Transcript of Why Are We So Anxious? Psychiatrist Dr. Michael Dulchin Explains

Part of what I think people are always trying to do with their lives is stay genuinely motivated. One of the genuine motivations is money, is success, is safety. So to keep making it a little unsafe means that keeps people fundamentally motivated. Fulfillment and achievement— lack of full fulfillment is part of what keeps people motivated, but it also keeps them a little unhappy.

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Before we start the conversation today, I want to deliver a personal message. Every day, families across America lose someone they love to an overdose. That's why I've partnered with the CDC Foundation through their COPE— Community Overdose Prevention Efforts— campaign and committed to matching every donation dollar for dollar up to $25,000. I've spent my life helping people recover from addiction, but if we can get to the place of prevention first, this would help save so many more lives. I hope you'll join me in supporting the CDC Foundation's overdose prevention work at cdcfoundation.org/cope. Thank you from the bottom of my heart. Joining us today is psychiatrist Dr. Michael Dolchin. He has spent more than 3 decades helping people better understand their minds, emotions, relationships, and behaviors. He's the co-founder of Union Square Practice in New York City and previously served as director of inpatient psychiatry at NYU Medical Center for 10 years. From anxiety and depression to ADHD, burnout, relationships, and performance, Dr. Dolchin works with people trying to function at a high level while navigating the realities of modern life. So what are we getting wrong about mental health today and what actually helps people get better?

Doctor, it's a pleasure to have you on today. It's a huge honor for us. So thank you. Very generous. Over the last 30 years you've spent in psychiatry, what concerns you most about mental health I mean,

it's hard to answer any question 2026 without thinking about AI and what that is going to do and what it's not going to do and how that's going to play into the sort of the general mental health of the world, what pieces we're going to be picking up and what new tools we're going to have available to us to help pick up the pieces. So AI is really my answer. Um, in that situation.

It's so anxiety-producing. It really is. I mean, it's, even if it's, it's happening, it's displacing so many people, right? Mm-hmm. But even if it doesn't affect you, how do you know it's not going to affect you? So the trauma is just everywhere. It really is.

Absolutely. And, you know, the way I think about it is that it's fundamentally destabilizing to a level that people didn't expect to be destabilized at. My temperament is one of, eh, it's always about the same. Decade to decade to decade, there's a new thing that people worry about. And it's like, well, this is the new thing, but everybody's worried about a new thing. For the first time in my life, I feel like, oh, this is fundamentally different. And it's going to be— we really can't predict what's going to happen over these next 5 or 10 years.

5 or 10 years? It's changing every 6 weeks. I swear to you, it's changing every 6 weeks. The trauma and the bad news keeps getting worse and worse. It's like a death of a thousand cuts. It's like, you know, you don't adapt and you're dead.

But absolutely. But even I agree with your timeframe, by the way. But even there, it's this 2-level thing or this multi-pronged thing, which is on the one hand, some of it's going to be good. Some of it works. Some of it's helpful. Some of it's going to be great. So I'm not— I'm just— it's just interesting, but interesting is stressful.

I know, but our default setting is the world's fallen. The world's— the sky's falling, isn't it?

First of all, you try to fight your way out of that. But yeah, I know,

I know. It's difficult. Are people struggling more today than they were 20 years ago, or are we simply talking about it more?

It almost goes to my previous answer, which is, for the first time in my life, my answer is a clear, people are struggling more today, right? And in an interesting way. I mean, this is a national podcast. I'm located in New York City. Many of the patients I work with in 2016 were not happy with the results of the presidential election, right, in a way that felt really catastrophic to people. And that's really all they wanted to talk about for months, a year, and things settled down. Similar situation today, but no one is talking about it other than to tip their hat to say, like, you know, I'm not happy with it, but it feels like it's out of their control in a way. There's a certain learned helplessness. I think AI is actually a little bit similar. People are seeing it, people are paying attention, people are in San Francisco and they're ahead of it and they're a little more optimistic. People in New York, it's coming to them. But people don't know what to do. People don't know what to do. And I think that that's the profound thing.

You know what you made me think of when you said that? The citizens of Russia.

Yeah.

Because they walk through life thinking, I have zero control, zero agency over myself. And that's what you just described for me, like the road there.

Yep, absolutely.

And I know for certain it's going to be great. It's going to be great medicine, right? I mean, that we know. It's going to be great in a lot of areas,

right?

But it's going to be devastating in a lot of areas. And as we both know, there are both good people, bad people, and absolutely horrendous people. And they each have, uh, access to these tools.

Absolutely.

It's, it's, it's a scary thing for sure. Just out of curiosity, how are your patients feeling about the new mayor?

Great question. Great question. I had a patient say to me yesterday, he said, listen, he said, right, I know that sometimes political views between patient and therapist can really rupture the relationship. He said, so I hope it's okay to say this. He said, but I don't care at all about the Knicks. He was joking. What leads me to that is people have very strong feelings about the mayor, often having to do with how they feel about Israel. Right? That patient population feels very strongly one way, Jewish patients. Patients feel very strongly the other way, Jewish patients. Right? So it's a big— that really seems to be the divider of how people, how people feel.

That was probably the most diplomatic answer you could give to that question. And we are going to leave it there. That is perfect. It's, it's funny though, man. It's like I never— before social media, right? Even with the internet, it got incrementally bad.

Mhm.

And with Fox News, all that one thing, and then MSNBC and all that one thing. So it was always getting worse, okay? Uh, the divide, but it never got as bad as social media. And the second social media took off, now the trauma collectively, in my opinion, is we don't know the difference between the truth and a lie.

Mm-hmm.

Tell me that isn't trauma. And when you don't know the difference between the truth and a lie, and you're staring down the barrel of something that is changing the world every 6 weeks to the point where you've got whiplash, okay, and you're frozen in fear. I mean, I think those 2 things going together is not great for the mental health of America.

Yeah, no, absolutely. What's going to happen to us? Without really being able to see the variables is very, very disturbing. People are okay when things are hard. Oh, that's hard. But I have a sense of if the effort that I put in, I understand what the out— what I get for that. It's when it's unclear that mental health suffers. And it's often what I'll say to people, you know, they come to me, right? Not necessarily to have everything be dandy. I quote a patient from this morning. but to have everything be understandable. That's why I'm in pain. One of the funny things after 9/11, right, was that I had a cohort of patients who came in and were like, existential terror? I've always lived in existential terror. So I actually have skills of how to handle that feeling. All of these people who were, quote, normal, they've never felt existential terror before. They don't know what they're doing. It was an interesting phenomenon.

So how, so how Do we give some relief to someone who's listening to this in order to get their head right and optimistic about the possibilities? Because as we know, a lot of this is perception. That's all the public is thinking about, right? How do we give them some hope? Because there's good to this. I just can't find it.

It's a great and very complicated question because it seems to me it gets to where you are on whatever, whatever you believe on activism or not, right? There's always been a question about what do therapists, what is mental health, right? Is it the job to help people feel better about the situation they're in, or is it to say it's the situation you're in that needs changing, you should be going out to fight and changing the situation? There's no one right answer. It's often a complicated thing, right? To my mind, when there is a very difficult situation that's unchangeable, what you want to help people do is realize they can't control that. All they can control is the efficiency of their suffering. Be better at it. Let it affect less of your life.

Can we go a different direction?

You don't think that's true? When people can't control it, you want to say, You can't do anything about that. Be better at being in your stressful environment.

Well, that's true. But I wouldn't have said that. That's your lane. That's perfect for your lane. My lane would have been focus on what you can control and stack up little wins, little wins, little wins, little wins, right? But you're exactly right. You're talking about resiliency. And it's like, So you gotta, you know, you gotta work on your resiliency, and then you gotta figure out what you can control.

Yeah, basically, absolutely right. If you can't control this, you're thinking about what you can control. But I'm really pointing out something that people will often think, that if they're not feeling good, they're doing it wrong. It's not feeling good is an input that says evaluate what you're doing. Maybe you're doing it wrong. But once you've checked everything, Feeling good just means to, you know, it's a shitty situation and you're not feeling good, if that makes sense. And then you're enduring through it and that you can be proud of endurance where you're people, no one's proud of passivity. Figuring out that difference is one of the things that can be really helpful.

That's so true. So what you're saying is nobody's proud of themselves for being paralyzed in fear, what you're proud of and being stuck and just paralyzed. But what people are proud of is if you're paralyzed in fear and you get out of bed and you go face the day and do it the best you can every moment of every day.

Yes, I agree with that, but I'm just pushing it a little farther.

I know, but I was making it— You're making it nicer?

Yeah, but I don't know. say to me who are depressed, right? They'll say like, oh my God, I'm in so much pain. What am I going to do until the medication works? And my answer is, we all know what you're going to do. You're going to suffer, but you're not suffering foolishly. We're waiting for the suffering to end. And that is the most efficient use of yourself. Don't beat yourself up for suffering. That's the nature of this. It will come to an end just by enduring. You want it to be more active, I can hear, but sometimes that makes people feel foolish.

No, I want it to be less painful. Because you're exactly right, but you can always support someone through the pain and make it, um, uh, less palatable and, uh, get you to the other side and even grow through it. So

absolutely. Absolutely.

Right. Okay. Stop being a baby, Rich. Such a baby. I don't want anybody to hurt for a second. All right. What do you think is the biggest misconception people have about mental health?

Here's my favorite question to ask all new patients and to put out there for people to ask their patients. Do you not know who you are inside? The way other people just seem to know who they are. Right. Most people don't quite understand the question. How could you not know who you are inside? There's a whole subset of people, right, who have identity issues, core issues, who will say either like, I understand the question, or I don't know who I am. To not know who you are Makes everything hard and makes the world traumatizing in a way, which is hard for people who fully know who they are to conceive of. A lot of people's experience of the world, a lot of it's written about depression, anxiety, right? Comes from people whose sense of self is not necessarily as full. And to not acknowledge that, understand that, treat that, hold that, is misperceived by everybody. It's like a psychiatrist, a therapist's inside view of a lot of what's written, a lot of what's on TV, a lot of what comes up in the news.

So that was probably the most beautiful and eloquent answer I could ever expect to hear on that question, which raises another question for me. Can you know yourself to the extent where you can, you've got the resiliency for, you know, catastrophic things that come up in your life if you don't have self-love.

Yeah, but it's a hell of a lot harder, right?

Yeah, it would seem that way because how the hell do you know yourself if you don't give a shit about yourself enough

to

take care of yourself?

Yeah, yeah, to think that you're fundamentally okay. You know, so many of the psychotherapies that we know are trained in, you know, say accept yourself in order to change. It's a bedrock of so many and is crucial. So knowing yourself as opposed to thinking everything about yourself is great. Big distinction, but I agree. Much harder to be resilient if you can be rocked to the core in the way other people can't.

Do you know, it's funny, I always tell people, know the room. And really what I mean is, you know, know yourself, right? Like walk into the room and gauge it and then just figure it out.

Okay.

Yeah, you're exactly right.

I have an analogy for this, which I just kind of like. And, you know, anybody who might be listening to this, heard me speak, I use it all the time, which is your personality is like your table base and your mood is tabletop. Right? It could be that you're depressed. If your table base is stable, you have a full sense of self. You put an antidepressant on, a little psychotherapy, back to normal. Back to, yeah, life makes sense. You get bipolar disorder, you put a mood stabilizer on, fine. Table base is a little narrow.

Do borderline personality disorder.

That's what I'm doing. That's what I'm doing. And that's why it is so hard. You're right on it, right? Which is when life comes at you, the table base isn't. So your table, you're spending so much energy on your balance, it's unfair that everybody else walks around effortlessly.

For a guy as smart as you, I'm in shock that you're this plain-spoken. Okay. We hear constantly about an anxiety epidemic. Why do you think anxiety has become so common?

I guess I'm going to go back to sort of the previous thought, which is There's just a tranche, a new level of uncertainty in the world, which just has people vibrating in a different way. It makes sense.

Is there a difference between achievement and fulfillment in your mind?

Yes, absolutely. Right. And it's actually interesting, because you've gotten me to a topic which I recently thought about in a different way. I work with lots and lots and lots of people who have been very successful. And one of the terms that people will use is the churn. I've made so much money, but it's still really stressful because I spend so much money. And the answer you could think will be, well, spend less money. This isn't so complicated. But that actually doesn't really hold water because anybody could spend less money. Right? You could be here and go down to here and you'd have not particular problems. You could not have a TV, you could not— or you're not having your second car, your third house, or whatever. Part of what I think people are always trying to do with their lives is stay genuinely motivated. One of the genuine motivations is money, is success, is safety. So to keep making it a little unsafe means that keeps people fundamentally motivated. Fulfillment and achievement— lack of full fulfillment is part of what keeps people motivated. But it also keeps them a little unhappy.

You know, it's so funny that you said that because, you know, before I had children, I wanted money and things. And the second I had children, I wanted to provide security and safety.

Yep.

And I didn't give a shit about anything other than that.

Absolutely.

It's so— and do you ever tell your clients, well, if you weren't such a vapid, soulless sack of shit, Okay. And you didn't, and you didn't care about things and you focused on your child, everything would be better. Then you'd be fulfilled because the only job you have is to make certain that your child is okay in the world when you're gone and to provide a model for him to live in the world, which is, okay, I'm proud of the way my father lived his life. Okay. Those are the only 2 things that matter. It's amazing. That's why I don't— that's why I only have 6 beds.

I'm going to make myself sound very Pollyanna-ish, and I don't mean to, right? Which is even before when you were sort of saying, you know, there's good people, bad people, and very bad people, right? Yes. On the other hand, no one in that group says, yeah, I'm the very bad person, right? Oh, I'm bad. Everybody, or so many people think, I'm trying to do something good. That person thinks I'm evil, but I'm trying. Nobody thinks they're the bad guy, right? So in the same way, even the person who, to use your phrasing, could be vapid and soulless, is usually showing up in someone's office looking for help saying, I don't feel good, right? And again, I understand what you're phrasing. And I, you know, I appreciate it. I'm not trying to say like I've been there saying, whatever, kumbaya with everybody, but to come straight at that is really helpful.

No, and you know, and you know, I wouldn't actually say it that way.

Of course, of course.

But, but that's the truth. It's like, it's like, you know, when the DSM changed alcoholism and drug addiction to substance use disorder, it's like, can we just be honest with these people? Nobody wants to grow up to be an alcoholic or, or a drug addict. Okay. I mean, let's start from a, from a truthful baseline. I mean, substance use disorder, I just don't even have an ear for it. It's like, at what point do we have to make people, uh, uh, we have to take care of people's feelings to the detriment of them themselves.

Yep.

I guarantee you there's not one drug addict or alcoholic actively that said, you want to know what? I'm offended. I'd like to be referred to as someone with substance use disorder. I think it, I think it actually, I mean, I'm, I think it actually harms them to hear that subconsciously.

I think I absolutely 1,000% agree with you, which is straightforwardness and transparency in communication. Is crucial. And you get to when you're actually talking to a human. Do it along the way. Did that sound right to you? Did you understand that? Did that offend you? Did that not offend you? I use that word. I love to— I mean, again, all the people who know me, one of my favorite questions, if I can tell that the person is going to really appreciate it, is, are you a dick or you just act like a dick? Right. And people are like, wow. That's a great question. I think I just act like one. I'm like, great, I agree with you. But then what are we going to do about that? Right? But if you ask that in a different context, it's just mean. Right?

Okay. That's a very Erickson move. Okay. You slapped him in the face. You changed his state. Okay. You told him the truth. He immediately has to be self-reflective. And then you tell them, good. So as long as you're not a dick, it's just your behaviors. Let's change your behaviors because you're not your behaviors.

Right. And sometimes people actually say, oh, I'm not sure. Right? Maybe really people do.

Then he's not a dick.

Good point. Good point. But sometimes people really do say, I'm not sure, I might have a little less empathy than other people. Interestingly, in that situation, now we're going to a whole other topic. which is neurodivergence. Love the whole topic. It's a little overdone on TikTok, but to see that as people who will think, I'm mean, I'm rude to other people, maybe I'm not a good person, and to say, oh no, maybe there's just a little autism spectrum here that you haven't figured out ahead of time.

A little, a little, a little get out of jail free card.

Yes. Yeah, absolutely. For people who deserve to get let out of jail.

Right. You want, or, or, or who think they deserve to get right out of jail. Um, yeah, just one point on the neurodivergence for me. I, I think these people that are, they're, you know, some, they're challenged in certain areas.

Mm-hmm.

Okay. And those can be worked on and, and, and just like any other muscle be built up, but they're so gifted in other areas. They're just so gifted in other areas. the neurodivergent people that I've come in contact with. It's like, yeah, you're kind of cursed over here, but you're so gifted over here. On balance, you're good. Right? Don't you have that experience?

I mean, to just really sort of widen the field for some people, many of the people I see, but there's lots and lots and lots of people not to go back to Judaism a little bit, or actually just Yiddish, right? Bella Abzug, right?

Right.

Politician from New York back in the day, women's rights advocate, used to say, listen, right, what is feminism? What is equality in this situation? The star women are going to do as well as the star men. She said, equality is when the schlemiel women do as well as the schlemiel men. Right? The people who are not very good at anything, that's where equality should be, right? So in the same way, sure, the star neurodivergent people who really do have that brilliance have a difficult— in all kinds of ways, it's the people who don't have the brilliance. That's the people we're thinking about who are struggling out there and are thought of as weird and all of that stuff. So to just— I'm sympathetic to it. On the other hand, I'm also eye-rolly when everyone in the world says they are. You're like, all right, calm down, everybody.

Adult ADHD seems to be everywhere right now. Are we getting better at diagnosing it or are we overdiagnosing it?

That is one of my favorite questions. And my answer to that is we're overdiagnosing it. How do I know? Because I overdiagnose it, right? I overdiagnose it because the question as a diagnoser is you have 2 choices: overdiagnose or underdiagnose. Yeah, we're always trying to do it perfectly. But we know that you tend to err one way or the other. And to my mind, given the people I'm working with who are usually, you know, sort of have a sort of support network to a degree, right, that the underdiagnosis, what that does to your sense of your efficacy in the world, to your sense of your own intelligence, to your sense of yourself as a screw-up, is worse than the risks of, yeah, sorry, now you're addicted to speed, which is a very bad thing and can happen, but happens much less than people think.

Isn't there a way to go through like extensive psych testing to be more clear about whether or not you're, let's say, for example, prescribing Adderall to someone who actually needs it, because then we know that doesn't speed them up. That just wakes them up. Okay. But if they don't need it, now you're addicted to speed. And I take care of those people. But I— what's your feeling about that?

No, interestingly, right, that for most part, attention deficit disorder is a clinical diagnosis. You often use neuro psych testing to help distinguish attentional issues from executive function issues, which don't respond. But again, it goes to the risk of who you're working with, right? What, you know, sort of the question— what I often say to people is they'll say, hey, is this medication going to work? Phrasing it gently, I would say like, how do I know? I don't know if it's going to work or not. I'm only answering one question, which is the one I recommend to you. Right. Is it worth the risk of finding out if it's going to work or not by trying it? If it was Russian roulette, 6 times it works, 1 time you're dead, no, it's not worth the risk. What's the risk for this particular person of trying a stimulant? They might only have 10% attention deficit disorder. But that 10% is crucial if they're in a super competitive world. And if they're not at risk for things, that 10% is super helpful to them. Then we decide.

And not just that, but only 10% of the population that didn't need it is going to end up with a problem. And only about 5%, uh, of the people are going to end up with a problem that rises to the level where they'll, they'll need treatment. So nothing's perfect. That was very mindful. Um, and I appreciate it. All right.

And even, even in that way, sometimes what I'll end up saying to people is like, are you taking your stimulants? How come you're not taking them on the weekend? Right? You're not getting anything done on the weekend. I don't like to take them. So it's an interesting back and forth sometimes.

What role do relationships, community, and purpose play in emotional well-being?

Yeah. Crucial, crucial, crucial, which we all know, but, and the way I think about it, is often in talking to people about work. It's a huge amount of their life, right? And I'm often talking to people who aren't happy in their work or are retiring, right? And so, I sort of divide work into, I think it's 6 categories. And how you feel about them is what you end up doing. Do you enjoy doing the task? Do you believe in the cause? How much do you care about money? How much do you care about status? How much do you care about stability? And how do you need your camaraderie organized? People need the right level of connection to other people and multi-ones. It's not all looking people in the eye and baring your soul. For so many people, it's having a mutual task, having acquaintances, having good friends, having second-tier friends, having all of that stuff, but fit to who the particular person is. People often find themselves isolated and vulnerable because they haven't figured that out.

Can I ask you a question? Because that was interesting to me because you know how I feel about things versus children. So it would appear to me, just a guess, okay, that women go to therapists more and to maybe talk about their children than work and men, the polar opposite. Is that, is that a fair statement? As a

general rule, probably less fair than it used to be. There's a fair amount of overlap. Again, I'm thinking about the people I see. It's, you know, maybe there's— but there's a big Venn diagram of overlap where it's the same. And I'm not just being, you know, whatever.

No, definitely, definitely, it's changing. But it came up for me because women are more nurturing than men. And they, you know, almost always, unless you're a stay-at-home dad, okay, almost always carry the lion's share of the responsibility, the day-to-day responsibility.

Yes, absolutely.

Dad's the fun time and mom is, you know, the heavy. Okay. And she's responsible for that. But I'm worried. I'm just wondering out of your male population, What percentage of these guys talk about being a better father or a better, or a better, forget that, a better husband, a better father, not just goal setting and how to get there and getting their head right. And, you know, I mean, do you, I know you're laughing because it's minuscule, isn't it?

No, I'm laughing because it's not.

Okay.

What I was laughing is to say, like, I'm not sure I'm giving a fully representative answer, but I'm thinking about the people I work with. And it's a lovely bunch of men who are really thinking about their kids. The amount of time we spend thinking about this kid's difficulty and that kid's difficulty, etc., is enormous. Work too. But there's a lot of kid involvement and, and feeling and worry and also relationship stuff. A lot of people are coming in Right. And a lot of what I'm working with is maybe I might be pushing it, but I'm saying, yeah, but what does she think? Let's— what's in her mind? What is she thinking? What is she thinking about that? So people have trouble with it. But people are often coming in wanting to change their— but now they're all totally into their kids. It's, for me, it's like 2026.

Good. That makes, that makes me feel a lot better. I didn't see that coming. Okay. See, that's why I'm not married to any of my positions. Evolved guy.

Yeah, you never know. It could just be the group I see. You never know.

No, listen, I was asking because you're in Manhattan. Okay. And I'm looking at you and I'm talking to you and I'm like, I know who your clients are. Okay. I mean, I don't know them by name, but I know who you see. And it makes me feel good. Okay. That, you know, there's some attunement to the wellbeing of their child, that it's a priority. That makes me feel really good. I didn't see that coming. So thank you.

How about this as an answer to this, which is, again, I'm just thinking about, you know, my practice, right? I started this practice with my friend and colleague, and we've got you know, 50-plus clinicians in the practice. And part of the ethos is being practical, and problem-solving, and drawing boundaries in the appropriate place, because you know how to use boundaries. What's right for this person is not right for that person. I had somebody 2 weeks ago talking about his daughter. And he said, hey, she's in the neighborhood, why don't you just come in? Great. New person just comes into the session because it was the most helpful thing to have this person in there talking about it, right? Other people would be like, no, that's just getting in the way of the therapy we're doing. But in this situation, it was great. So much fun to meet the characters.

That's fantastic. That's fantastic. If you're raising teenagers today, what scares you the most? How old are your kids?

I have twins. And at their next birthday, they're going to be 30.

Wow. Yeah. So you got to go back into—

I got to go back. Yeah. And I sort of— exactly. I had an easy time of it because it was when New York was particularly easy, friendly, and safe. And then out of college after, you know, before COVID hit. So it was, you know, sort of, you know, skirted around some of those difficulties. Yeah. I mean, I think really it is— I remember having a talk about pornography with kids, right? I was like, listen, this isn't so complicated, right? Real sex is to pornography as real violence is to movie violence. You know what would happen if movie violence got in touch with you? Like, you'd have a concussion, broken everything, you'd never recover. Right? So just realize that's that. And this is a totally different thing. With everything that's coming with social media, with all of those things, with isolation, with, you know, it's, I think there's a lot less learning about all of that stuff. I'm basing this on what I read, what you read, you know, everything, but that people are isolated, right? And don't necessarily have the same set of easy social skills. And if that starts at an early age, It is harder and harder and harder to learn.

A lot gets baked in early on.

Yeah. For me, the scariest thing is, is the fentanyl crisis. That's to me, and it's why I came back to work. You know, I didn't have to come back to work. Sometimes I wish I never came back to work. I wish I never came back to work. Before the podcast. But, but, you know, it's— I'm scared. I mean, I never did a podcast. I've never seen a podcast. I've never listened to a podcast to this day. I mean, I just, you know, this is something I just felt I had to do. That's my biggest fear.

Yeah. How do I— I'm asking you a question now. Given everything you asked How does all of that relate to the fentanyl crisis as you see it?

Well, you treat addiction the same way you would treat a mental health disorder, right? So the reason I wanted you on is because you're the king of this, right? So now let me ask you a question. What do you do when you have someone with an active addiction? Booze on their breath, manic to the point where, you know, they're either on cocaine or meth. What do you do in that regard?

I mean, it really does depend on a particular line of severity, a particular line of support, and a particular degree of motivation. Right. You know, I used to run the psychiatric hospital at NYU, the inpatient unit of the Tisch Private Hospital.

For a decade. For a decade.

For a decade. For a decade. Yeah. You

were the head of that hospital for a decade.

Head of the inpatient unit. Yes.

Okay.

Um, and, and I would say like, well, inpatient, you've got a lot of power, right? You could say you are a danger to yourself, you know, fully clearly so, because you want to let people who aren't, who just disagree with you. Right? You know, you need to really kind of do what I say. Outpatient, right? I always think it's like fly fishing, right? You've got somebody online, but the line can break. So you have to be very thoughtful about who you're working with. It's often the case that— and then thinking about what the right setting, what the right venue is. Do they need someone who is a sober coach once they're sober? Do they need an outpatient program? Do they need your program? Do they— Inpatient. Do they need all of those things. But the most awful part is, I'm sure you know better than I do, is the people who are out of control having a hard time, and everyone around them who knows it but can't figure out how to do it. You know what's good, you know what's going to come. But you have struggled to figure out a way to have enough power to intervene.

That's why we need all the therapists, psychologists, and psychiatrists To really recognize this because the booze is one thing. It's still dangerous because alcohol, as we know, affects your decision-making. But if you see somebody coming in and nodding out, or you see somebody so manic, okay, even if they're wealthy, they're going to be cut off at some point. And then they're going to be looking. And they're going to go to the street. And because they don't have, um, uh, tolerance for fentanyl, they're going to take it once and they're going to die. Okay. Um, so, you know, that's why these people immediately, depending on the severity, but they immediately, uh, uh, need to go to treatment. Okay, they could try outpatient first.

I

don't have an outpatient facility, but I think that they need to be sent immediately or recommended immediately. And the way I would do it, not to tell you how to do your job because you've forgotten more than I'll ever know, but on this one little aspect, you know, get as many releases as you can from the wife, the parents if he's young enough, the girlfriend, and say, hey, I want to know what's really happening from all perspectives so we can figure this out and give you what you need.

I just finished reading Empire of Pain, right? You know, the book about the Sacklers? You read it, I'm sure, or know it.

No, you're big on pain. You're big on suffering. You're

big on pain.

Yeah, tell me about the Sacklers and Purdue.

Exactly. Patrick Radinkey's book Empire of Pain, which just goes through the whole history of the Sacklers and of OxyContin. OxyContin, etc., etc. And part of the Sackler argument was always, it's drug addicts who get addicted. It's their problem. It's not the medication. And then there's just endless, endless, endless data, which says all of these people who had no substance problem got put on OxyContin and ended up vulnerable to it, right, who had no problem before.

Do you know why that is? And why they lost that argument? Because the early iterations of those drugs, of OxyContin, they knew that when you crushed them up and snorted them, and when they changed it to where it would dissolve, then they went to heroin. They immediately lost 80% of their market share, which meant 80% of their users of that drug were using it not as intended. They were abusing it.

Yeah. But many of them— yes, absolutely. Yes, that's— yes. But many of them had started on it by a doctor after an injury.

That's right. Well, that's because you got one week of substance use disorder training in medical school. One week.

But what was also interesting about that book is that when I was in medical school in the you know, late '80s, early '90s, right? You were taught that previous doctors were bad because they weren't paying attention to people's pain, right? That people were being accused of being drug addicts, and they were being undermedicated. And we as a profession were not helping people's pain. I was taught that it was in response to previous generations' misbehavior, or, you know, not perfect behavior. Right? And you should be giving people, what's your pain scale? 0 to 10. What's your pain? What's your pain? What's your pain? The book, you know, The Empire of Pain is like, oh yeah, that was all kind of organized by the Sacklers going out there to say, we need sort of people paying attention to pain. We need doctors paying attention to it. And so I didn't know I was— I mean, I wasn't prescribing, but in going back to the idea of no one thinks they're the bad guy, everybody back then thought they were the good guy doing it.

Right. Do you know that's all true? Okay. But it's one of the reasons the rehab industry started in the first place. It was actually a very organic thing that filled a gap. Nobody. So when they talked about the pain, the drug addicts always say a 12.

Mm-hmm.

Okay. The non-drug addicts will tell you the truth, right? And the reason the rehab industry started in the first place was because nobody wanted to treat them anymore. They were unreliable. They wouldn't show up to their therapy. They'd only go to the doctor's med-seeking. They'd see the same people over and over and over again. And so that's what happened. Can you expand on the performance coaching aspect of what you do?

Sure. So we have 2 sort of practices. One is Union Square Practice, which is mental health, which is getting people from feeling bad to fine. And then we have another wing of this called Strada Performance. My co-founder of both of them, Jonathan Fader, he was a psychologist for the Mets, then the Giants, then he was director of mental health for the Major League Baseball Players Association. And what we think there is, we're trying to define what sports psychology is, right? We're like, we need a good elevator pitch, because it's hard to put into words. And what we came up with is, it's using the techniques of cognitive behavioral therapy, essentially, in order to win, not to feel better, how to perform under the pressure, under the pressure that you invite.

So to get better, so to get better.

Yeah.

Then I got to ask you the obvious question.

Yeah.

Why do the athletes get to get better when the normal people just get to go from bad to fine?

Well, that's a good segue. Because it's not just the athletes, because we're happy to work with anyone to perform better since we work with lots and lots and lots of people who put themselves under enormous pressure and want to just be the best they can in those particular ways.

So just to frame this for my audience, the first business is to get you back to baseline. Okay. Right. And the second is to get you thriving.

Exactly. As you know, as one of the quotes we like is one of my colleagues, the person he was coaching said, like, have you ever been booed? Right. Imagine If you ask a question here poorly, and immediately 55,000 people boo in real time, that's pretty stressful. You'd want to figure out how to handle those types of pressure situations. You're playing for the Knicks or the Spurs, you've got your free throws. Look at those guys missing free throws at the end. Right? It's amazing they made any of them given the pressure. You want to have rehearsed that and use all that sort of science knows at this point about how to perform under pressure.

So it's visualization. It's visualization of making it. It's watching past tape of making it.

It's— yes, but here's my favorite. It's also visualization of there you are at the foul line, and your breathing is shallow, and you're nervous, and your shoulders are up. What— how are you going to keep together? You want to visualize that moment and figure out what you're going to do with it. So just the idea of negative visualization, you're like, Whoa, I didn't know that. My partner told me that.

Right. Let's not get— let's keep all the garbage out of your head at the free throw line.

Exactly.

I think, I think we've touched on all of it. I'm so grateful. It was an honor and a privilege to have you on.

Yeah, similarly, it's great to meet you. Great to be here and great, you know, a great place you run. Really a pleasure speaking to all your people. They've been super helpful. And very, very, very responsive. Um, and we're at new@unionsquarepractice.com, just our website, you know, and we're happy to speak to anybody about any help that we can give.

I want to commend you for your good judgment and being in Chelsea and not Union Square. All right, see you next Tuesday, everyone.

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