She Doesn’t See Broken People. She Sees Terrain. with Dr. Arwen Podesta | Ep. 008

Dr. Arwen Podesta is an addiction psychiatrist in New Orleans who has spent her whole career sitting across from the people our culture has decided are the most broken among us — the addicted, the relapsed, the ones who keep reaching for the thing that’s hurting them. And here is what undid me about her: she doesn’t see broken people. She sees terrain. She sees a nervous system doing exactly what it learned to do to survive. She’s board-certified in psychiatry, addiction medicine, forensic psychiatry, and integrative medicine, and she built her practice on the many hands — psychiatry alongside nutrition, acupuncture, somatic work, story, and the natural world. 

She wrote a whole book, HOOKED, making the mechanics of addiction make sense, and then she spends her days reminding everyone that mechanics were never the whole story. We talk about addiction as intelligence rather than defect, about what real repair asks for that the fight narrative completely misses, about place as terrain in a city that knows something about collapse and something about coming back, and about the hunger underneath the substance — what people are actually starving for. She’s doing in the field of the mind almost exactly what I’ve tried to do in the field of the body. Her terrain is the nervous system. Mine is the cell. Same gospel, different soil.

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Transcript

SPEAKER_03 0:00

I want to tell you how I met today's guest because it says everything about why she's here. I had been following Dr. Arwen Podesta's work for a long while before I ever stood in front of her. The way you sometimes circle a person's ideas for years, nodding along from a distance, sensing they're asking the same questions that you are, but maybe from a different doorway. And then last summer, in this beautiful event in the mountains of Virginia, at a gathering called Momentum in the Mountains, there she was, in person. And she was every bit as extraordinary as I'd hoped. Maybe even more. Dr. Arwen is a psychiatrist. Addiction is her field, which means she has spent her whole career sitting across from the people our culture has decided are the most broken among us. The addicted, the relapsed, the ones who keep reaching for the thing that's hurting them. And here's what undid me about her. She does not see broken people. She sees terrain. She sees a nervous system doing exactly what it learned to do to survive. She trained in the hard sciences, the neurobiology, the genetics, the forensic edges of all of it. And she built her practice in New Orleans, a city that knows something about collapse and something about coming back. She surrounds her patients with many hands: nutritionists, acupuncturists, story, connection, the natural world. She wrote a whole book called Hooked, Making the Mechanics of Addiction Make Sense. And then she spends her days reminding everyone that mechanics were never the whole story. She is, in other words, doing in the field of the mind exactly what I've tried to do in the field of the body. So this is less an interview than a long overdue conversation between two people who found their way to the same place from opposite ends of the map. Health doesn't happen in isolation, it happens in a terrain. The biology, the rhythms, the relationships, the meaning you're still making. All of it shapes whether life expresses its vitality or quietly begins to unravel. And each week I sit down with scientists, physicians, farmers, artists, patients, and systems thinkers. People who talk about bodies, but also about land. About healing, but also about grief and belonging and what it means to become human again. This isn't a show for quick answers, it's a space for better questions. Pull up a chair. One of the most interesting things, first of all, I've done it, everyone's got a little sense of you from my introduction here. But you, and we kind of were talking before the recording really started, that you and I are both presenting at a big mental health conference uh later in the fall. And it's kind of ironic that the topics of things like trauma and cancer and the things like addiction sort of get put onto the side stages and not the main stages. I think you and I are both kind of on a mission to make sure we're the main stage discussions about this because it's it's endemic of what's going on. So you have spent your entire career with people the world have mostly has mostly given up on. And somewhere along the way, you decided not to see them as broken. Just moves me so much. And I don't think that's a position you arrive at from a textbook. So I'd really like to understand where this started. What was there a patient, a season, a moment when the story you'd been handed about addiction or brokenness just stopped holding water? And what did you learn and what did you do differently about it?

SPEAKER_00 4:21

Yeah, there's many, many opportunities that came to me over time, even before medical school, before I even thought I wanted to be in medicine. I was at a festival event and I was very I was studying genetics and undergraduate, genetics and biochemistry, and really learning that the genetics of the brain back in the 90s was almost nil, and that I was dedicated to learning more about how I can understand the biology of the brain and the genetics of the brain and brain diseases. And so I thought I was gonna, you know, finish my undergrad and go and get a PhD and be like an uh Ivory Tower uh researcher doing this sort of thing, and I worked in Ivory Tower research in the Bay Area as well. Anyway, at a festival, I was watching different friends of mine experience the same substance very differently. One of our friends had to be helicoptered out of the festival to get health care, and other people were doing just fine, and some people over time ended up becoming full-blown addicts, and some people had no experience like that. And being that budding geneticist, I was thinking, what the heck is different between this person's biology and this person's biology? And so many people blame the drug, and I came to learn through an academic route, but also a friend route, that if we blame the drug, then we both kind of enable the continuation, and we also um don't uh give credence to the biology and what people are set up, you know, at what sort of predilections they are. And so that was an important decision tree for my career, really. And then I'm in medical school and I'm realizing that we dedicate zero time to addiction and zero time to nutrition and zero time to HIV. And this was in the uh late 90s, early 2000s. And so uh Friend and I, that were both passionate about all of those things, we started kind of a little secret club, and we got some sponsorship, and we ended up putting on a required forum for the whole medical school class, and that was it went well, and it was on HIV and substance use disorder. So I then um ended up volunteering at a harm reduction clinic at a needle exchange, and I found myself working in festivals to do what was like the drug testing to see if things were really what they said they were, and then I uh weirdly found myself in a family situation where a loved one overdosed and died unintentionally, and it was um out of a real lack of understanding and compassion for what he was going through from trauma to major depressive disorder to um substance use, polysubstance use, and the permissiveness and the lack of education and the turning a blind eye was really part of the problem. So that is the three kind of pinnacle pieces that put me on my path. I found out I was good at treatment as well when I was in residency, had no intention of going into and doing an addiction fellowship, but because I was evacuated after Hurricane Katrina, you've heard this story, Nasha. I'm up in central Louisiana instead of New Orleans, where doctors without hospitals, we're seeing patients and MASH units, and we're, you know, trying to be our best doctors and in training. And so during that, um, we're also looking for experiences that were not sanctioned by the ACGME. And so we're looking to fill our time and serve and learn. And I ended up working in a uh treatment center with uh drug and alcohol treatment center, and interestingly, they were, because it was post-Catrina, they were getting a lot of attention, and they actually brought someone who lived in who was born and raised in that community, but now was like the president of the American Society of Addiction Medicine. Wow. They brought him in, and I just shadowed him. I was just a little duckling following him and his social worker and his trainers around. So I learned how to set up a modern treatment program in rural central Louisiana. And then I carried that out and continued to do that in multiple places. And you know, the patients are so grateful. They say this all the time, just what you said. And that this happens with trauma too. You know, I've never thought anyone was listening to me. Maybe they f didn't know that they were being listened to by a healthcare provider. Maybe the healthcare provider was listening, but oftentimes being, you know, didactic and finger wagging as well, or judging. And so we find that our um patients in the addictive space, the substance use disorder space, are really stigmatized. And they're very harshly unlistened to. And making a dent in one person's life, it affects many, many layers and generations. And I love, love, love it.

SPEAKER_03 9:52

Wow. You know, like hearing you speak last year at the Momentum in the Mountains event in Virginia, uh, you brought uh you reminded me and brought some tenderness to my own heart. I grew up in a very addictive forward family household, and uh that judgment piece was very much there. In fact, my one of my first real jobs when I was an undergrad was working in a I got at my CAC level two, my certified addiction counselor level two, working that while I was in school because I thought I'm gonna work and I'm gonna, I'm gonna like crack the code on addiction, thinking it was something like external that we could somehow impose upon. And and having folks that there was a lot of my own trauma from their addictions and how it spilled over on me, thing you spoke about and you write about in your book, Hooked, which is right there behind you on the shelf. Um, these are the pieces that I thought was so profound. And I alluded to this in my intro for you, as well as in our first question, which is addiction is is a sort of an intelligence and it's not a defect. And and one of the things that was also drawn to you was your passion for things like epigenetics and for the understanding of the human condition as well as to how it plays out among the environment in, on, and around it. And so you stepping in, for instance, in the HIV community, talk about stigma, and you stepping in in a time of a major uh event with a huge hurricane that left the most disenfranchised people, the most vulnerable, you stepped into that, you continue to show up in these underserved, understood places. So on this show, this Tend the Terrain podcast, I continually return to the idea that the body isn't broken, that it's responding intelligently to its environment. And when I hold that up against addiction, thanks to some things I've been learning from you, the thing we've spent a century or moralizing or criminalizing, it just really reorganizes everything. So I love that you shared the story that brought you here and you alluded to some of the work you do now, but help me understand how you do it. Like, how do you first of all meet again and again and again that this is not a failure and that it is a kind of intelligence? And what is the nervous system actually trying to solve when it reaches for a substance?

SPEAKER_00 12:14

Right. Yeah, I mean, I have a whiteboard over here, I have like my little drawing of the brain, and we can talk about the neural pathways of the reward system that basically get inspired when something of salience that gives a big reward, dopamine reward spike, GABA reward spike, a calming at energy. So all of those substances of use and misuse, they do kind of the same thing in the same central pathway of the brain. And I think that's really important to note because part of my understanding is that some people, based on genetics and epigenetics, based on certain genes and certain pathways and certain traumas, certain environments, are set up with a low dopamine tone, a low serotonin tone. And I don't want to reduce it to just these two monoamines because it's so complicated, the brain is such a complicated place. But those are like we're reducing it a little bit so we can understand it. And so if someone has severe trauma, um, you know, adverse events of childhood is what we call it, adverse childhood events, ACEs, but any trauma, big trauma, little trauma, and feels less than and feels feels ousted, feels like they don't fit in already. If someone has a dopamine processing problem or a dopamine production problem, which we know that there's many genes that are actually responsible to make sure that you make enough dopamine and serotonin, et cetera, et cetera. And if you have some hindrances in those genes, you also have a predilection. So we add biology, we add epigenetics, which is how the genes fold around the environment. We add the environment and the psychological health of the person as well. And each one of those can set someone up for a risk of like taking a substance and then having this blow up that's like, okay, where have you been all my life? I've heard that time and time again. The first time I took an opiate as a patient getting a surgery, and the first time they took the opiate pain pill, they were like, blah, oh my God, I finally feel normal.

unknown 14:30

Yeah.

SPEAKER_00 14:30

How is it they've been, and many of these are, you know, professionals with careers and with families, and they are looking normal on the outside. But then we find out, just like probably some people in your family that was very um addiction forward, as you said, we find out on the inside they never felt normal. They felt something was wrong. They felt judged, they felt like they didn't fit in. And I get into the questioning and I get into the child questioning I ask about childhood in high school for sure. And I ask, tell me, I always ask people, tell me four adjectives about describe yourself around your, you know, if you used drugs in high school, let's go before that. Describe yourself. You know, wallflower. I felt like I didn't fit in, I felt judged. I mean, these are my distillation of that, these are the most common, but there's hundreds of adjectives that really describe how people feel when they are low on the area of good neurotransmitter balance. And then you add whatever substance it is, and it gives you either a dopamine spike, or if there's a lot of trauma and a lot of like hypervigilance and a lot of sympathetic tone, fight or flight, constant, constant, constant, then you add certain drugs and it puts up a life vest, feels like they're finally putting up a life vest. So why wouldn't someone continue to take those to balance out the brain, to balance out the mood and the mind? And so if we judge, you know, we what would be best in my mind if we didn't have these things available, and that we paid attention to early childhood feelings and activities and made sure that we elevated people so no one felt that way. It's not happening. I just did a presentation this morning on um tons of these corner store or even black market psychoactives, such as like creatum and TNP and xylazine and 2C and uh so many, I probably just did the laundry list. Man, and it's a game of whack-a-mole because our humanistic nature is that someone is gonna create something to continue to do that to the person's brain that wants to feel that. So if we go to a country where heroin and opiates are not available in our outlaw, or if we go to a system where there's no pain pills available for true pain management, we still are gonna see people finding something. And it's the same folks that, you know, that we need to be tender to that feel stigmatized. So that's kind of a tangential way of talking about what I do.

SPEAKER_03 17:23

I love this. Well, you know, I think this is a really good and timely discussion because you're talking about what's sort of the over-the-counter or black market or easy access to some of these tools, but there's also some interesting research emerging in other forms of psychoactive substance that substances that can be of help in this space. I'd love your impression about it, your opinion about it, what you think is good about it, maybe what the cons are about it. Talk to us what the research is showing in this arena.

SPEAKER_00 17:54

So exciting. I am so excited about this. We've been watching, we're talking about hallucinogens in particular. Um, we sometimes lump ketamine, which is now FDA approved in the nasal form for um for major depressive disorder, standalone, and it's changing lives drastically. Um, but we lump ketamine into the psychedelics kind of, and then there's the LSD, MDMA, and psilocybin, and then we also are starting to lump other things from other countries such as Ibogaine, um, Iboga into that category as well. Well, I try to stay on task with what the research shows. I try to not dive into you know anecdotal experience or um recreational experience. So I'm gonna stay on target with that. But these are not ibogaine, iboga, but um psilocybin, LSD, and MDMA are in phase two and three clinical trials, particularly for PTSD, but they're looking at other avenues for major depressive disorders, social anxiety, generalized anxiety, and they're on all different stages with multiple pharmaceutical companies doing it. I think that's important to have the pharmaceuticals being able to, you know, for whatever it's worth, spend a ton of money to do a very large trial to really look deeply at the data so that we can do better with our patients. Now, for people that are using, I mean, we hear always about people, especially in the past five years or more, but and and definitely, you know, in my dad's era and my previous um uh previous decades, you know, people using full dosings for recreation and now of psychedelics, but now people using micro-dosings to learn new languages, to um to enhance uh their well-being, to self-treat major depressive disorder or anxiety. And so we hear about that. And my problem with that is just like, you know, we're kind we're when we when we use something that's from the street that hasn't been psychopharmacologically evaluated, sometimes we compromise safety because we don't know exactly what's in there. Sometimes we compromise effect, and sometimes um the effect is uh varied because dosing isn't identical and has never been tested. There's lots of street pharmacologists that do pretty well, but from my experience, hearing from so many patients, this is not about psychedelics, but it but kind of an analogy of like, do street pharmacologists actually do the testing? I have so many patients that, you know, use cocaine occasionally, have used cocaine regularly, and I'm working with them to move cocaine and alcohol, move off cocaine and alcohol or something like that, you know. Um, and so before putting them on an opioid blocker for cocaine and alcohol cravings, it's on label for alcohol cravings, off label for cocaine cravings, but it works. Before putting them on naltrexone and opioid blocker, I do a urine screen. And guess what is always in the cocaine, not in the testing that they're doing on the street of the powder, but in my patient's body, in their urine is fentanyl.

SPEAKER_02 21:31

I was just gonna say easy danger, danger, danger. Yeah.

SPEAKER_00 21:35

I know. High, high, full agonist opioid. And it's just in the party cocaine that our teenage friends, our you know, adolescents, our loved ones, my patients are using. And it's so scary. And so when I hear street pharmacologists, even my PhD friends that are creating their own stuff and growing it themselves. I need to have a higher level of vigilance with being able to be ready to trust the rigorous process of testing. So that's a bit of my diatribe about the fact that it's exciting. You know, there is a psychedelic community that has been doing this for decades, and it's actually been advanced greatly by some of the leaders in the folks that are working as advisors for the pharmaceutical companies. So that's fantastic. The merger's there. But I am ready to use it as a prescription, as a medicine. In this country, I feel strongly that that's that we need to wait. So you saw my video, I think, that was on like, it's not fringe, but it's not ready for prime time.

SPEAKER_03 22:52

Yeah, I love this. And you know, this is, I mean, I want to speak um to what Dr. Arwen is saying here, and that everyone and their dog is learning about the application of these substances in the treatment of addictions and the treatment of trauma and the treatment of facing end-of-life, you know, uh conditions. Again, most of those have been anecdotal. I had some patients go through psilocybin studies for end-of-life care through Harvard years ago that were folks who were six months or less to live, you know, in a hospice setting who really did have some remarkable uh good deaths, if you will, and even full remissions or stabilization of their disease. That was an accidental finding, not expected. So, to Dr. Arwen's point, there's a lot of really exciting research and there's a lot of shit out there that is dangerous. And, you know, just simply because I know you love the SNPs as much as I do, and specifically the pharmacogenomic SNPs, we know, like for me, I'll be very candid, I have what I call the batshit crazy gene when it comes to cannabis. So I can easily go into cannabis psychoses. And so THC does not work in my body. People don't know they are have a problem with that until they have a problem with that. Until they're running down the street naked, getting picked up by the cops, you know. Absolutely. Who's trying to give you cinnamon and lemon scrapings to like deactivate it? So laughing, not so funny because I'm a doctor and knew better, but it was still a really bad experience, especially with the nature of, like you said, the sort of corner mom pop shops where you can get these things. I want I want before we leave this topic, one of the things that's very interesting to me when I am seeing some environments that I think are at least being more thoughtful that are testing some of their product in some of these environments. They're not clinical academic environments, but they're places that I think are trying to do it better. They screen. They screen very much. So for instance, you're a psychiatrist, so please fill in the gaps that I'm absolutely missing here. But a lot of these things are actually contraindicated if you have things like bipolar disorder. Could you speak to what we know so far or what we've what we expect so far from that type of information and who is maybe a candidate to consider this or not from what you've learned so far?

SPEAKER_00 25:10

Yeah, well, I am very intrigued by the studies, and I want to dive into the SNPs, the single nucleotide polymorphisms that make up our genetics, that make us at risk for certain bad outcomes, like what you said, or good outcomes. Who, and I think that what I like about pouring money into the research is that we can have some better understanding of who is the right candidate for this, this, and this, and who is not. So, right now we only do those, we don't do a functional MRI before we do a test for most psychiatric medications. Some of them are starting to do that though. We don't do much biomarker testing. Some are starting to look at things like BDNF enhancement, and then even there are some that are looking at neuroplasticity pre and post treatment, which is very exciting. Um, as far as usefulness in or as far as who is a candidate and who is not a candidate, thus far, what we know is that psychedelics have a dissociative property. People that already have a dissociative disease, such as dissociative disorder, any sort of uh thought disorder that comes with that, they may not be candidates for it. And in fact, when I see folks with bipolar disorder or schizophrenia or schizoaffective disorder that use psychedelics, it gives them something, but it sticks a long time. I've had some folks that ended up in a hospital setting for much longer than anyone would have expected and very treatment resistant for tons and tons of medicines. I mean, one guy I'm thinking of for years and years and years, you know, we call it like candy flipping, where people, they're using psychedelics and MDMA, and that combination for someone with either a family history, a pre-existing history of schizophrenia, schizoaffective, bipolar, it can flip them hard into a lifelong psychosis. And I've seen it multiple times, usually in the forensic hospital setting, because that's where I see people in the long, long, long-term treatment, you know, long-term, um, long-term care. So not everyone's a candidate for everything, as we know. We know very well. When, like here, you are in the oncology world, and and I always compare that I don't do a brain biopsy. You have the opportunity to do a fine needle aspiration, to do a biopsy to even my um my dermatologist did a derm tech recently, which is so cool. It's a little sticker that pulls, you know, uh it does then um polymerase chain reaction on about 25 genes to see if any of this little mole has any stuff. And why I can't do that in the brain. I just can't. So what do we do? Well, we take great clinical guesses and we have a very valuable. I always say that our clinical interview is our stethoscope, wow, is our biopsy. So we have to ask, be very curious, align with the patient, ask questions, but not all patients are patients, not all people are patients, and so this is a message that not everything is a good fit for everyone.

SPEAKER_03 28:38

We already know that. I'm so grateful for this because I know that the excitement, the enthusiasm is out there for patient and provider alike, right? And researcher alike. But we need to, I think you say, tread a little carefully and also not appropriate ancient medicines in a way that are being abused as well. That's that's a whole nother topic in and of itself, which I think you've also touched on in some of the talks I've heard you do in other places. But one of the coolest things about your work, I mean, it's really unique, the type of things you do. There are many hands involved in the care for the patients you work with. You've built something very rare, a practice where it sounds like a beginning of a joke here where a psychiatrist, an acupuncturist, and nutritionist, and therapist all walk into a bar. But that's not right. That's not anyway. But kind of, but you're all holding vigil or holding space or holding court for the same human being and through the lenses of your experience. So most of medicine is very engineered to do exactly the opposite, to slice a person into specialties and hand those pieces around. Why did you insist on so many hands and so many lenses? And what what does it cost you and the system to practice a way that goes very much against the current?

SPEAKER_00 29:49

Yeah, it does it is against the current. It's so fascinating. Um, yeah, I have two acupuncturists that I work very closely with in my office. Um, and uh actually one of them also is gonna be working in a large hospital system, which is amazing. Amazing. So that's ridiculously advanced, which I was never expecting. Um, but you know, my background before medical school, I grew up in the terrain. I grew up on partly, I grew up in um, you know, in the in a city with my mother and my father lived on a commune.

SPEAKER_03 30:22

I remember this.

SPEAKER_00 30:23

This is the coolest story. I'm so excited you're telling it. So I had some really great, you know, terrain time, utopia time, and non non-culti, non uh uh it was like a utopian society and really cool. And so listening to the body, listening to the mind, listening to the spirit, being very involved in the earth and in, you know, regenerative farming and and really the the creation of that in the United States in some capacity was right there in our backyard. And so that was always, you know, nutrition as medicine, yoga as medicine, barefoot walking as medicine, looking at the sun and the stars and the sky as medicine. That was always just my being. And then when I went, uh my father was a massage therapist early days, and so I watched him kind of, you know, literally touch people and change their lives. Um, and then when I was wandering about, not knowing what I was going to do with my life before I decided to eventually go to college, I went to massage school, you know, family history. And it was a very comprehensive uh 15-month training, and I worked with I worked closely with a lot of physicians and osteopaths and uh and uh chiropractors and nutritionists, and so I just saw how collaboration worked. And I don't have room in my life for people that don't collaborate, and I won't collaborate with people who won't collaborate. So, and uh I became very passionate about that. Psychiatry is a little bit unique because we really do um uh embrace the biopsychosocial phenomena, and that means that we need help. We need psychologists and therapists, we need the prescription pad. We don't really know it in our field as much, but we need the nutritionist, we need the primary care, we need the whole spectrum, and um we need the lifestyle, exercise, diet, etc., sleep, you know, all the things. So I wanted to make sure that I was providing that in the best capacity I could, and I had the opportunity to open a business with my acupuncturist friend, and that's what we did. And then we brought on a couple of other folks, and we've just been, you know, coasting and floating and doing our very best. Uh we are an um out-of-network facility. Um, however, for acupuncture, it's interesting. The VA does send folks and cover or the VA is just up the street from us. And um, I do have folks that um, you know, I work with financials as necessary and we're very crafty and we're very generous. Um, of course, we still have to be able to pay our mortgage and you know, do our things. But um we're it so you know I have compromised some. I think that if I were working for a large hospital system, it sounds terrible. Um, I were, you know, if I were doing that again, I would probably be much less happy and I would be much less balanced and be making much less effect, but I would be making two to three times the cash flow.

unknown 33:40

Right.

SPEAKER_03 33:41

And two to three times the cash flow with two to three times less the effect. Let's just be real.

SPEAKER_02 33:46

Yeah, I would age less faster.

SPEAKER_03 33:48

Yeah, and I would age faster. Burnout's real. Yeah, it is. Whoo, this is so, so big. I mean, I I think you understand. Well, first of all, I'm imagining you understand it's a collective that there's no one person um at the helm here to make this magic happen. Um, it sounds to me very patient-centered, and you're bringing in so many lenses. That in and of itself must feel very life-affirming for the person who's in the center of that equation to have so many care, caregiving eyes on their case. Like that is that's medicine in of itself. What a model.

SPEAKER_00 34:22

Yeah, yeah. And the openness. And now to be clear, not every patient sees all of us, but you know, we refer within and we know that we're there, and many patients do see many of us or all of us. And it's it's very validating to just have that in one building where people can come in and say, Oh, I can see an acupuncturist here too. Or I that it opens their mind to things. I mean, I have folks that are coming in after being in an intensive outpatient program with me for addiction, they're on medications for opioid use disorder, and then they come to my private practice and they, you know, feel um feel loved and welcomed, and then they open their eyes to all these other aspects that they never even thought about.

SPEAKER_03 35:08

Yeah. So beautiful. Boy, this just gets my wheels turning here, but I think about, you know, again, you've got so many, you have your own so many experiences that have come to the table, which is so beautiful, which explains why you have such a diverse um opinion about this as well. But, you know, I feel like underneath the neurobiology, that when I got to see you do your presentation with the whiteboard, that is a sight to behold, by the way. I think people need to see you in action with that because it's really fun the way you uh tell the story of the brain and the neurotransmitters. But underneath that neurobiology, the dopamine, the receptors, the genetics, you map it so cleanly in your book, hooked like that. And it's a short and easy read, you guys. You will read it in a short airplane ride. You know, it's super, super digestible. Yeah, it's just right, it's so good. There's a question I suspect you sit with and correct me if I'm wrong, um, that isn't strictly medical, which I know you play in this realm easily, but so much of what we call addiction looks to me very much like a person trying to come home to themselves and unfortunately reaching for the wrong door on occasion or maybe a wrong set of doors over time. And so let me ask you very plainly what is the hunger underneath the substance? What are people actually starving for?

SPEAKER_00 36:27

Well, we talk about the opposite of addiction being connection. I think connection is it, and it's you know, what this is why when someone feels rejected from society, rejected from a partner, rejected from a job, their tendency, if they have some of the predilections, is to fill that hunger, they're getting rejected. So, and we we do say this a lot, the opposite of addiction is connection. So all the other things, and that's why people do well with a non-judgmental approach, because if someone is finger wagging and ousting and telling them they feel wrong or that they're wrong, then they feel rejected again. And that's why we are so keen on motivational interviewing. And regardless of what substance it is, regardless of what medication I'm using to help balance the system, because we do need to rebalance the receptors and the system in general, regardless of that, we need to put arms around safe, safe connection around people. And that's why, regardless of what people think about 12-step, good or bad, I don't care, but that's why peer support is so important. I am not religious, but I recommend all of my patients find their spirituality and find their church that works for them or whatever support group. Even a patient of mine that is a therapist that went through she's 86 and she just lost her husband, and she's not what someone I see for substance use disorder, but she was concerned about doing grief therapy in a group because of her status in as uh in society. And she got there, I just saw her yesterday, she got there, and she's gone for eight weeks now, and she said finally she had to let her ego go, and she had to sit and listen, and it changed her life too. Because connection versus isolation, that's really the problem at hand, whether it's substance use disorder, major depression, anxiety, you know, whatever, connection versus isolation.

SPEAKER_03 38:40

Ooh, girly, I got goosebumps all up and down my arms here. So I end my conversations like this because now you've told us how you help support other people tending their own terrain. What are you currently tending in your own terrain these days?

SPEAKER_00 38:54

That's awesome. Thank you. I love that. Well, I have a life that is very left and right brained. I live in New Orleans where I spend a lot of time. This is a muses shoe. I'm not in the crew of muses, but I spend a lot of time with New Orleans uh family and lifestyle. I love my, I just came back from another conference that's also my heart, Psych Congress, and we're um doing that in New Orleans this fall as well. And so I love our Psych Congress family, very convivial, just like our IMMH family, and that feeds my soul. My right brain husband is the brilliant sculptor and artist, and Alex Podesta, and he um and the art world keep me relatively sane and balanced. And then, you know, we talk about this, Nasha, travel, always open to new experiences and new adventures. And I think between those things, I'm not really a hobbyist, but I think um my hobby is uh people and culture and art.

SPEAKER_03 40:08

I love it. And you know, being with you in person in a few environments over the last year, you live, you look, you embody the artistic expression, which is so fun and so vital. It's like I even dressed a little bit for you today because I knew you are someone who just inspires like color and expression and moves.

SPEAKER_01 40:28

As I'm wearing glasses, glasses.

SPEAKER_03 40:36

But no, this is incredible. And your work is so transforming, especially in an era of despair that the scientists are calling it when we have in the West one of the poorest longevities in the world, um, literally losing longevity every year thanks to drug overdose, intentional or otherwise, and suicide. And so this is your life's work. So you are a longevity specialist in my mind. And so, how do people learn more about you and the work you offer and find people like you out in the world?

SPEAKER_00 41:09

Yeah, well, I will start with finding people like me out in the world because it is kind of challenging to find a uh someone who specializes in what I call functional psychiatry. It's really a root cause mental health medicine. And so finding through Institute of Functional Medicine, or but finding a psychiatrist or a psychiatric specialist, like a nurse practitioner, that someone that's a detective. And then on top of that, someone that also maybe has some training in opioid or in addiction in general, um, you know, if that's whatever the specifics are. So it's hard to find. Um, my website is drarwin.com and also and I do teach a master's class related to this for addiction. And my YouTube channel is Dr. Arwen, and my general website is Podesta Wellness, my last name Podesta Wellness, and then my book is on Amazon. And I, you know, I would be delighted to have a conversation, drop a question or a comment in the in the comments here below. And uh yeah, and Nasha, we've got a lot of work to do. Both of us, I I I want to ask you, I'm sure you've talked about this recently, but what feeds what tends your terrain, what feeds your soul?

SPEAKER_03 42:34

Look at you turn the table, you psychiatrist, you. Well, I'll tell you, I to be very honest, to be fully transparent, because I think that um I a lot of us in the field of medicine, we try and pretend our shit doesn't stink. And so I really wasn't tending my ter terrain very well the last few years. Um, I really lost sight of that, and I really got myself sucked into kind of a vortex of negating who my natural tendency is to be, which is to be joy and connected and relational and the furthest from transactional in the world. And so, as such, that is what I'm absolutely committed to going back into. And for me, that does require rhythm and connection. And so, doing just that, I am putting myself first, which is super rare for me, so that my eye can pour from a from a full cup. And it has been really beautiful these last few months digging into that and getting back to the fundamentals. You've already nailed them light, water, air, breath, movement, love, joy, laughter, quality food, travel to places that bring me joy, all of those things. So thank you for asking that. I am tending the living crap out of my terrain right now.

SPEAKER_00 43:50

Do it, do it, girl. I love it. Well, I feel strongly that we have a lifelong friendship because of exactly that. When we first met, I know that your your joy and your vision and your knowledge and your enthusiasm and just your character was very intriguing. And so I appreciate you so much, and I appreciate you tending to this topic because you know we do have a big, a lot of work to do.

SPEAKER_03 44:19

We do, we do, and I can't wait to see where you are taking it and the future generations that you are teaching through this. And I'm hoping that someone who's hearing this today realizes there is a lifeline for them or someone near and dear to them, and that there's another way to look through this. You are not broken. That's right. And I just really appreciate the work you do. So many blessings, my dear. Thank you. Thank you. Wow. I hope that conversation landed in you in the way that it landed in me. I am so grateful for the years that this woman has spent sitting with the people that no one else would, and for never once mistaking their pain for their identity. I am so grateful that Dr. Arwin and I's paths finally crossed in the beautiful mountains of Virginia. And even more grateful that Dr. Arwin agreed to join me today in this very important conversation. Thanks for tending the terrain with me today. Whatever stirred in you, don't rush past it. Let it compost. Because when we tend the terrain, life knows what to do. See you in our next conversation.