Leveraging Rigorous Honesty and Prosocial Shame in Addiction Recovery w/ Anna Lembke

Join Tara in this fascinating episode as she talks with Anna Lembke, author of Dopamine Nation.  Learn how addiction works in the brain and how to keep the balance between pleasure and pain on an even keel.  Anna discusses how rigorous honesty helps heal relationships and strengthens the brain. People who practice "strict" sobriety tend to  have a better chance of recovery.  And can the right type of shame actually help? Listen to find out more.

Transcript

Rigorous Honesty, Commitment, and Prosocial Shame in Recovery w/ Anna Lembke

 [00:00:00] Dr. Anna Lemke is a professor of psychiatry at Stanford University School of Medicine and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. A clinician scholar, she is the author of more than 100 peer reviewed publications, has testified before the United States House of Representatives and Senate, has served as an [00:01:00] expert witness in federal and state opioid litigation, and is an internationally recognized leader in addiction, medicine, treatment, and education. In 2016, she published Drug Dealer MD, How Doctors Were Duped, Patients Got Hooked and Why It's So Hard to Stop. It was highlighted in the New York Times as one of the top five books to read to understand the opioid epidemic.

Dr. Lemke appeared in the Netflix documentary, The Social Dilemma, an unvarnished look at the impact of social media on our lives. Her latest book, Dopamine Nation, Finding Balance in the Age of Indulgence was an instant New York times and Los Angeles times bestseller, and has been translated into 30 languages. It combines the neuroscience of addiction with the wisdom of recovery to explore the problem of compulsive overconsumption in a dopamine overloaded world. 

Tara: Welcome to Pathway to Recovery. I'm your host, Tara McCausland, and I'm so excited [00:02:00] to have here with me, Dr. Ana Lemke. Thank you so much, Ana, for being here with me. 

Ana: Thank you for inviting me.

Tara:  Ana was one of our keynotes at our 2022 SA Lifeline Conference. [We are ] so, so grateful for the work, the great work that you are doing in this field, Ana.

I know I learned so much from you last year and your book, Dopamine Nation is, I think, a game changer. And a lot of what we'll be discussing today comes from your book, Dopamine Nation. So, to start us off, it's really important that we give people a kind of a framework so they understand where we're coming from.

Can you tell us a bit about addiction and the brain components surrounding addiction? 

Anna: Yeah, well, first of all, addiction broadly defined is the continued compulsive use of a substance or behavior despite harm to self and or others. And addiction is a brain disease. What we mean by that is that the behaviors [00:03:00] that make up the phenomenology of addiction change the brain over time. And, importantly, they change the brain in a way that reduces our autonomy or ability to choose. 

So although we may initially choose to do a certain behavior or ingest a certain substance, with enough repetition, our brains can get into the addiction state. Actual neurological and brain chemical changes occur to a point where we are no longer choosing to do this activity or ingest the substance - it is choosing us. Although, we can dilute ourselves and have the illusion that we still have some modicum of control. So I think that's really important to recognize.

You know, the exact changes that go on are still being understood, but important findings involve dopamine, our neurotransmitter, [00:04:00] our reward and motivation and neurotransmitter, the more dopamine that's released in the reward pathway and the faster it's released, the more reinforcing that substance or behavior.

People release different amounts of dopamine in response to different stimuli. So we're all a little bit different, but in general things that are rewarding or intoxicating for one person are often rewarding and intoxicating for other people. And sexual behaviors and orgasm itself release a lot of different neurotransmitters, but the final common pathway is the release of dopamine in this pathway.

And for people who are vulnerable to sex and love addiction, the cycle of seeking out and obtaining and recovering from those hits of dopamine can lead to addiction for that kind of behavior. 

Tara: So thank you for that explanation about [00:05:00] addiction and, and dopamine and how that affects the brain and why we become addicted. In your book, you talk a great deal about the pleasure pain balance. And I know that having an understanding of this will be really critical for our listeners as you talk more about honesty and pressing on the pain side. Can you tell us more about again, this relationship between pleasure and pain and how we go about finding a balance? 

Anna: Yeah. So one of the important findings in neuroscience in the last 75 years is that pleasure and pain are co-located in the brain. So the same parts of the brain that process pleasure also process pain and they work like opposite sides of a balance.

So imagine that in your brain, in your reward pathway, there's a balance, like a beam on a central fulcrum, for example, something like a seesaw or a teeter totter in a kid's playground. And when that balance is at rest, that beam is level with the ground. And that balance [00:06:00] represents how we process pleasure and pain, namely they’re opposite sides of a balance.

When we experience pleasure, the balance tips one way. When we experience pain, it tips the other. In order to understand addiction, it's essential to understand the rules governing this balance. And the first and most important rule is that the balance wants to remain level and our brains will work very hard to restore a level balance with any deviation from neutrality.

So for example, if we do something that's reinforcing, we release dopamine, our reward neurotransmitter in the brain's reward pathway and the balance tips to the side of pleasure. But no sooner has it done that, then our brains are going to work very hard to try to restore level balance by downgrading dopamine transmission, not just to baseline levels, but actually below baseline levels.

That's called neuroadaptation. And I like to think of that as these little neuroadaptation [00:07:00] gremlins who hop on the pain side of the balance to bring it level again. But the gremlins like it on the balance, so they don't get off as soon as it's level. They stay on until it's tilted an equal and opposite amount to the side of pain.

That's the come down, the after effect, the hangover, that moment of wanting to eat one more piece of chocolate, watch one more TikTok video. Now, if we wait long enough and don't consume our substance or engage in our behavior again, those gremlins get the message that no more dopamine is going to be firing here for the moment.

They hop off the pain side of the balance and a level balance or what neuroscientists call homeostasis is restored. But obviously when we're in that state of gremlins on the pain side of the balance, there is an overwhelming physiologic urge to restore the balance by doing the behavior again. And this desire is often called craving.

And when we're surrounded by easy access to our drug of [00:08:00] choice, whatever it may be, it's very hard to resist that urge. What happens if we don't resist that urge and we continue to consume our substance or our behavior of choice repeatedly? Well, those gremlins start to accumulate on the balance. And over days to weeks to months to years, we end up with enough gremlins on the pain side of the balance to fill this whole room.

And they're essentially now camped out there, tents and barbecues in tow. And now we're entering “addicted brain.” We're walking around with a pleasure pain balance that's chronically tilted to the side of pain, which means that we need more of our drug in more potent forms, not just to get high, but to feel normal and level the balance.

And when we're not using, we're walking around with a balance tipped to the side of pain, experiencing the universal symptoms of withdrawal from any addictive substance, which are anxiety, irritability, insomnia, depression, and intrusive thoughts of wanting to use, also known as craving. [00:09:00] 

And this is the addicted state. This is why people will relapse, even after sustained periods of absence because it can take a while for the gremlins to get off. And this is why it's very, very difficult and in some cases nearly impossible to stop using. This is why we lose our autonomy because we've got that incredible physiologic urge to restore a level balance. And with easy access to our drug of choice, it's very difficult not to continue those behaviors.

Tara: Thank you for that wonderful explanation. I personally have a hard time explaining neuroscience. So I love the images in the book and the explanation with the teeter totter and the gremlins - that made sense to me. 

So in previous episodes, we began talking about what we call it at SAlifeline, the recovery puzzle, and this is our unique approach to recovery and what we believe long term recovery requires. [00:10:00] And two of those pieces that we're going to be speaking to specifically today are committed or commitment as well as rigorous honesty or what Ana likes to call radical honesty in her book, Dopamine Nation.

And so with that understanding in mind of the relationship between pleasure and pain, we're going to discuss radical honesty and why that plays a critical role in recovery. So to pose the question on it, what does radical honesty have to do with overcoming sexual addiction?

And maybe you can go at it from a scientific point of view, as well as an anecdotal point of view. I know you have several stories in your book that really resonate. 

Anna: Yeah. Well, radical honesty is the intentional practice of telling the truth about all things large and small. And it's important to acknowledge that that's very difficult for humans to do because we're all natural liars.

The average adult tells [00:11:00] one to two lies per day. Children at certain ages tell more. So radical honesty is something that we really have to work at and pay attention to. In my clinical experience and in my research, radical honesty appears to be fundamental to long term recovery. 

So people can get into shorter term recovery without it, but for long term recovery, embracing this idea of radical truth telling is essential. And it's something I observed in many patients over many years; those who were committed to radical honesty or rigorous honesty were the ones who tended to be able to maintain good recovery long term. Those who weren't paying attention to that or were lying with impunity couldn't maintain recovery.

So I got really curious about what was the link between long term recovery and radical honesty? And, what I concluded is that it works on many different levels. [00:12:00] First of all, radical honesty restores trust in intimate relationships, and that may be the only way to do that.

And trusting intimacy is a fabulous alternative, healthy source of dopamine. We often talk about human relationships as the ultimate antidote to addiction and addiction as leading to isolation. I think that's true, but we don't necessarily always give specific tools for cultivating intimacy, which is really important.

And radical honesty is an important tool. I can give you one anecdote from my book. A patient of mine who had been in recovery and abstaining from his sexual addiction practices for many months, leading to a reunion with his wife. She moved back in with him. They got a new apartment together. They were moving in with all their stuff. 

She was putting up [00:13:00] the shower curtain and she noted that one of the shower curtain rings was missing. So she called out to him and said, “Hey, do you know what happened to the shower curtain ring?”

Well, he knew exactly what had happened to it because he had used it months prior to make a masturbation machine. He was a scientist and that's what was part of his addictive behaviors, and he was struck with terror because he had promised her as a contingency of their getting back together that he would be honest with her. And yet the first thought that entered his mind when she asked him was, “I don't want to tell her this because it's just going to dredge up all that old pain. And we're doing so well and why bring it all up again and I made that machine, you know, months ago and I haven't done anything since and it's just, it's just going to open a Pandora's box and there's no point and I don't want to do it.”

But he checked himself because he remembered that as he and I talked, and what he’s been learning in his 12 step groups [00:14:00] is that he didn't get to choose when and how and how much of the truth he tells. He has to tell it all.

So he told her the truth, and he was sure that she would be repulsed and pack her bags and leave again. And instead she walked right over to him and gave him a big hug and said, “Thanks for being honest with me.”

So powerful, right? So powerful. So the point is that we think that people are going to be repulsed when they know the things that we've done. But in fact, the opposite happens. They see in us their own broken humanity and they come closer. So honesty really is the ultimate, maybe the ultimate gift we can give each other as humans. It's terrifying to do so, but it's really, really important for intimacy and relationships, especially in recovery from addiction.

So in addition to intimacy, there are very many, many other levels that it [honesty] works on, but I'll just mention one based in science, since that was your request. 

Two, [00:15:00] it's probably true that the willful practice or intentional practice of telling the truth about things large and small every given 24 hour period that we encounter, because we have to renew that commitment every day, is probably strengthening things in a part of the brain called the prefrontal cortex. The prefrontal cortex is that large gray matter area right behind our foreheads. It's essential for delayed gratification, future planning, but also interesting, for autobiographical narrative. What I mean by that is we're always telling stories about our lives. And those stories that we tell are really fundamental, not just for understanding our past and where we've been, but also for shaping our future. Because the stories that we tell become signposts for how to make decisions at every fork in the road going forward.

And if we've been lying to ourselves and others, then we don't have very good [00:16:00] roadmaps. But if we've been telling the truth, we have a much better roadmap for navigating the future. So, the way that we tell our stories, whether or not our stories approximate truthful narrative, as close as we can get - we all have our blind spots and our biases. But we know when we're lying and when we're not at the end of the day. So as close as we can get to telling the truth as we perceived it, we're going to have better roadmaps for decision making because we're going to have access to more accurate information that we need to put through our prefrontal cortex in order to know what our next move should be.

Also, there's a very fascinating experiment that was done by Christian Ruff and colleagues in, I think, the Netherlands, where they examined lying in a group of individuals who they had engaged in a die rolling task in which they would roll the die, a number would appear on a computer screen, and [00:17:00] if the number that they rolled on their die matched the computer screen, they were eligible to win certain small amounts of money.

And what they found is that people lied, you know, because people do. And this wasn't like a casino where anybody else was looking over their shoulder or saw their die roll. It was just based on trust. And they knew, based on the simple statistics of die rolls, how often they should have gotten it right. And people were lying about 10% of the time. 

So then they did something very interesting. They applied a transcranial magnetic stimulator to the prefrontal cortex, this large gray matter area behind the brain of these individuals, and had them do the task again. And what they discovered is that people lied less after their prefrontal cortex was stimulated.

So what that tells us is when we stimulate the prefrontal cortex with an electrical current, people are less likely to lie. Which suggests that the [00:18:00] inverse may also be true, that when people are actively engaging in the behavior of truth telling, they're probably through a bottom up process stimulating the prefrontal cortex.

So it's a way to make our prefrontal cortices stronger so that our recovery process can be healthier, more robust and more long lasting.

Tara: I think we all hopefully grew up with someone telling us that we should tell the truth whether it was a religious leader or a parent, but recognizing the incredible value in this principle. So many of us lie frequently and forget it's an incredible, as you said, an incredible cultivator of connection and keeping relationships strong. 

And you talked about the stories that we tell ourselves and the signposts and how we're essentially creating our own futures through what we say, both inwardly and outwardly. We just need to start being [00:19:00] radically honest for all of these reasons, as you have talked about. 

Anna: One of my favorite things is that neuroscience is now showing us the kinds of things that ethics and religion and spirituality have been teaching us for thousands of years. So it's really nice to see a lot of that stuff kind of converging. 

Tara: Right, right. So thank you for that explanation. So closely tied to this principle of radical honesty, we need to learn how to be able to press on the pain side. So telling the truth is painful, but you talk about in your book pressing on the pain side by dopamine fasting and also just other self binding behaviors and being committed to those in order to recover.

Can you tell us more about this concept of pressing on the pain side to equalize that teeter totter? And how can someone who is dealing with an active addiction can begin [00:20:00] to utilize those tools?

Anna: Sure. So, dopamine fasting is really the first step. That's where we abstain from our drug of choice, whether a substance or behavior, for long enough to allow those neuro adaptation gremlins to hop off of the pain side of the balance so that a level balance or homeostasis can be restored.

When we first give up our behavior, in this case our sexual behavior, whatever it may be, we have a lot of gremlins accumulated on the pain side of the balance. We're going to crash down to the pain side. We're going to experience the universal symptoms of withdrawal from any addictive substance, anxiety, irritability, insomnia, depression, craving.

In some cases, some of my patients with sex addiction also have physical symptoms of withdrawal, headache, nausea, vomiting, dizziness, cramping, and body aches. So it's important to acknowledge that this is really a painful period, but it usually lasts about 10 to 14 days. And on average, if people can abstain for four weeks those [00:21:00] gremlins have started to hop off the pain side of the balance.

Healthy dopamine firing is being restored. We have more ability to look back and see the true impact of our use on our lives. And we also recapture the ability to experience pleasure in more modest rewards or things we used to enjoy before we got caught in the vortex of addiction.

Now pressing on the pain side is related to this concept of hormesis. Hormesis is a new branch of science that has discovered that when you expose an organism to mild to moderate doses of noxious or painful stimuli, you actually increase the vitality and healthfulness of that organism. So it's counterintuitive, right? We're exposing organisms in animal studies, for example, to you know, say intermittent starvation, or believe it or not, radioactive influence, or extremes of [00:22:00] temperature, heat, or cold, or extreme spinning behavior.

And what we see is that if it's the right sized amount of a toxic stimuli that it actually extends the life of the organism or makes them more agile or robust in different ways. And the same is true in humans. 

And if you remember back to our pleasure pain balance, what it means is that if we intentionally press on the pain side of the balance with things like exercise, cold water immersion, those are the classic examples for which we have human studies, what we see is that those neuro adaptation gremlins actually pop on the pleasure side of the balance to bring it level again. But they like it on the balance. So they stay on until it's tilted an equal and opposite amount to the side of pleasure, which means that the gremlins are now causing the release of the dopamine in our reward pathway. 

But the key here is that we've obtained our dopamine indirectly by doing the work upfront. That [00:23:00] means we do not go into that dopamine deficit state that so characteristically follows the use of stimulating intoxicating substances in behaviors like pornography. So what that means is that this is very exciting news because that means that we can potentially get our dopamine indirectly by doing hard things first. 

And it probably also includes social, cognitive and emotional challenges. So things like prayer and meditation, which require persistent and sustained effort, things like unplugging and tolerating boredom for a period of time, things like apologizing, telling the truth, cleaning out, you know, the mess underneath your closet, doing something that takes creative and sustained effort - these are all things that probably press on the pain side of the balance and indirectly lead to upregulation of not just dopamine, [00:24:00] but other feel good neurotransmitters like serotonin, norepinephrine, endogenous opioids, and endogenous cannabinoids. 

That means that we can mitigate withdrawal from addictive substances and behaviors by hormesis or intentionally pressing on the pain side and we can also potentially prevent relapse once we're in long term recovery by getting our dopamine indirectly by pressing on the pain side.

Now obviously an important caveat here is that we don't want to press too hard or too fast on the pain side of the balance because then that's no longer hormesis, that's essentially self harm and that's not what we're talking about here. It is true that when people cut on themselves, that does immediately release endogenous opioids as the body responds to perceived injury, followed by a hit of dopamine, which is exactly why people do it.

But it's not a sustainable behavior because over time, very quickly, when it comes to [00:25:00] a sudden release of endogenous opioids, which is what you get with cutting, we develop tolerance. So it's not a repeatable, sustainable behavior. It's basically turning pain into a drug. 

And we do sometimes see people get addicted to pain, things like exercise addiction. I even once saw, you know, a burgeoning cold water immersion addiction, where this individual was engaging in ever more extreme temperatures. So we need to look out for that. That's not what we're talking about here. We're talking about right sized pain, not too little, not too much, but just enough to keep our pleasure pain balance supple and healthy and responsive. And to get the kind of dopamine that gives us that long lasting good feeling without going into that dopamine deficit.

Tara: So we often talk about, in the 12 steps, step zero is sobriety. It's abstaining from the behavior. And it's interesting how often we hear that people don't [00:26:00] feel that abstaining from the behavior of choice, whether it be porn use or masturbation or whatever their drug of choice isn't important for their recovery. What would you say to someone who insists that sobriety isn't a critical factor to starting the path of recovery? 

Anna: Well, let's parse out the language a little bit here. So sobriety is sort of an AA term for recovery. We like in medicine to use the term recovery because it's less moralizing, but how you define recovery is not an easy thing to capture.

It means first and foremost, as you point out, getting out of the addictive pattern of use, but sometimes that can mean using in moderation. So it's not abstinence. Recovery is not necessarily abstinence. Having said that, in [00:27:00] my experience, recovery has to start with abstinence. Meaning that even if your long term goal is to engage in that sexual practice in a non addictive way, you're probably not going to be able to get there unless you start with abstinence. Which when it comes to sex addictions, it means not only not viewing certain images, not engaging in certain behaviors, but also no orgasms with anybody, even with your beloved married partner.

And the reason we ask for that is because we really want to insulate your reward pathway from that particular source of dopamine for long enough to allow those neuroadaptation gremlins to hop off the pain side of the balance and for homeostasis or a level balance to be restored. And that can only happen by abstaining from that drug.

I mean, if you were addicted to cocaine, we would say no cocaine for four weeks. If it's orgasms in some shape or form, as well as [00:28:00] whatever the stimulating image or practices, then you have to abstain from that too. And once people are able to do that, and we ask for four weeks, because again, that's about the average time it takes to reset reward pathways.

Then we talk about next steps. Okay. You know, you're feeling better and about 80% of people feel markedly better once they get to about four weeks, but it's not a cure, right? It's the beginning of a very long process of maintaining recovery. And the first step in that maintenance phase is defining what recovery will look like for that individual. And that's of course going to vary based on your community and your values. 

Tara: That's a very fair response and sex addiction is unique in that sex is a good thing in the right context. And so being able to recognize that recovery in this arena is going to look different for, as you said, for [00:29:00] different people based upon their values.

And SA Lifeline has probably a tighter sobriety definition than a lot of organizations do. And I think that that's really critical as you're starting this process to ask yourself, “What are my values? And how can I lean into that so that as I'm starting this path, I'm not making excuses so that I can go back to behaviors if I feel like I can do them in moderation?” Or “Do I really value abstinence and recovery? That looks like...xyz.” Only we can know that for ourselves and going to the God of our understanding and to the people closest to us, like what does this need to look like for you so that we can have a committed trusting relationship?

Anna: Something that I think is really fascinating is that this strictness concept within groups is true across 12 [step] subgroups, whether it's a 12 subgroup for alcohol or cannabis or other [00:30:00] drugs or whether we're talking about sex addiction. And what's really interesting is that although we don't have a lot of data on this, because it's hard to gather, my sense is that the stricter the group, typically, the better the recovery in that group.

So for example, I will have patients who may not define their recovery the same way as a strict group has defined it, but they'll still attend the strict group meetings because they just find it works better, which is interesting, right? Realize that humans, we need those kinds of guardrails and we need them to be pretty high, especially in early recovery, if we're going to have a fighting chance.

And that you would think that a looser group that's more welcoming to different ideas and definitions of recovery might help more people, but it doesn't look like that's necessarily true. And then in fact, [00:31:00] it is these very strict definitions that are ultimately going to be more helpful for people with more severe addictions.

Tara: So as we're wrapping up, one of the most fascinating parts in your book to me was this concept of pro social shame. And the reason why is because, especially in this field of sexual addiction and betrayal trauma, there is so much shame related to this particular addiction. So talk to us a little bit about what pro social shame is and how that can work for us as we are working our recovery in this arena.

Anna: Yeah, so I like to put this concept forward because most often when we think about shame and we talk about shame, we see it as all negative. And it's certainly true that we can be paralyzed by shame and that that can inhibit our recovery. But it's also true that without shame, we wouldn't be motivated to make a change in the first place.[00:32:00] 

That is to say, if we didn't feel shame about some of our behaviors, why bother changing them? And this is what I mean by pro social shame. Shame is a gut punch of an emotion. It's incredibly powerful. You know, the thought, even the thought of getting caught or getting exposed can elicit the beginnings of feelings of shame, which then are accompanied by feelings of terror and fear of abandonment, getting kicked out of the tribe.

And in fact, shame is what keeps us often adhering to our group social norms because we don't want to get kicked out of the tribe. Right? So pro social shame is a motivator, and it's a very positive and important motivator in the sense that it is pro social.

So how do we walk this fine line between leveraging shame so that we're motivated to change the behavior but not feeling so overwhelmed [00:33:00] by malignant shame or destructive shame that we don't want to, you know, that we can't make any changes? And this is where I think peer recovery and mutual support groups have really kind of cracked the code on this, as opposed to, for example, some religious organizations where there's a kind of like a don't ask, don't tell policy, and they claim to want to help people with these deep seated, shameful behaviors, but they really don't want to know about them because they sort of don't know what to do with it.

This is fortunately changing in a lot of religious organizations, but you know, historically that hasn't been the case. Whereas in 12 step groups, what's so nice is that when we are honest about our shameful behaviors, we're actually welcomed into the fold, right? We provide important social goods to that social organization as newcomers who then are fodder, so to speak, for old [00:34:00] timers to to be their recovery coach.

So it's a positive thing, but at the same time, even within these groups, we can leverage pro social shame in the sense that if people are somewhat shamed, not for the addiction itself or the behaviors that go with the addiction, but there's a kind of a pro social pressure to actively engage, right? To work the steps, to get a sponsor, to tell the truth, to go to meetings.

And so if we're not doing those things, our sponsor will probably gently say, “Hey, you know, where were you?” or “How’s that step work?” or “I get the sense you're not telling me the truth.” So how do we create a space in which people can be radically honest, not be shamed for their addiction, but nonetheless be provided a path forward for making amends and changing the behavior. Because if you've got radical honesty without behavior change, that's not really going to get you where you want to go. 

Tara: Well, thank you so much for taking time today to [00:35:00] help us understand better the nature of the brain aspect of addiction and helping us understand this radical or rigorous honesty, as well as pressing on the pain side and doing so by dopamine fasting and all of these things will really help us hopefully gain some real ground in our recovery work.

Before I let you go, and I guess this is our blanket question that we like to end with and it's kind of a two parter here. What would you tell a newcomer who's just starting this pathway of recovery? And what would you also tell someone who's been walking this path for a while?

Anna: I would tell a newcomer, actions before feelings. I have a lot of folks who come to me and say, “If I only understood why I am addicted, then the addiction would stop.” And that's simply not true. And sometimes insight is the booby prize. 

So what we need to do is to do the [00:36:00] behavior change and then the feelings, including the good feelings will follow. So this requires a lot of faith and a lot of patience, but actions before feelings. For someone who's an old timer and has been around for a long time and is in long term recovery, I would just say, “You are my hero.”

I think that long term recovery is a remarkable accomplishment in life and something to be incredibly proud of and a wonderful way to give back to others just by living your recovery. 

Tara: Well, thank you so much, Dr. Lemke for all that you have shared with us today. We're grateful for the great work you're doing in this field.

Anna: Thank you for inviting me. It was my pleasure. [00:37:00]