests that professional help is always necessary. And in fact, one of the little known facts about addiction is that in the majority of cases, people will quit on their own, usually by the time they're 30, in their early 30s. Now, if someone's 23 and has a raging habit, not for a minute what I say, now just hang on a few years, you'll be fine. Of course not. But the natural history is that this is actually a remitting condition. And those in which it is chronic tend to be folks who also have depression and anxiety and other problems. But the point is not everyone needs medication. In fact, that's good because we really don't have good medication for addiction. Not everyone needs treatment. Also, a neurosentric model overlooks the person's psychology and the environment in which they find themselves in. And those two contexts are absolutely huge in treating addiction. They have much more explanatory value in why people start using, why they continue to use, and why they stop. So what we're really talking about here in terms of neurosentrism is you'd find, so you'd find you can see the brain level, that's about five down. That would be the neurosentric level. But there are so many more, so many more that are important when we think about addiction. And these are all valuable levels of analysis. That's what they are. Some are more helpful than others in explaining certain phenomena and asking certain questions. But again, we can't sacrifice these other levels for the brain. When I mentioned before that contingencies make so much of a difference, one of the most dramatic examples is one from the history books in 1971 when Richard Nixon was told that there was a epidemic of heroin use in Southeast Asia and our soldiers in Vietnam. He panicked, as did many politicians, and they thought that, oh my gosh, when these soldiers come back to the United States, they're going to inflame the inner cities with more drug use, and this has to be stopped. So the military instituted this program brilliantly named Operation Golden Flow, where you had to give a urine sample and it had to be negative or you couldn't leave. You could not get back on that plane. And when this policy went into effect, people were given a few weeks to clean up. The vast majority cleaned themselves up and left. Those that didn't stayed an extra week, went through detox, and they left. The vast majority of folks were out of there. And in follow-up studies up to three years later, only 12% of those who had heroin dependence, addiction in Vietnam, not just use but addiction, had re-experienced addiction once they were back in the state. So that trope of once an addict, always an addict, was blown apart. We know in the criminal justice system through various programs that some of them are drug courts. There's another very, very advanced one in Hawaii called Project Hope. Project Hope takes methamphetamine addicts. Methamphetamine is considered to be one of the most toxic drugs of abuse. And yet these offenders are told that their charges will be dropped, but they have to comply with a system where, again, they give negative urine, and then they are basically left alone. They're not put in treatment, they're not given anything. They're only given treatment if they can't comply with this requirement to give clean urine. If they don't give the clean urine, there are some consequences. It's not jail, it's maybe one day in jail, or some sort of concept of graduated sanctions. But the idea is that the responses are swift, certain, but not severe. And these methamphetamine addicts, folks using the most allegedly neurotoxic drug there is, can manage to comply with those directions. And the results of re-arrest and re-incarceration and drug use in that group are halved at least. I can provide more data on that. Very compelling. Also, we know that people can engage in, and this is the kind of thing we do in therapy. This is where we take advantage of people's motivations is that we help them deal with their craving. I mentioned craving is, it is that unbidden. It's Pavlovian, it's clearly conditioned. One can't help it. You can't help it if you're trying to quit alcohol and you pass a store or a bar and you have a very intense desire to use. And that can be very threatening to your recovery. So how do people avoid that? Well, there are all kinds of strategies that they can adopt. They're called self-binding, where you don't walk around with any free cash in your pocket. You walk home a different way from work so you don't pass your dealer. I once had a patient who was a teacher and the chalk, always reminded him of, the chalk dust reminded him of cocaine, so he always had to use a whiteboard. Let's say, Stockbroker who used his arms so much for injecting that he had to cover them up with, he had to wear long sleeves all the time, not just for cosmetic purposes, but because he found his bare arms so inviting. But these are ways, some of them are very idiosyncratic, that people, they observe themselves, they see what stimulates them and they bind themselves. Now you might think, well, but people are, when people are involved with drugs, they can't even think straight. You know, that's rarely true. Most of our patients work. Granted, they're not paying taxes, but they work. There are many, many lucid periods during the day of an addict. People make all kinds of decisions. One of them could be to come into treatment, but as I said, most people figure these strategies out by themselves. And finally, another point about neurosentrism that is that it deprives you of, it deprives one of understanding that people use, they use drugs for reasons. People use drugs serve a purpose in the short term, and then over time all these noxious consequences pile up. So that's really what underlies the, I guess, the ultimate paradox of addiction, which is that how can something, oh, pardon me, how can something that's so self-destructive also be part of a behavioral dynamic that also has so many elements of choice in it? And the way, in fact, one of the brain disease proponents will often say, I never met anyone who wanted to be an addict. You know, who would want that? And granted, who would want that? No one would choose that. But that's not what addicts are choosing. Addicts are choosing to feel better in the moment. No one who is obese has ever chosen to be fat, but they choose to feel better in the moment. And these incremental moments pile up and up, and the habits become entrenched. So to pull back, I mean, I've been talking more narrowly about addiction and how we reconcile neuroscientific findings with the fact that this is a complex phenomenon in which there are considerable elements of choice where motivation can make a huge difference. And yet we have such compelling images, such compelling pictures, and such fascinating science that I am convinced is going to teach us a lot more about impulse control, about reward mediation, about motivation, about depression probably. I'm personally a little pessimistic. We're ever going to find a medication that will help profoundly. But I know we'll learn an enormous amount along the way. But the larger challenge to me is that as we get better at offering biological explanations for all kinds of behavior, one implications does this have for the way we'll think about agency, personal agency, civic, legal responsibility. And to me, this is really one of the biggest cultural projects that neuroscientific advances are posing. So I'll close by saying, going back to addiction, sure it affects the brain. Somehow it seems very apt that we would be talking about addiction in a gambling mecca. Almost everything I've said applies to gambling, except that you're obviously not taking in an exogenous substance. But in terms of much of the biology, not all of it, there are similarities. The reward pathways are heavily engaged. The conditioned craving elements are huge. Casinos take advantage of that all the time. But even though we can image things in the brain and see them and they're there and they're vibrant and they're compelling, we can't forget also that from the level of the clinician and the level of the policymaker, the brain is not the level, I'll say yet, although I happen to think it will never be, the level at which our interventions are the most meaningful. I think of the brain really as the brain as the realm of mechanism and the mind as the realm of meaning. And when you're working with addicts, addiction is very much a human drama in many ways. And that is the level at which you appeal to people, you reason with them about their behavior, the strategies that can conduct it, and the kind of hopes they have for their future. Thanks so much.