Heart thumping. Mind racing. Muscles tight. Fingers of dread kneading their way into your brain.

Nope, not a night spent in a haunted house.

Alan: You are checking era commons to see if your grant was funded

This, for some people, is a night spent in their own bed in the comfort of their own bedroom. Today, we’re going to talk about the pain of sleep anxiety.

Sleep anxiety usually happens innocuously enough. A person has a bad night’s sleep. They’re pretty tired the next day. That night, when they go to bed, they wonder if it will happen again. And then, what if it does happen again? How are they going to make it through work the next day? And they have that big presentation to give. They can’t afford to not sleep. What if…? What if…? What if…?

Alan: What if it the grant goes non-discussed?

You can already see where this is going. When we become anxious, the brain and body shift into a state of heightened alertness. That’s pretty much the opposite of what you need for sleep. In the end, the fear of not being able to sleep can become part of what keeps a person awake. That’s sleep anxiety.

Some people have a ton of sleep anxiety. Some have none. I had a good friend in college who I witnessed literally laid down on the grass at Disneyland and take a nap. Amazing! But, I digress. That’s another post— the easy sleepers.

Alan: I’ve fallen asleep during take off, numerous times. Departmental zoom meetings, etc.

Sleep gets interrupted

There are so many reasons for sleep to get interrupted.

Too hot. Too cold. Spouse too noisy (yes, you Alan). Legs in too much motion. Dog too heavy on your feet (yes, you Titan). Air conditioner too loud. Cat kneading face (yes, you Cali). Have to pee. Pee again (oh, that’s me).

Alan: The plane lands. Someone accidentally leaves their mic on during a zoom meeting as they cuss out a car.

But anxiety affects the brain’s ability to sleep, too—both falling asleep AND waking up in the middle of the night. A typical pattern is to wake up at 2 am or 3 am and check the clock. “Oh, my gosh, it’s 3 am I only have 3 more hours of sleep left. I have to fall asleep right NOW.” Which quickly spirals into more clock checking, more count downs until the alarm actually goes off.

And, of course, trying really hard to fall asleep is generally not a particularly effective way to fall asleep.

We can sabotage unintentionally (Or intentionally, I suppose)

Coffee.

The first thing a person reaches for after a long night of tossing and turning is that eye-opening stimulant from the gods.

Don’t get me wrong, caffeine has its benefits: it wakes people up, it has some antidepressant effects, it’s especially tasty in the form of a chai latte. But we humans are actually not great at metabolizing caffeine. Caffeine has a surprisingly long half-life—often around five hours, and sometimes considerably longer. So, that morning coffee can stick around until night and even to the following day.

Another potential sleep sabotage? Sleep medication. I’ve found that when a person asks me for a sleep medication, they want something that helps them fall asleep and stay asleep, but is magically gone by the next morning. It’s just not how it works. While it’s true that sleep medications can be appropriate for some people, they aren’t a magic off-switch. And many of them have side effects like next-day sedation, tolerance, dependence, and effects on sleep architecture.

The right sleep medication—and whether medication is appropriate at all—is something to discuss with a physician. And there are definitely non-medication options to consider before reaching for melatonin or benadryl or trazodone.

There are some other culprits too—ahem, screen time. If it’s you, you know.

Alan: I am kept up by my belief I can defeat sleep with stubbornness, and existential angst. Mostly stubbornness.

There are things to do about it.

Sleep anxiety is an insidious cycle. But what to do about it? “Stop being anxious about sleep” is not particularly helpful advice.

The best treatment for sleep anxiety is CBT-I (Cognitive Behavioral Therapy- Insomnia). CBT-I is neither counseling nor sleep hygiene. There is no investigation of the role your mother played in your neuroses or the analysis of your weird dreams. It’s a type of treatment that specifically targets fear and anxiety surrounding sleep. It explores the reality and myths of sleep (and poor sleep), it challenges unhelpful notions regarding sleep, and gives a person the tools to break the association between bed and worry, frustration, and wakefulness. CBT-I teaches a person how to protect the “power of the bed”—essentially, stimulus control—and what to do during those 2 am clock checks. CBT-I is pretty quick—typically 4-8 sessions and is the first line of treatment for chronic insomnia.

Sleep hygiene

Here’s a quick sleep hygiene refresh: early morning sunshine, stick to a routine, no screens or exercise before bed, limit caffeine and alcohol. I’m pretty sure you’ve heard it all before…

Alan: If getting good sleep hygiene makes you anxious this is called sleep anxiety anxiety. If having anxiety about your sleep hygiene anxiety then you have …

Please know that sleep hygiene matters, but if the problem is that you’re lying in bed frustrated and fretting about not sleeping, telling yourself to avoid blue light isn’t going to solve the underlying problem.

One last thought, medical issues and medications can affect sleep, too—so, always a good idea to check in with your physician if sleep is causing you to gnash your teeth.

Alan: If these are illicit drugs then check with your drug dealer — so long as they have a valid licensed in your state.

Now over to Alan for the Brain part of Boots and the Brain.

Alan: I’m not a sleep researcher and I don’t even particularly like sleep1. But I did write an earlier post on sleep where I get into a good amount of neurosciency stuff it’s an oldie but a goodie. Go ahead clink on that — it will make me feel better.

I’m not going to repeat any of that here, because then you won’t check out the old post also because what Sarah is talking about isn’t really sleep. It is about anxiety. When we think about anxiety, we often think of worry or fear or anticipation of something negative. It is easy to forget that we are often even more affected by the lack of something we find rewarding (response cost or negative punishment). This has been linked to sleep therapies.

It is easy to point to things we avoid because they cause pain: a rabid dog, parking, and the dentist. But often it is things we avoid because the potential reward that we hope for will not arrive, be it grant funding, existential angst, or sleep that may disappoint. I would say negative punishment drives our actions as much as positive punishment2. The link of sleep to the hippocampus along with reinforcement learning to the same brain structure makes this cycle all the more insidious as the parts of the brain that benefit from sleep are needed for effect relearning and recovery.

Sarah: And a step below grammar knowledgeable.^*

I’ve never been diagnosed as dyslexic, but I think it’s a safe bet (I think my friend Bethani can vouch for me on this). I spent my first 40 years having read ~5 books. Then I discovered audible, podcasts, and (more recently) libby (thanks Andrea). Now I go through a couple books and ~50 podcasts a week (usually at 2.5 speed).

I have so much catching-up to do, I’ve been running through The Greatest Books of All Time and asking people who can read (thanks Mark). All of a sudden, I need to learn how to appreciate literature.

Sarah: You could also do with learning how to appreciate chocolate.
Oh wait. No, that means less for me.
Alan, you should really try learning to appreciate scooping kitty litter.

Sarah, I know the move is to try to understand books using the sporkful framework. I mean sporkful is great, but I don’t know if I have Sarah’s skill to decompose all things into forkability, sauceability, and toothsinkability.

Sarah: I’m decomposing now.

I need to look deep inside and determine what am I looking for? What is my goal? Where is my happiness?

Sarah: We’ve been together for 30 years. I can answer those questions for you:

1. A New York Strip

2. Rare

3. On your plate

And how the written (aka spoken word) can do that. So, what do I want? 1) it should be readable, 2) it would be nice if it has a point/thought, 3) it would be great if I am different in some way at the end of the book.

Hold my interest/be readable

Assuming that it is written competently, but I don’t care for wordsmithery (sorry Herman Melville).

Sarah: * see my first comment

What I do care about is that while the plot is rolling out, is the plot interesting enough, does it mildly to moderately defy my expectations?

For example, I tried Middlemarch, but I didn’t grow up the English midlands in the 1870s. My prior experience left no space for the minor perturbations of their obscure lives to resonate (I couldn’t finish).

Sarah: Should I be worried that Pride and Prejudice and Zombies resonated just fine with you?

Alternatively, my prior experience (especially after having kids!) left me ill-prepared to read Lolita as the thoughts were too far from my experience (couldn’t finish).

But strangely, I can just toss back anything Terry Pratchett writes, so while I don’t inhabit those worlds, the variance from my expectations of these worlds hits a sweet spot. I think for millions Steven King owns this one.

Sarah: Ah, yes! I’ve enjoyed many a book by Stephen King: Misery, Dolores Claiborne, Fire Starter. I haven’t read the scary ones because…well…scary.

So, this one is for readability and pacing…I’ve got you so far.

Have a point/goal

When a book has my interest, I want it to use that time to give me something to think about. Something I can discuss with Sarah on our morning walk. Anna Karenina is beautifully written, it has amazing chapters that you could write a PhD thesis on, but I don’t care about rich people problems so, while it has a point – I don’t care.

In comparison, Crime and Punishment and Brother Karamazov are not as well written but given the contemplation of action and reaction or the allegoric divides of societal impulses – I’m in.

I feel like so many of the great books don’t land for me on this regard. Kafka and Phillip K Dick also fit my idea of having a point – but strange points.

Sarah: Okay, I’m going to re-phrase this because in the writing world, writers talk about plot points and goals of main characters but, what you’re actually saying here is not that the characters want something but that the book itself is trying to say something. The big theme.

Change me

This is a high bar. Really to date, this is just Siddhartha. I’ve been looking for another book that does this for me. So much of this is not what the book is but who I am when I read it. So maybe for someone else the Alchemist meets the moment. I’ve tried 3-4 other Herman Hesse books but no dice (Glass Bead Game, I’m looking at you).

Sarah: Whoa. You made an APP???? Way to bury the lead. Excuse me. I have to go check this out…

Ok, I’m back. Well, that’s pretty cool.

Folks, check out the app. Don’t be shy. But if you don’t want people looking up your preferences, use a fake name that you’ll remember. And please, keep it clean, guys, there are kids on here!

The time factor of books

Looking this over, the dimensionality of my appreciation of books is “time.”

There is:

1) in the moment, I think of this as the interoceptive moment when your body has a contiguous and continuous physiological presence – I’m thinking in the brain this is insula – this is seconds to minutes. [holds my interest]

2) in the mind, you are now testing a concept and seeing if it holds – I’m thinking prefrontal DLPFC, dACC. This is hours to maybe days. [makes a point]

3) in life, the cosmic kick to the head – I’m thinking this is where the brain re-wires (pruning of adjacent synaptic connections). This may be why this book comes in early adulthood – so, months to years. [changes me]

I’m intrinsically against further dimensional reduction. While I am most interested in books that take purchase in the mind (Have a point/goal) those aren’t the ones that stay with me most. They are not the ones that I would suggest to others.

Sarah: Hi Mum! I’m going to mum-splain Alan here for you. He takes time into account when evaluating a book.
If he’s busy reading this very second: the book warrants a high “holds interest” score
If he’s thinking about a book for hours of days: It has a high “made a point” score
If he’s thinking about a book years later: It has a high “changed him” score.

Some examples

This is my quick scoring of a few recent reads. I thought it was interesting that these scores tell you less about the book and more about what a person is looking for. You might disagree with my scores because you are looking for something else.

While my scores won’t help you, I the exercise of thinking of what you are looking for was worth the read.

Sarah: * see my first comment

Sarah: I want to do a shout out to my good friend from college the very avid reader, Marissa. Mars shared her book rating system1 with us and it was seriously impressive. Mars, any feedback you have on the app and we’re all ears!

“Boots on the Ground” of Boots and the Brain…

Sarah: That was Alan’s Brain part—although admittedly, only a sliver of dorsal lateral prefrontal cortex today…

Alan’s musings really stuck me.

At the end of the day, it’s not so much “how good is this book?” or how many stars we give it. It’s more about our relationship with the book and what we want in that moment.

I rated The Last Unicorn quite high in how it changed me. Now, I did very much enjoy this book. And it has a point. But it stayed with me because my mum (Hi Mum!) told me that when my Granny was dying she had a stack of beloved books on the bedside table to re-read and she wasn’t going to go until she was done with them. The Last Unicorn was one of them.

Reading the same words my grandmother read and knowing they resonated with her gave me a piece of who she had been as a person (We lived in different countries and travel was expensive, so, I only met her once when I was a child).

So, did it change the way I see me and the world? Not so much. But did it make an impact on me? Yes.

I think this is true for many of our interactions on a daily basis. Whether something impacts us, resonates with us, or stays with us has to do with where we are in life and the lens through which we’re seeing the world.

The same book can be forgettable to one person and life-changing to another. And perhaps that’s the only rating that really matters. (Sorry, Alan, of course I also meant readability and having a point were important, too!)

Just so you know, Granny finished the books on the table. And I hope she found another shelf somewhere with The Last Unicorn waiting for her.

Dementia and the when of placement

I see a lot of patients with dementia. One of the things that families struggle with is when to move their loved one into a facility.

As a psychiatrist, I can tell you that families often keep a loved one at home far longer than is ideal.

Alan: You’re talking about me aren’t you

It’s completely understandable why. There’s a strong cultural expectation that good families keep granny at home for as long as possible. So many times I hear, “I promised Mom I would never put her in one of those places.” It can be painted as giving up or not caring or simply not trying hard enough. It doesn’t help that the loved one with failing memory often begs to go back home. The decision comes with substantial guilt.

But here’s what I wish more families knew.

A good memory care facility is staffed by people who know dementia. They know how to help someone bathe when they don’t want to. They know how to encourage medications without every interaction turning into an argument. They’re watching for falls and keeping your loved one safe from wandering. A good facility provides music, exercise, art, and social activities that many older adults simply don’t get at home.

Alan: At a bad facility an Egyptian Mummy feasts on the souls of older adults.

Returning to your real job

Most importantly, placement takes you out of the role of authoritarian.

When my eldest was in elementary school, I used to sit with them every night and say, “Great. And now do the next problem. OK. Good. And now do the next one. And the next.” An hour of cajoling a lovely, wonderful child to do math problems. At the end of the hour…or two…I just wanted to take a break.

I suddenly realized that Alan and I were spending a significant chunk of time helping them do homework instead of playing games with them, drawing with them, going to the pool, or taking them out for ice cream. I’m so grateful that we found and could afford a tutor in the neighborhood and we outsourced the homework policing. It was one of the best parenting decisions we’ve ever made. We could suddenly enjoy just spending time together without a homework agenda.

Alan: And we had a great time going to the pool and eating ice cream. It was a shame they had to stay back and do their homework.

Memory care can do something similar. Loved ones with dementia often become more rigid and difficult. Caregivers spend more and more time engaged in negotiating showers, taking medications, eating meals or just hovering to ensure safety. And then, when the agenda is accomplished, they need a break. With a facility, you get to be a daughter again. Or a son. Or a spouse. Your real job is to be there and enjoy your loved one.

Alan: Wait, you snuck in spouse! What you planning?!?

Yet the guilt often comes roaring back when your loved one looks at you and says, “I want to go home.”

It’s heartbreaking. And I have families who avoid visiting their loved one because the words hurt so much.

But I want to offer you another way to think about that sentence.

Your loved one doesn’t want to go home. They want to go back in time.

Alan: Much like Elvis1

Dementia and the Power of Time Travel

If you took them back home today, they would still struggle to remember where they were. They would still need help getting dressed. They would still be at risk of falling or wandering. Their body would still hurt. They would still argue with you about medications and showering. They would still get muddled and frustrated. Their problems wouldn’t disappear.

They want to go back to a time when their knees didn’t hurt. When they could walk to the mailbox without worrying about falling. When making a cup of tea didn’t require help. When their mind felt familiar.

Alan: Back when they were “the king”2

That is the home they’re searching for. Unfortunately, that home only exists in their memories. And you do not have the power to take them back in time.

What’s going on?

Let’s talk about Alzheimer’s disease, the most common cause of dementia.

Imagine your memories are a house you’ve been building your entire life. As a child, your house has just a few rooms. One room holds learning to ride a bike. Another holds your favorite teacher. Another remembers the day you fell off a motorboat when you were ten years old.

As you grow older, you keep adding rooms. Your teenage years. College. Marriage. Children. Your career. Trips you’ve taken. Every stage of life adds another room to the house.

Alan: Then you go crazy with guilt and eventually it becomes a tourist spot.

Some rooms become incredibly sturdy because you’ve visited them thousands of times. Maybe you’ve told the story about falling off that motorboat at family gatherings for fifty years.

Other rooms are newer. Maybe you visited Paris for the first time in your sixties. You’ve told that story a handful of times, but nowhere near as often. In Alzheimer’s disease, the newest rooms disappear first. While the old, well-worn rooms remain standing much longer. That’s why someone with dementia may vividly remember something that happened when they were ten years old but have no memory of a vacation they took ten years ago.

As the disease progresses, the house gets smaller and smaller. Eventually your loved one may no longer recognize friends they met later in life. Or a spouse. Or their own children. But they remember falling off a motorboat when they were ten.

Alan: Sometimes you get staircases to nowhere.

So what do you do?

Don’t argue with them. Don’t try to convince them they should stay. Instead, meet them where they are.

Ask about the early rooms. “Dad, didn’t you fall off a motorboat when you were a kid?”

I recently saw a patient with dementia who had been a painter3. He couldn’t tell me where he lived. He couldn’t tell me who had brought him to the appointment. He couldn’t describe what he did yesterday. But I asked him about painting and his face lit up. Up until that moment, he had had a blank expression and muttered one or two empty words. But when I asked, he told me about darkness and shadows and the way the light revealed a person’s soul. For a few minutes, he was back in one of those sturdy rooms that was still standing. I could see him there young, full of life, with his easel and paint palette.

When you visit your loved one, ask about their favorite childhood meal. Ask whether they played sports— even if you know the answer. Ask about first jobs, first loves, and holidays when they were young.

Alan: Also defeating a Mummy can be invigorating4

You can’t take your loved one back in time. But sometimes, through a conversation, you can visit those old rooms with them. And for a little while, they’ll feel like they’re home.

And now, I’m going to hand this off to the “Brain”…

Alan: My very first paper was looking at the interaction of culture and genetics (APOE-4) on stress in caregiving. I was working in a lab with Larry Thompson and Dolores Gallagher-Thompson. I remember working in their lab, they did a bunch of work on trying to treat depression in older adults. I remember that the most important thing was for people to do things in their day that brought them joy.

Sometimes that joy is being in the moment, sometimes it is being in remembrances.

I know I’m supposed to be the neuroscientist — but I have to confess — I’m not an expert in long term episodic memory. After that first paper, I forgot about forgetting. I forgot about how the hippocampus appears to create a connective network across the brain from which memories can be resolved. It was so long ago that I learned that revisiting these memories we change them, we re-substantiate them, and they become constellations in our cortex without the hippocampus needing to connect the dots.

It can be nice to think back on that first paper and the time Larry said to me “Alan, you seem to be good with these computers. You should quit grad school, use your computer skills, and make yourself some real money. Then — if you are really really really want to — finish your psychology degree just for the fun of it.”

Oops

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(Lansdale, J. R. (1994). Bubba Ho-Tep. In P. M. Sammon (Ed.), The King is dead: Tales of Elvis postmortem. Delta.)

Sarah: Admittedly, I don’t recognize any of these as languages.

I’m pretty fluent in R (I can write nested apply loops in real-time). I appreciate object pascal for allowing compilable code with built in memory handlers and linkage to openGL libraries. But it’s the inclusion of Esperanto that actually leaps of the page and makes me seem like a nerd.

Sarah: Yeah. That’s what leaps off the page and makes you seem like a nerd. Yup. That.

But Esperanto is actually pretty great and completely underrated. Esperanto is a constructed language (meaning intentionally made-up). However, this hides what makes Esperanto great. There are a lot of ways I could go with talking about Esperanto, focusing on the hopefulness it was born from. The history of Esperanto through World War II is so interesting. The relationship of Esperanto and microstates (you gotta read about Republic of Molossia) or the UN. But I’m going to focus on the structure of language.

Sarah: Okay, I take it back. I did know about Esperanto. My grandparents on my mother’s side used it.

Esperanto has only 16 rules of grammar (most languages have 50-200 or such). But this is a mostly meaningless number that hides the glory of the language. It isn’t the simplicity that I love it is the matrices, specifically I love the tabelvortoj.

Sarah: Alan didn’t add this, so I’ll jump in here. A tabelvortoj is the table of words you see down below. It combines prefixes and suffixes to generate words from a small set of word building blocks.

Get this they have 5 prefixes (e.g., question, indication, etc.).

Sarah: Stretched along the top.

and 9 suffixes (e.g., person, place, time, etc.).

Sarah: Along the side.

So, if you are talking about time (-am) you get:
kiam (question/time: when?)
tiam (indication/time: then)
iam (undefined/time: sometime)
ciam (universal/time: always)
neniam (not/time: never).

Which kind of tracks in English. So when/then and what/that are coupled but in English why and how don’t have couplets because English sucks but in Esperanto we have kial/tial and kiel/tiel respectively.

Sarah: As you might have guessed. Alan’s Achilles heel is English.

But man, we are just getting started. Everything is actually built right. If you dance a dance at a dance, English gives you a stupid sentence where all the words are the same.

In Esperanto dance (danc-) can be specified as a noun (-o) and a verb (-as) easily. Hell, it can be an adjective (-a). It can be an adverb (-e), a tool (-ilo), it can be becoming (-igas). You can just glue together things and there are words there. The fun never stops.

Let’s take something like owl (strigo). You are owling with an owl-like owl with an owl-tool? You can say “Mi strigas striga strigo kun strigilo.”

Sarah: I’m owling with an owl-like owl. Lol. I’m wondering what an AI image generator would make of that sentence.

But, honestly, this is pretty cool. It’s like building a language through Lego blocks.

And there is no ‘a.’ I mean who needs ‘a’?

Sarah: So true. I need cookie. I need chocolate. I need nap. I don’t need “a.”

It also highlighted things that were stupid in English that I didn’t even notice that that language had that as a problem. Specifically, that. English has “that” fill so many different uses (I can count ten before I run out of fingers). But does Esperanto do that? no.

Sarah:
That is my house. (That as pronoun)
That house is mine. (That as adjective modifying a noun)
I know that you’re tired. (That as introducing a clause)
The movie that we watched was great. (That as which; relative pronoun)
It wasn’t that difficult. (That as indicating degree)
It was so loud that I couldn’t sleep. (That as result clause)

What is my point? I wonder how much poor conventions or practices cause problems in our world. For example, how much does not being in metric cost America annually? Probably billions of dollars? What is the cost of time-based errors - converting between seconds/minutes/hours or am/pm or daylight savings errors? That has to be in the billions?

Sarah: That as demonstrative pronoun.

But language failures? That shows up in so many places.

Sarah: That as demonstrative pronoun.

This can be errors in countries communicating? Cost of translation. But also things like laws that are written inaccurately because of language.

Sarah: That as which; relative pronoun.

This has cost us so much pain, money, and lives. But what really interests me is something more than all of that.

Sarah: That as demonstrative pronoun.

It is the idea of what a language could allow us to think. I ranked python my number one because of the way it lets me interact with machine learning packages. I could have said Jane, but, while better constructed, it doesn’t have the same highly developed libraries. What if our society was programmed in a well-constructed language? Would it change the way we think, the assumptions and connections we could make? What if there was a language more wellconstructed than Esperanto?

What if we had a language where ideas and thoughts and realizations were discoverable in the interactions between constructs of language? Much like scientific theory aims to predict something new and, if provable, then we gain belief that the hypothesis is real.

Sarah: That as complementizer/subordinating conjunction); By the way, a completely useless and unnecessary word in the sentence.

What if language developed and was proven by the effective discovery of thought? Why isn’t the programming of all our thoughts and interactions governed by a simple rule of self-verification? Why have languages like English continued to exist and even spread without any validation in a world where we have gained so much understanding of the world and its mechanisms through a thoughtful process of scientific inquiry?

Finally, how would our brains be different if we were optimized to a software that was constructed in accordance to our experience and delineation of the world?

Sarah: That as which; relative pronoun

I would tell you, but I don’t have the words for it...

Now for the Boots part…

Okay, Alan, I hear you… organically derived languages aren’t great. They’re messy, filled with ambiguity, and full of weird, inconsistent rules. An efficiently manufactured language could reduce errors and improve communication.

But what if the purpose of language is not just communication? What if language has a dual purpose: communication and serving as a training environment for the brain?

The imperfections of language might actually be a driving force behind cognition—not only in an evolutionary sense, but also in the development of an individual person. Language teaches us how to be patient when faced with uncertainty. It teaches us how to infer meaning from incomplete information, recognize metaphor, and update our understanding based on context.

Ambiguous language requires the brain to generate competing interpretations and select the one that best fits the situation. I remember, that many years ago you told me that your side kicks were lackluster and ankle high.

[That as complementizer/subordinating conjunction.]

I immediately presumed you were revealing your true villain self with the villainous sidekicks “Lackluster” and “Ankle High.” This obviously makes sense because you have an English accent, you were a neuroscience professor devising brain experiments, and you were menacingly petting a cat at the time.

You meant (supposedly) your karate sidekicks were lackluster and ankle high.

For a moment, my brain had to hold multiple possibilities (one much cooler, admittedly). Context resolved the ambiguity, but that resolution required prediction, interpretation, and updating—some of the core features of cognition.

I’m not saying we’d be dumber if our language was smarter…but maybe?

I also think it’s important that humans often resolve language uncertainty by connecting with other humans.

“Can you explain what you meant by...?”
“When you said that, I heard...”

Language is not just an information-transfer system, it also acts as social glue. Some anthropological theories propose that language evolved when primate groups became too large for grooming alone to maintain social bonds. Grooming was the social mechanism that kept ape groups connected—but as groups expanded, an individual could no longer groom everyone. Language may have evolved as a way to create social connection across a much larger network.

Interestingly, one could make the same argument about Esperanto. While it was a manufactured language designed for clarity and ease of communication, its ultimate purpose was also social: creating connection across cultures.

So, perhaps Esperanto and other engineered languages optimize one aspect of language: precision. But natural languages may optimize something else: human adaptability and cognition.

I talk, therefore I think, therefore I am.

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How We Name Things Matters

Why?

Alan: Because middle schoolers are mean.

Because of locus of control.

Locus of control refers to whether we see ourselves as having influence over what happens to us (an internal locus) or as being at the mercy of forces outside of us (an external locus). The words we use subtly shape which direction we lean.

Alan: Not to be confused with locust of control (aka, Jimminey Cricket)

Sometimes I hear patients say, “I’m depressed”, “I’m a depressive”, or “I’m a depressed person.”

I encourage patients to shift that language slightly to “I have depression” or, “I’m going through a depressive episode right now.” The problem is that “I am depressed” can turn depression into an identity. It’s static— it can become a definition of self.

Alan: For example, I’m never sick — although occasionally I do have allergies…

Whereas, “I have depression” frames it as a temporary and dynamic condition. Something outside of ourselves that can change and be treated. Most importantly — something that is not forever and includes within this thought the concept of hope.

It’s interesting that, although depression is a medical and neurological condition, we tend not to think about it the same way we perceive other medical diagnoses. We instinctively separate ourselves from other illnesses. A person might say, “I have cancer,” not “I am cancer.” They say, “I have an ear infection,” not “I am an ear infection.” Illness is something happening to us — not the sum total of who we are. Depression deserves the same distinction.

Alan: Interestingly, I am more likely to say “I am gassy” rather than “I have gas.” However, regardless, sorry about that…

A Little Clinical Context

Two common forms of depression I see are:

• Persistent Depressive Disorder (dysthymia) — gray day after gray day, sometimes stretching over years.

• Major Depressive Disorder (MDD) — a darker, more acute episode that can feel like being sucked into a black pit.

Major Depression can affect how we see the world—this moment of pain feels like forever; hope for the future dissolves. The depressed brain whispers to a person that this feeling is never going to end. And with dysthymia, it’s also understandable that someone living with long-term depression might begin to see it as part of their identity. If they’ve felt low for years, it can be hard to remember a version of themselves being untouched by it. But even then — it is still something they are experiencing. Not something they are.

Alan: There are times I can’t even remember a non-gassy me.

Both MDD and dysthymia are treatable. Treatment can include psychotherapy, medication, lifestyle changes, and interventional psychiatry. (I specialize in transcranial magnetic stimulation TMS, and I’ve seen how powerful it can be for the right patient.)

The larger point is this: There are options. Depression does not have to become the definition of a person’s life.

Words Shape Experience

Language changes alone don’t cure depression. But it can change how we relate to it and to other things in our life.

Think about the difference between:

“I have to go to the grocery store.”
“I get to go to the grocery store.”

Alan: Let me try… “Sarah gets to go to the grocery store”… yeah, that works well. Thanks!

It’s the same task but the different framing gives a different emotional tone. One feels like an imposition. The other feels like opportunity.

Now scale that up to how you describe yourself.

Alan: disruptive

Are your words rigid or flexible?
Defining or descriptive?

If we take control of our language, we take one small step toward reclaiming control of our lives.

That’s it from the boots-on-the-ground camp.

Now let’s bring in Alan for the Brain…

Alan: In our living room we have a digital frame. Mostly pictures of the kids but there are a few figures mostly from papers that never got published.

My favorite may be one a study where we did MRI and PET scans on about 47 people, we published some of this but not everything. We showed how things related to depression and stress — this mostly used the functional MRI. But what we didn’t show was measures of trait characteristics mostly related to PET images, and only structure in the lightest way.

This is exactly what you are saying. Depression and stress feel permanent because they can last for years — but they are just thoughts that self-perpetuate (fMRI is picking up on the thoughts of the moment). They are different from traits (like, openness) that we pick up using PET (which measures brain energy utilization/glucose use) which works on a much slower timeline. But even this isn’t structure.

I see depression and anxiety as metastable states—our brains do as well. The use of language (like metastable states) can create the prediction of the overestimation of the duration of our suffering.

One of my fond college memories was when me and my buddy, Chad, had an art class together and we did a crazy improv dance to some music. It was thematically an interpretation of the evolution of humans and society. We had a rough plan that involved us jumping around the classroom and flinging stuff around. It was loud and random and interactive and messy and fun. Much like everything that we did in that class, we tried to find out where the boundary of what the professor thought was acceptable and just push it a little too far.

Sarah: Things never change.

I’ve often wondered what creativity is. There are existing theories. For example, Misha Rabinovich (theoretical physicist, poet, polymath, friend) did a fun paper [or here] on creativity. I really like his paper because it captures the notion of the dynamic or chaotic aspect of creativity. It’s so cool, I’m going to explain it a little.

First off, I’ll need to give two definitions:

1. Metastable states: These are temporary states that our brain pauses. In the figure below they are defined by an attractor that keeps us in a general space (the blue circles in B or the Si,Si+1,… in A)

2. Static Heteroclinic Channels (SHC): These connect the metastable states in a pseudo predictable path (the path of the blue line in B/A).

The way I think about these is like the foot holds in a climbing wall. These foot holds are metastable states, a stable low energy state where you tend to dwell as you climb. The path you take up the wall are static heteroclinic channels. If you clicked on the links above you can see the math behind all of this and the use of a Rabinovich–Fabrikant attractor.

Thoughts are inherently chaotic. Our thoughts are like a frenetic weasel running up a hill.

Sarah: I’m feeling a bit tired. Can my frenetic weasel run down the hill?

What is really important in this model is not so much the weasel but the hill.

Sarah: Shoot.

Our metastable states are a product of autobiographical experience (or priors in Bayesian statistics), our emotional state, our attentional state, our sensory perceptions, etc. So your energy landscape (or climbing wall) changes over time and is different between people.

Sarah: Ah! I see. So my metastable states are based on me liking chocolate, Star Trek, having a sister and growing up in the US. While yours are based on steak, steak, steak…more steak.

But what makes it creative? In a word, surprize (or prediction error in Bayesian statistics). It’s not creative if it is completely predictable but if it has no predictive signal it’s unstructured chaos and not interesting. For example, if I spell surprize with a z (UK spelling) instead of an s (US spelling) that is predictable but lower probability and causes a prediction error. If I spell it surprije (wrong spelling) that’s not considered creative but a typo. As you can see what is surprising really depends on what is the expected experience.

As your editor, I did a lot of editing then unediting in that last paragraph. Mental note, read ahead before fixing “typos.”

Interesting. This makes me think of book genres. A mystery has a predictable course and a writer would need to stick to it. But, stick too much to it and it’s a snooze to read. Readers might say, “Geez, I feel like I’ve read this before. Too tropish.”

In his paper, Misha quotes people in different walks of life saying that the creative process is often a flow that is achieved when your mind is in the right place. Or your SHC has clear and plausible metastable states — but these are not the standard states.

Another nice way of thinking about creativity is a very related construct of Kalman filters and reinforcement learning (much thanks, Mark and Danny for your reflections). Below, I had claude make me a doodle of what I’m try to say.

So story crafting is a nice model for something you are creating. Let’s walk through the panels with that as our example.

Panel 1: This is the creator’s experience: They are effected by rules of the world as they understand it, memories, society, thoughts, feelings, and they all combine to allow the writer to add the next sentence, word, or concept. The next concept would be the most highly predicted but there is an intentional modifier (m_t above) that they volitionally interject to create a prediction error. This prediction error creates interest for the reader.

Sarah: When I’m writing I often think, “Yes, now to volitionally interject a prediction error.”

Panel 2: This is the evolution of the concept: The concept evolves moving from its initial condition on the left to its conclusion on the right. At a certain point the concept has change or evolved to where it is not the initial concept. Once it has become something more appropriately predicted by new priors the story can be considered complete (much like a superhero origin story).

Panel 3: This is the witness evaluation of creativity: What is creative for someone can be considered random by someone else. For a creator they may find what they have done as interesting (a nominal predictive error) but a non-related individual (with different priors — see Panel 1) may consider this noise or random. The evaluation then depends heavily on the priors (a few examples of witnesses are given — a elite witness could be a book reviewer or English professor, etc.). For example, my priors on fashion are at the un-related level and I have no understanding or context (priors) to perceive creativity or experience interest in clothing.

Sarah: So maybe a super, super, super elite would see you clothing choice as creative and not just noise?

But, seriously, this reminds me of Everything Everywhere All At Once. Many people loved it. Many people thought it was just noise. I suspect the people who loved it had priors that involved superheroes, sci-fi, multi-verses, and martial arts. It was all of those things pushed to the limit. I imagine if someone had never been exposed to Jackie Chan movies, Marvel movies, or anything written by Amy Tan— it would have been a lot of a lot—too much to even try to make sense of…noise.

Thoughts, like art, is a creative act, so you may look at this all and think that this concept is interesting or even creative OR you may look at this as chaos and noise just like the other students in the art class with Chad and I did as we stood on the table yelling and beating our shirtless chests.

Now for the Boots on the ground part…

Sarah: I find this really interesting and I haven’t thought about creativity in this way before. So, Alan, thank you for that!

All this talk of creativity has gotten me thinking about my friend, Carol, who makes the most amazing collages. She cuts images out of magazines and then she brings them together in beautiful and unique ways— I realize now that she solicits the expected then launches the images into a surprising and unexpected world. I love her work and every time I see one of her pictures I’m astounded by her creativity. She made a card for me that I treasure and display every year on my birthday.

Sometimes, I meet people who feel they’re not creative. Perhaps they’re thinking about the end state of creativity and expecting themselves to be there right away without realizing that creativity is the transition from concept A to concept B.

So, a simple exercise to spark creativity is to draw or write or paint something expected— something that, for you, follows the rules— then choose one element and change it. This could be switching one of the words for a different, unexpected word. It could be switching out an expected color for a different color. Moving the horizon in a photo to an unexpected place. This simple unexpected change is the basis of creativity.

I went through a phase where I was bingeing Naked and Afraid. Know the show? Two contestants are dropped into the wilderness (naked) and have to survive for 21 days.

Alan: The original name of ‘Fortnite at Frotteurists’ did not land well with the focus group.

There was one episode where a young woman—a yoga instructor—was paired with a beefy, extreme survivalist. As a psychiatrist, it was fascinating to watch. They had completely different mindsets about how to survive, what it meant to survive, and even how to define success.

Alan: When you say “as a psychiatrist” do you mean “as an occasional rubbernecker of the absurd TV shows?”

He was there to prove he could master the environment. He was going to tame the wild, feast on animals, and live his best conqueror-of-nature life. She was there to test herself, live harmoniously with the wilderness, and simply make it through to the end.

About a week in, the burly guy was curled up naked under some bushes, crying. He tapped out, and the rescue team came to cart him off and back to the luxuries of toilet paper and chocolate covered corn nuts (which I just discovered at Trader Joe’s BTW).

The yoga instructor who was absolutely starving to death stayed.

Alan: Naked and Attuned?

If I remember correctly, neither one of them found food—and that didn’t change after he left. The last week showed her sitting on a rock, meditating. She was gaunt, but she was at peace. And I don’t know how she tapped into that inner strength but it was clear she was going to make it.

Alan: Naked and Anorexic?

It really struck me—the difference between them. Every setback was backbreaking for him. For her, setbacks were still hard, but she pivoted. Watching them, I realized I was seeing radical acceptance in action.

Alan: Ah, Naked and Accepting!

I first heard about radical acceptance in a lecture, and I’m not exaggerating—it changed my life. I told a bunch of psychiatrists about it because it had such a profound impact on me. The concept is simple: life doesn’t create suffering. Not accepting life does.

Alan: Well, not accepting suffering — and pickles. Pickles are gross.

Emotions themselves are actually brief—often lasting seconds to minutes. That sounds ridiculous, you might be thinking. I can still get mad about my sister swiping my brand-new sleeping bag and having sex in it with her obnoxious boyfriend for…oh…well, it’s been about forty years now.

Alan: That is bad. But I still think pickles are worse. You throw pickles in it and might as well just burn that bag.

But that’s the point.

The emotion flares. What keeps it alive is the rumination—the replaying, the “it’s not fair,” the “that shouldn’t have happened.” We keep feeding it.

Alan: Shout out to Jessica Bomyea who just got a grant on Repetitive Negative Thinking!

When we fight reality—when we insist something shouldn’t have happened even though it did—we create ongoing pain: anger, sadness, grief, anxiety.

Radical acceptance teaches that no matter what happens, the first step is to accept that it did happen. Once you accept it, your mindset and how you see the world shifts. The struggle eases. You can move on to the next question:
That sucked. Now what am I going to do about it?

Alan: For example, ban pickles in the house (note: this would include Branston pickles).

And problem-solving is powerful. It makes us feel productive, reminds us of our resilience, and often leads to actual solutions.

Alan: Feeling better already.

For example, consider a trip where the weather turns terrible—pouring every day. You can stew, rage, pace, and complain. You can do that for the entire vacation. (I think I have done that for an entire vacation, actually. Well, the younger, less emotionally mature me at any rate).

Alan: You are actually wonderful on vacation…at least when you take me… cause sometimes you don't…

Or you can say:
“The reality is that the weather is bad. Now how am I going to salvage this and still have a good time?” (By the way, the answer is playing D&D with the kids or Unstable Unicorns or Exploding Zombie Kittens. Also, chocolate tastes good—weather be damned.)

I sometimes wonder if American culture makes this harder. We’re raised on stories of conquering the wild, pushing through, never accepting defeat. We admire people who don’t take no for an answer. Thinks pioneers. Cowboys. That lady from the 1980s “Where’s the Beef?” commercial.

Alan: I often ask myself What Would Clara Peller Do?

That mindset is useful—until reality isn’t negotiable.

Alan: Do you mean like when Clara found beef in soup and negations with Wendy’s came to an abrupt end?

By the way, radical acceptance isn’t about giving up. It’s not agreeing. It’s not approving. It’s simply acknowledging what is true.

Alan: True

I’ve seen patients endure unimaginable things—children dying, spouses dying, cancer diagnoses. They weren’t okay with it. It was (and is) devastating. But somehow, over time, they moved through the anger, grief, and fear into acceptance—and from there, into whatever came next.

So the next time something bad happens, start there: this is reality.

But the suffering we carry by fighting it—that part is optional.

And when you stop fighting, you create space—to breathe, to think, and to decide what to do next.

Maybe at the end, we’re all naked but we don’t have to be afraid.

Alan: My end is famously naked…

That was the “Boots on the Ground” psychiatry part. Now onto Alan for his neuroscience hot take…

Alan: I can readily accept that readily accepting is good. But what do we mean by accepting? I conceptualize it as containing two keep parts: 1) rumination and 2) prediction error.

As I mentioned, Dr. Bomyea just got a grant on repetitive negative thinking (RNT) — similar but different to rumination (note: me bringing up the grant again is what I call repetitive positive thinking). RNT impact peoples experience through cognitive impact (e.g., memory; hippocampus), emotional impact (e.g., mood; amygdala), and environmental impact (e.g., behavioral triggers; amygdala, dorsal anterior cingulate).

Prediction error, is a key concept in Bayesian statistics and computational psychiatry. The core to this idea is that we have our expectations on something happening and when the event happens we use the difference between our expectations and our experience (i.e., prediction error) and use this to adjust our expectations for next time.

Both RNT and prediction error engage areas of the brain that monitor external and internal stressors. Two pertinent things regarding the cost of both RNT and increased prediction error: 1) 25% of the energy of the body is expended by the brain, thus there is a cost of depleting this important resource on non-productive action, and 2) activation to the areas we are talking about can activate the stress systems of the brain (i.e., HPA axis) and lead to release of neurotoxins (e.g., cytokines, glutamate).

The winners on Naked and Afraid seemed to be those who recognized that it is not a matter of mind of matter but rather it matters to mind the gray matter.

Not my best pithy summary but I’ve learned to accept that... and accept it radically.

I’ve been a parent for most of this millennium. Which has given me a lot of time to think about parenting. There are competing concepts of parenting which, not surprisingly, are mirrored in the competing concepts of artificial intelligence and the brain.

Sarah: You don’t find that surprising? You are a very odd person.

Broadly, early theory on artificial intelligence could be split into two camps.

Rule-Based Systems

Much of the initial AI research used rule-based systems that made decisions based on pre-existing rules. For example, way back in the 70s, Edward Shortliffe (ironically named considering he studied disease) made a rule-based system that could diagnose and suggests treatment for blood infections better than most doctors.

Another example, when I was young, I had an electronic chess set. I could battle the computer at various difficulty levels. From playing on this chess set, I learned to mimic the “best” openings and in time I could beat even the hardest level.

For parenting there’s: “don’t run with scissors,” “don’t talk with your mouthful,” etc. I mean, we are also talking all ten of the commandments here. These can be very valuable for safety. These are very valuable early on in parenting, especially when the kids are relatively stupid. Not meaning to be mean, but my kids are now much smarter than me in so many ways, but I still remember when they licked the railings at Disneyland or thought “Goodnight Moon” got better with each reading.

Sarah: Hey! I loved Goodnight Moon.
Come to think of it, maybe I didn’t, actually. Maybe I was desperately leaning into the cadence with the wishful thinking that I was hitting a magical off switch.
I wasn’t.

Much of our brain runs this way as well take, for example, the subcortical brain. It is highly efficient in pathing important signals from the body and often initiates action without the cortex getting involved. Like when you touch a hot surface your hand jerks back.

Sarah: I always thought it was very cool how jerking the hand back from a hot stove doesn’t actually involve the brain. The signal of “heat” travels via the peripheral nervous system to the spinal cord. The spinal cord instantly responds by jerking away the hand. It takes a moment later for the brain to actually receive the information. So, by the time the brain thinks “Ow! That hurts,” the body has already moved itself away from the heat.

Your breathing continues without oversight.

Sarah: Thank goodness.

You balance as you walk without meaningful contemplation. These subcortical systems allow for quick and effective rule-based actions that facilitate safety.

Learning-Based Systems

At the same time that these rule-based systems were gaining success, people were trying to build up learning systems. The more mundanely named Frank Rosenblatt (who sadly had far too short a life) built a device called the Perceptron. When reinforced, this device could recognize a triangle, but already the potential of this model—with cross- and back-communicating neurons—was very flexible and could be taught to do more. After a few bumps along the way, this led to our current AI revolution.

While hugely adaptive and powerful, for these models to fulfill their destiny, they need more computational power and more time to develop and train. This is the Stockfish - the chess AI on my phone that can just destroy me every time. An important aspect of these models is the concept of transfer learning. We could develop a training model on one dataset (say vision) and we could clear the lower levels of a deep neural net and jump start learning in a new domain (say hearing). Anthropic (the unchallenged leader in ethical AI) even wrote what amounts to a parent’s wisdoms document anticipating that their child would soon be powerful than them (I’ve been there).

For parenting, this is letting our kids learn by experience. But this isn’t just dumping them in the deep first time in the pool. This is really the application of transfer learning. This is the ‘nudging’ that Finn talks about. As a parent, we’re trying to give insights from our experiences and suggest pieces of information that we think our kids should be paying attention to when they make their decisions.

Sarah: Getting them to pay attention to it is a completely different matter.

For our brain, this is the role of the cortex. It continues changing and evolving well into adulthood. This is where our brain differs most from that of other animals. This is where the vast majority of the brain’s energy is spent. This is where much of the evolving learning along our life path occurs—where we optimize for new situations.

Unlike the subcortical aspects of the brain, which do not adapt in the same way, the cortex uses information from the subcortex to optimize our decision-making in a dynamic and changing environment.

On Parenting

I feel like parenting is the balance between rule-based and learning-based approaches. One of the biggest tricks is realizing when you should be engaged in each. I was so excited when, as a parent, I could leave behind rule-based parenting and move to learning-based (or maybe more transfer-learning-based) parenting.

I got to watch Finn do high school and college better than I ever did. I got to watch them move from the electronic chess set to the Stockfish engines that make decisions that, in my youth, I wish I had the wisdom to make. To now watching them be that person for someone else.

Now for the Boots on the ground part…

Sarah: This got me thinking about nudging. Especially nudging teens.

YOU know you have the answer but THEY are just not listening. The classic, if I tell them to do it, they won’t dilemma.

So, how do you give your kids advice? Or “nudge” in an effective way?

First off, kids often resist advice not because the advice is wrong, but because advice can feel like a threat to autonomy. The minute a child feels “managed,” the brain shifts from learning mode into defensive mode.

So the trick is often to become less of a lecturer and more of a collaborator.

A few angles explore:

• Ask before advising: “Want my thoughts, or do you just want me to listen?”

• Help them think instead of telling them what to think.

• Give observations, not pronouncements.

• Offer small nudges rather than full speeches.

• Timing matters enormously. Advice given during emotional moments rarely lands.

• Sometimes the best way to be heard is to say less and leave space.

• Kids are often far more open to advice they feel they discovered themselves.

Remember: sometimes our teens are just not going to agree with our points of view. If they go down a path and it doesn’t work out, “I told you so” is your friend if you want to feel superior. If you want to have a loving and lasting relationship, the better answer is “I know this didn’t go how you hoped. Anything I can do to help?”

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Nothing can affect workplace satisfaction like a bad boss. And “bad” comes in all types. Recently, however, someone reached out to me asking how to deal with the condescending boss.

Alan: Actually, technically, I really don’t think you count as my boss.

Alan: Actually, technically, that’s not true but I do think you’re a good boss.

You can already feel it, can’t you? A few smug one liners:
“Having a hard time keeping up, eh?”
“This is an advanced case, I want Bob to handle it.”
“You’re overthinking it, it’s pretty simple.”
“You’ll understand why later.”
“That’s not how we do things here.”
“Oh, I love how you’re trying to pull everything together.”

Alan: “You seem so much better at AstroBlaster™ than I remember. If you keep trying you might find someone you can actually beat.”

By the way, this is so much tougher for women. I remember being partnered with a fellow woman and we produced extraordinary content and deliverables, another woman joined our team and the boss, a male, took me aside and let me know that he “knows” how women get and he didn’t want us to be catty or gossipy with each other. I remember being in absolute jaw dropping shock.

Alan: As the representative male on our team I’d like to say: What the hell!

The perfect comeback…one hour too late

Did I deliver a blistering rejoinder? Nope. I wish I did. I was thrown off balance. It took my brain an hour later to come up with the perfect response. Why so long? I’ll leave the technical explanation to Alan but basically, condescension is seen by our brains as a threat. When we feel diminished or evaluated, the nervous system shifts toward protection. Working memory and cognitive flexibility get strained. The brain becomes less effective at finding precise language under pressure. Very often the zinger you’re looking for arrives later when the system has settled back to baseline.

Alan: I’ll be honest. I didn’t see much in the literature that hits this well. There are famous papers on social exclusion being experienced in a way similar to physical pain. But, apparently, I need to do a study where I just get all mean and condescending with strangers — in the name of science of course.

So let’s break this down.

Are they just a jerk?

First, why is the boss being condescending? For a variety of reasons. The need to feel powerful. Maybe they feel insecure and have a fragility they’re protecting with the condescending bluster. Maybe they need leadership coaching. They could simply be a jerk. Are they stressed and overwhelmed? Is this representative of the department’s culture? Are you being targeted? Different reasons lead to different responses. You did not create the dynamic, but you still get to choose how you want to respond.

Alan: Yeah, you don’t have to feel sorry for the jerk. You don’t have to fix the jerk. But sometimes getting info can make it so you can predict the jerk.

What’s going on in you?

So, let’s switch the focus to you and identify what’s behind your emotional response. Condescension can trigger all sorts of emotions. A condescending comment can quickly stir up and build on previous experiences of being dismissed, underestimated, or needing to work hard to establish competence. Common reactions may include self doubt, over explaining, anger, defensiveness or shutting down. These are protective mechanisms and they may or may not be helping you.

Alan: My go to with my work-bosses was always rage (Hey, I never claimed maturity).

First step is to think about what the comments or tone are triggering in you: anger, shame, self-doubt, the need to prove yourself? Once you notice what has been activated, you have a little more room to decide how much of the interaction belongs to the present moment.

For example, when I first met Alan, he would often say, “If you stop and think about it…” Boy, it would really, REALLY piss me off because he was implying that I wasn’t thinking. And being thought of as stupid is a big trigger for me. I recognize now that he didn’t mean offense he had simply wandered into my no fly zone.

Alan: Yeah, and if I really was to think about it carefully — this was probably not my best turn of phrase.

I’m definitely NOT saying that you’re overreacting. I am NOT suggesting that you’re imagining the condescension. I’m only saying that in two person interactions we have to consider both people. That does not make the condescension any less real. It simply means our own history can shape how intensely it lands and what it stirs up in us. Once you are aware of yourself, your triggers, and thoughts, then it’s easier to view the condescension through a place of neutrality.

Alan: However, I was really not being condescending, I promise!

Now, what to do about it…

In the moment, the answer may be not to focus on correcting the boss’s interpersonal style but instead focus on getting the work done while disregarding the crap they’re bringing to the table.

The best way to do that is to keep responses short and neutral. Avoid any emotional counterattacks.
For example:
“I understand—can we talk through the specific concern?”
“Can you clarify what you’d like done differently?”

Alan: “You want to go big man?”

Next up is steering the conversation away from the vague to concrete questions. Condescension can become less powerful when it has to become specific.

When that stuff doesn’t work

Go with the simple first, but sometimes it just doesn’t do the trick. There are other options to turn to…

• Address it privately if the relationship has enough safety.

• Use reflective language: “During rounds, when you said X in front of the team…” is usually more effective than “you always talk down to me.”

• Document patterns if it becomes repeated or consequential.

• Reality-test with trusted colleagues.

• Escalate when needed

What is winning?

And finally, keep in mind that when working with a superior, “winning” is rarely the goal. The reality is that someone else’s condescension is not a reliable measure of your competence. Stay anchored in what you know, what you can do, and what the work actually requires. The goal is staying effective, protecting your footing, and not letting someone else’s posture become your internal narrative.

As my mother always says, “Don’t let the bastards get you down.”

And now over to Alan for the Brain part of Boots and the Brain…

Alan: These are all excellent points. Building on this last one. Figure out what is important to you. I remember I had a really bad work relationship. I had a co-worker who, I felt, was out to destroy me. Two questions I had to ask myself were 1) what is important to me? and 2) what was my goal?

What is important: When I was angry, frustrated, etc. I would think that no matter what happened in my day, I would go home and I would get to talk with Sarah and I could think about that relationship when I found myself thinking about a bad work relationship.

What is my goal: I didn’t want to ‘win’ against my co-worker. I wanted to get along. I couldn’t do that with our work projects. So, we started rating local area restaurants. This was a no risk interaction. This didn’t fix everything but at least it meant sometimes, we got along fine.

My go to was always anger. Which lead to many timeouts and detentions in my youth.

William James explained the architecture of emotions that your body reacts first and we then determine our emotional state from our physiological reaction. It can be really hard to interrupt this cycle. But I learned to bookmark that feeling and to use that reaction as cue to consider what was important to me and what is was my goal. Fortunately, I was always getting angry as a kid. I got a so much of practice.

And if you really think about it, we can’t handle every situation the way we wish we would but it’s important to recognize when we do something that works for us and take the win.

Sarah: Once you teach Alan that things can be placed on the stairs to be taken upstairs, he never sees those things again. Despite tripping over them. Every time he goes upstairs.
-Sarah

I can sit in a cafe everyday for a week but if you ask me a week later what the chairs or tables looked like, I’d have no idea.

Sarah: But you do know the exact quality of the iced tea. And whether its chilled. And the exact size of the cups. And you have the bathroom code memorized...

Reducing things to their abstractions is an important aspect of thought and is often very helpful. But it’s important to be aware of how and when we reduce things by labeling them. Potentially, the worst and most common manifestation of this is metrics.

I’m a great believer in metrics. At the same time, I see them as the path to the devil.

Sarah: Also “avocado paste.”

I greatly enjoy looking at the metrics for basketball statistics. I love Daily Adjusted and Regressed Kalman Optimized (DARKO; https://apanalytics.shinyapps.io/DARKO/) mostly because I love state-space models. But I recognize it leads me to pick a single metric for mapping the players against each other. I can put in Lebron James, Kobe Bryant, and Steph Curry and get the impression that Kobe Bryant is overrated. But if I watch them play, I can see that Kobe Bryant was probably the most talented of the three, so talented that he could often escape his mistakes through pure talent (note: he is also my least favorite of the three). I feel like, as I recognize what the metric tells me, I can add it to my experience to round out my understanding of what I see.

As a researcher, I’m evaluated by metrics as well. They’re simple metrics but also often used. The primary metrics I have are: # grants, # papers, and h-index. H-index is taken pretty seriously as a metric to evaluate the ‘impact’ of a researcher. The h-index is the maximum number of papers (h) that have each been cited at least h times. It’s a single number to summarize my productivity as a researcher. This has the problem that if I cite myself then that number goes up. Also, when I cite myself more it increases the number of times other people cite me. Knowing the metric and how it’s scored can change my behavior as a researcher.

Sarah: Ah! Did you know that there’s a metric for taking things on the stairs up the stairs? I hear knowing that changes behavior…

In schools, grades were created to provide a summation of scholastic performance when the number of students became so large that letters and description of performance became to onerous. But, as it is with metrics, they subvert things. The idea that the knowledge gained from a class is a more critical goal than the grade gained is frankly antiquated. Large language models (LLM; i.e., ChatGPT, claude) can provide the ‘wealth’ of information from the internet to further either the knowledge or grade gained. This creates an argument of the toxicity of LLMs, but the actual problem is our reliance on metrics not LLMs.

With all of these cases, we start to only see the metric and loose site of the goals that these metrics were created to summarize. Each of these are ways the metrics hide that which they are trying to describe. So going back to the quote by Jiddu, “We no longer see the bird once we have named it.” So what do we do about this? How do we escape this? I’ve got a few suggestions…

Suggestion 1:

Lean in: We have several posts on "sporkful of..." In these posts we try to unpack an idea describing something not with a single metric but with three metrics!

Sarah: Forkability, sauceability, tooth sinkability…it’s not just for pasta!

So is this better or three times worse? I vote better. I get a better idea of the player if I don’t look at their VOR (value over replacement) but instead look at points, assists, and rebounds – if my goal is to understand the player instead of rank them this is a substantial enhancement. The Sporkful framework is nice because each construct tells you something and is mostly independent. Imagine that instead of getting one grade you got three grades for different capacities. What should they be? Is there a Sporkful of Scholasticism that needs to be written?

Sarah: Well, to be honest, you are pretty awesome despite stairs objects. Funny, intellectually stimulating, loving, caring, eye candy. Sauceable, tooth sinkable and oh, so, forkable.

Suggestion 2:

Cluster: In my day job as a researcher, when I’m faced with too much data my automatic responses are 1) feature reduction – for example run a principle component analysis – which honestly is suggestion 1 above, and 2) cluster analysis (and I have a whole post on that coming). I won’t go deep on cluster analysis, but in our basketball analogy we can look at multiple features and describe things not by a singular value but a descriptor. So if a player’s ranking on assists is greater than points and rebounds they may be a point guard; if their ranking in blocks and rebounds is greater than assists they may be a center. If they rank high on points, rebounds, and assists they may be Nikola Jokic.

Suggestion 3

Blow it all up: If you don’t need a metric, don’t embrace a metric. For example, I like baths. My enjoyment of a bath is immersing myself in water. I don’t need to evaluate it, I don’t need to measure it, or judge it. I just have to soak in it. This is the philosophy of mindfulness. You observe but you don’t judge. As you can tell I’m not great at this because I ranked this one third…

Boots?

Sarah: A couple of thoughts… First, for a neuroscience take on reducing information down to usable packages, we have one of my favorite articles linking neuroscience, brain function, latent variables (or metrics) to multiple personality disorders.

This got me thinking about wellness initiatives in health care. I’m involved in creating and leading physician wellness for a large health care organization. The problem? Physician wellness is not easily captured by metrics. Physicians feel supported. They’re glad the program exists for their colleagues. It helps them weather adverse events, burn out, and stress. It serves as a bridge to professional help. But, at the end of the day, metrics pave the way to dollar signs and it’s hard to reduce wellness to a buck on the table.

Organizations forget, however, that money isn’t everything (gasp.) You may be able to throw money at a physician but whether a physician stays or leaves depends on more than the heft of their wallet. Making a difference. Working toward something bigger. Mastery. Work life balance. Community. This is what makes a meaningful difference to people. The money is nice but only one strand in the complicated and nuanced web of satisfaction and indeed happiness.

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Content note: This post discusses suicide and depression

It’s an easy enough question to ask:
“Have you wished you could go to sleep and not wake up?”
or
“Do you ever have suicidal thoughts?”

Most psychiatrists ask when the need is obvious—for a depressed patient or someone in clear distress. But we don’t ask every time. Even though we know suicide is what kills our patients. Why would a psychiatrist choose not to ask? There are a lot of reasons. But I suspect one of the biggest is a cognitive bias: the Hot–cold empathy gap.

Alan: I’m not a fan of the term ‘hot-cold empathy gap’ but the construct is interesting.

Alcohol, Chocolate Cake, Bicep Curls—and the Hot–Cold Empathy Gap

I’ll come back to suicide in a moment. First, a few familiar examples.

“I don’t even like the taste of alcohol anymore.”

When a patient with alcohol use disorder says this, I get nervous. Everything may look great—work is steady, relationships are good, health is improving. Alcohol is in the rearview mirror.

Except their brain is fooling them. Relapse is common. Programs are built around anticipating it.

Alan: Sometimes when you ask how long that has been the case — it may just be a day or two.

“I actually crave salads now.”

The sweet tooth turned meal-prepper. Peaches for dessert. Organized containers. A new identity.

And yet, most people regain weight after dieting. (Yes, that’s a dated stat—and yes, GLP-1s are changing the landscape—but the pattern is familiar.)

Alan: I think “craving salads” is an obvious lie like just babies pictures from day 0 are “cute” or “handsome” or “not at all unnerving”

“I’ve never felt better. This is the new me.”

The new exerciser: 10,000 steps, gym routine, downloaded plans. And then… life happens. About half of people drop out of exercise programs within six months.

I’ve lived this loop many times. I’ve tried the steps, the weights by the couch, the half-marathon plans, the micro habits. Every time, I believe it: this is it. I’ve even lasted for a awhile. There was a two year stint where I ran regularly three times a week. I had great calves which is kind of a weird thing to notice about yourself.

Alan: the trick is low expectations: “today, I’m not going stub my toe on the weights.”

Sometimes it only lasted two hours. (In my defense, Trader Joe’s lava cakes are really, really good.)

So what’s going on?

The Gap

The hot–cold empathy gap is simple:

• Cold state: calm, rational, clear

• Hot state: emotionally activated—stressed, sad, hungry, irritable, overwhelmed

When we’re in one state, we’re terrible at imagining ourselves in the other.

We make plans in a cold state and assume future-us will feel the same way:

• Future me will go to the gym

• Future me will clean the house

• Future me will read something meaningful instead of doomscrolling

Alan: Future me will come up with a funny comment and go back and edit this.

And then future me becomes current me… and is annoyed at past me.

The gap doesn’t just affect how we see ourselves. It affects how we see other people—and what we think they’re capable of feeling or doing.

In everyday life, this sets us up for abandoned diets and unused gym memberships.

In psychiatry, it can be lethal.

Back to the Question

Psychiatrists know the risk factors: depression, anxiety, mania, insomnia, prior attempts, substance use, grief, access to firearms, demographics—the list goes on. We also know that there are proven strategies to help patients when they become suicidal.

And yet, sometimes we don’t ask:
“Have you wished you could go to sleep and not wake up?”

Why not?

We might say:

• “This is just ADHD.”

• “They’ve never been suicidal.”

• “I’m running late.”

• “They’d tell me if it were a problem.”

Hopefully no mental health professional believes the old myth that asking creates suicidal thoughts. Maybe they’re not asking because it’s uncomfortable to dive in on a potentially awkward question. Sometimes it’s time pressure.

Alan: When working with Veterans, they can be asked so often in such an automated way. Just asking is not enough. You need to be clear that you asking because you honestly want to help in anyway you can.

But often, I think it’s the hot–cold empathy gap.

Four Clinical Moments

Patient cold / Psychiatrist cold
The patient is calm, doing well, maybe far removed from a past crisis. They can’t imagine ever feeling that way again. The psychiatrist can’t really imagine it either—they’re just doing so well.

The idea of suicidal thoughts feel irrelevant and the question doesn’t get asked.

Patient hot / Psychiatrist cold
The patient is distressed. The psychiatrist sees it clearly, asks directly, intervenes. This is the moment we’re trained for. This is where we do well.

Patient cold / Psychiatrist hot
The psychiatrist is running late, is distracted, has to pee, is human. The patient looks fine.

“They’d bring it up if it mattered.”

The question doesn’t get asked.

Patient hot / Psychiatrist hot
Frazzled patient. Frazzled psychiatrist.

In an ideal world, we’d drop into a calm, focused state and do what’s needed. But sometimes we don’t get there. Anything goes in this scenario and things can be missed.

The Dangerous Moment

This gap is especially risky after discharge from a psychiatric hospitalization.

A patient may have had a serious suicide attempt days ago. Now they feel hopeful. Clear. Certain they’ll never go back. They’re entered a flight into health and they can’t imagine the return of suicidal thoughts.

Sometimes, neither can the clinician—especially a new mental health clinician that just feels so relieved that the patient is feeling good. They forget that suicidal thinking is often cyclical and don’t give preventative strategies like a safety plan.

Here’s the tricky thing about suicidal thinking, it’s not just cyclical, it also hits in the “hot state” when people are least prepared to ride it through. In general, suicide attempts tend to be reckless, impulsive and when a person’s brain is experiencing a neurocognitive storm. Safety plans are simple, concrete strategies designed to help a person through the hot state of suicidal thoughts. How can you distract yourself? If that’s not working, who is someone who can help distract you? If that’s not working, who is someone you can tell that you’re in trouble? The neurocognitive storm lasts about 20 minutes; the goal is to keep a person safe until they’re back to thinking rationally and the frontal lobes take over again. In other words, the safety plan is designed to protect a person in the hot state until they re-enter the cold state.

But if a patient is in the cold state in the office meeting with a psychiatrist also in the cold state, the hot state of suicide seems far away. The concrete simplicity of the safety plan feels trivial and irrelevant. And ultimately, a mental health professional might be lured into forgetting that suicidal thoughts are cyclical. They might skip the question. They might skip creating a safety plan.

Like dieting. Like exercise. Like early sobriety.

People fall off diets. They stop exercising. They relapse. They get suicidal.

The Question Behind the Question

If you’re a psychiatrist and you find yourself not asking, it’s worth pausing. Not just whether to ask—but why are you deciding not to ask? Is it truly clinical judgment? Or is it that, in this moment, suicide feels too far away to be real?

Because that feeling—that sense that it’s not relevant right now—that’s exactly where the hot–cold empathy gap lives. And that’s when the question matters most.

Alan: I like how you link this to other behaviors and decisions. The decision to eat the leftover Easter candy when you’re going about your day is a split second decision. Sometimes not grabbing candy sounds easy. Sometimes it seems so difficult. Much like a patient’s decision regarding suicide. Much like a provider’s decision regarding asking. This is why one of the main interventions for suicidal patients is to come up with an action plan if the feels come back. And why your post is an action plan for people who want to help the patient stay safe.

Doing brain imaging studies in suicide is challenging for the exact reasons you bring up here. When someone is in the scanner they’re in a different state than when they’re feeling suicidal. We can look across groups, try to match on other variables, try to look at static features, try to study the brain post-mortem. The best evidence is that areas in the medial prefrontal cortex and anterior cingulate cortex (the area between hemispheres in the front of the brain) are effected but largely this is not notably different that what you see for depression. This is not causal but more an indication that the patient’s “hot state” can be a higher risky state. Being aware that the person in front of you is not always the person they are when they’re in front of you is key to make sure you are looking out for all the different versions of them.

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If you are feeling overwhelmed, in crisis, or thinking about harming yourself, please reach out right now:

• U.S. and Canada: Call or text 988 to reach the Suicide & Crisis Lifeline.

• International: Find crisis support and suicide prevention hotlines in your area at the International Association for Suicide Prevention or Befrienders Worldwide.

• If you are in immediate danger, contact your local emergency services.

Sarah: Yes, absolutely crazy. Who buys a bag of M&Ms, eats one, and then leaves the bag out?

Now, Sarah is a classy person with classy taste in classy chocolate and didn’t like M&Ms. But she knew the bag was there and she would eventually work her way through the bag, just in time for my next yearly purchase. I’m not saying this is what compelled me to study craving, but …

Sarah: They weren’t even peanut M&Ms. If you’re going to do this, at least buy the peanut ones!

Craving is a very popular concept for thinking about drug use. While not part of the DSM diagnosis until DSM-5 (2013), craving is often centric to the way drug misuse is conceptualized. And not to sound like a grumpy old man, but I don’t know if I like the inclusion of craving.

DSM-5 substance abuse is diagnosed if 2 of 11 are endorsed.

1. taking more than intended

2. desire to cut down

3. too much time spent getting/using/recovering

4. craving

5. causes failures at work, school, or home.

6. causes social problems

7. reducing other important activities

8. physically dangerous

9. causes physical or psychological problems

10. tolerance

11. withdrawal

I guess I should explain why I’m not a fan of including craving…

This mainly comes down to William ‘Billy Boy’ James. Billy Boy revolutionized psychology (or fathered it) and one of his, numerous, brilliant insights is that when our body reacts, it triggers an emotional response (as opposed to the idea that an emotion triggers a body reaction). So, when someone jumps out at you (event), your body freaks out (physiological response), and you realize “I’m freaking out here … I must be scared!”

Broadly speaking, our emotions are post-hoc explanations of our physiological reactions.

Sarah: So, I hear the music for Star Trek: The Next Generation and my heart quickens. My eyes widen. I break into a smile. I must be excited and happy about watching an episode!

By the way, this is a lot like cognitive dissonance, where when a behavior differs from the emotion, we alter the emotion to fit the behavior thereby minimizing the dissonance. This is why in college I always asked Sarah for a ride to the airport. I was hoping she would think: “I’m always dragging this guy around, maybe I like him?” Even now, I make significantly less money than her and hope she’ll think “I’m always dragging this guy around, maybe I like him?”

Sarah: Goes both ways… you’re thinking, I’m always putting up with Star Trek:TNG and half eaten bags of M&Ms lying around. Maybe I like her?

If Billy Boy was right, then our feelings represent us interpreting our body. In some ways that means we should never ever trust our own opinion. Our we often use emotions to shape our decisions and planning but our emotions are really just interpretations of our bodily reactions.

This brings us back to craving. Craving is a strong feeling that is very much based on what our body is telling us. It’s also not a quick experience like the Freddy jump scare. Often craving is a prolonged state based on the body (think of my relationship to Freddy) and behavior (think of my relationship to Sarah). All of this makes me really question whether craving drives our behavior or describes our body and actions.

Some of the work I do in my day job is studying pain (almost always with my friend Irina Strigo). Some of this work is on people who are undergoing treatment for chronic pain. The general thought in the field is that craving should drive increased use of opioids. That craving is a result of pain and depression in people using opioids and that if you’re trying to reduce the use of opioids (MEDD in the figure below; MEDD=Morphine Equivalent Daily Dose) you’ll be battling people’s craving (okay now you can look at the figure below; the funny d is delta which means change in opioids).

Recently, Irina did a paper that looked at craving in people going into an opioid reduction treatment. We did some fancy math (structural equation modeling (SEM)—which is super fun) to see if opioid use was affected by various things including pre-treatment subjective opioid craving, pre-treatment pain catastrophizing, depression, pain intensity, opioid intake, as well as treatment goal, and treatment satisfaction. This can be described nicely in the figure below.

We found that pre-treatment depression influenced craving, as well as pre-treatment opioid intake dose and treatment satisfaction influenced the amount of success in reducing opioid use. But there was no significant relationship with self-reported craving. Now, admittedly this differs from other substance use disorders (there was a big meta showing this). But, it’s important to note that this wasn’t seen in our chronic pain people who were trying to reduce there opioid use.

All of which bring us to the question, what is craving? Is it the disease we treat it as or is it just a description that we come up with to make stuff make sense? Is craving a self perpetuating experience that is birthed from behavior? Is the word to describe the overwhelming momentum of Billy Boy’s theory of personality with a sprinkle of cognitive dissonance that exists as … a latent variable.

Sarah: Hahahahaha. I should have known the “L” word was coming up.

Now, for the Boots on the ground part of Boots and the Brain…

This reminds me of using an emotional lens to navigate the day. Sometimes I’ll be talking with a physician who can describe their internal state in vivid detail—but can’t quite find the word for it. But pausing to name the emotion can be very helpful.

Take irritability: snapping at staff, making quick judgments, feeling on edge. If they can recognize, oh—this is anger, then we can work backwards. Anger usually points to a perceived violation. Something about this day is registering as not okay.

What was the violation?
An overbooked schedule?
An added shift that wasn’t really optional?

Once the path is visible, it changes the task. The goal isn’t to eliminate the anger—it’s to understand it well enough that it doesn’t ruin the day for the doc (or for anyone else). The shift still needs to be worked. Being furious at yourself, the patients, and the staff while you do it just adds a second layer of suffering.

So, the re-frame is simpler, and more humane: this is a tough shift. Now what?
Maybe they decide to notice one good interaction.
Maybe they take pride in delivering excellent care, even on a day that didn’t feel fair.

Maybe they bring in a lot of half eaten bags of M&Ms for the staff.

Click to see a previous post on emotional lens.

Last year, I was lucky enough to be on a small boat with 120 people for three weeks (Thanks for the trip, Mum!). I learned a lot about the way people talk. More specifically, how people talk and talk and talk...

alan: I was left at home and learned a lot about how people talk to themselves.

Alan: Yes, yes I did… and talk and talk…

Every dinner in cruiseland:

“I’m going to tell you in painstaking detail what cruises I’ve been on. Don’t worry, I’m going to tell you about the plane flights I took to get to the ship, the name of the ship, my level of jet lag, the lay out of the ship, and what I saw from the balcony. When you think I’m wrapping up, never fear, then I’m going to tell you about my next three cruises.”

I’ve now sat through this conversation upwards of 20 times (and it has never once been interesting). I’m not a particularly social person so I imagine the very social people on the boat engaged in this talk at least 40-50 times.

Alan: You telling people it was uninteresting makes you kind of look like you’re probably not a social person.

alan: True, sometimes people just want to feel heard. To feel seen. Included…

After 3-4 of these ritualized interactions, I tried to shortchange them and gear the talk to something meatier or more revealing or just plain different. I’d sprinkle in a weird question and…nothing. It barely shifted the flow. It was like that Star Trek TNG episode (“The Loss”) where the Enterprise was caught in a group of 2D creatures heading to the cosmic string and no amount of 3D interventions (like photon torpedoes) affected the drifting pattern of the organisms as they pulled the Enterprise closer and closer to its doom.

Alan: Nerd.

alan: Sorry, he’s being a hypocrite — have you read his last few posts!

After many failed attempts at trying to divert this cruise ship vise grip, I realized I needed to stop fighting and understand it for what it was. Human nature. If everyone was doing it, then it must serve a very important purpose for our shipboard community.

After far too much field research, five small talk patterns emerged:

1. Small talk as token exchange

Small talk is psychologically important. It’s a way to test safety with an unfamiliar person. “I’m going to throw a simple, basic, meaningless question at you and if you’re normal you’ll respond with a simple, basic, meaningless answer.” (i.e. “How’s it going?” “Fine, thanks. And you?”.)

Small talk as token exchange ferrets out: “Do they understand and follow the same etiquette rules as me?”

Small talk as token exchange is great. It paves the way for deeper conversation later on— conversations where people are vulnerable and real connections can begin. (“Wow! Thanks for telling me all about your cruise history. Do you ever have existential dread?”)

alan: That’s a nice point, thanks for sharing

2. Small talk as filler

People generally feel uncomfortable in long silences. Not everyone, though—research shows that Scandinavians are less likely to fill the silence. Psychiatrists and therapists are trained to sit with the silence, too. Why? Because the power of silence is beaten into them during training: Don’t fill the space. Embrace the discomfort so the patient fills it with something (hopefully therapeutic) instead.

I’m a fan of this type of small talk, too, because people who fill the silence are primed for deeper conversations—all it takes is a simple nudge in the right direction.

Alan:

3. Small talk as telegraphing social status

Oh geez. The worst. This one is for the “right kind of people” to find the other “right kind of people.” Damn, there were so many “right kind of people” on this boat and their small talk announced it loud and clear. “Well, I truly love my summer home but not as much as my winter home or spring home. But who has time for all the homes when there are so many cruises? Here, let me tell you about my next cruise and my anticipated level of jet lag.” Their small talk swiftly and efficiently exposed my social standing of “No, I don’t have another cruise planned—this one emptied my bank account. We’ll be living off dried lentils for the next six months.”

Dr. Alan “the Brain” Simmons, PhD: Personally, I’m above this nonsense.

4. Small talk as armor

This is promising small talk—in my office, that is. It hints at oodles of pathology ripe for some good ole fashioned psychotherapeutic healing. But, the last thing I need on my vacation is to stumble onto someone’s trauma. The small talk as armor is something to respect while on vacation. Don’t dig. Don’t investigate. Just enjoy the same conversation for the 12^th time. Cue up my next line: “Any cruises you’re thinking about for the future?”

Alan: Interesting, what’s #5?

5. Small talk as the ever-loving interest

These people LOVE the small talk. They are full of small talk and they can talk about ANYTHING devoid of content without ever running out—weather, sports, bird types, jet lag, what cruises they’ve been on….did I mention what cruises they’ve been on? No matter what you do, there’s no heading this small talker off at the pass. They love it, they live it, they’re skilled at it and it’s their happy, happy place. Sit somewhere else for dinner.

It’s no surprise that I’m lousy at small talk—it’s an occupational hazard. When I go to the waiting room and call a patient’s name, the patient (keenly aware that American healthcare appointments last 17 seconds) jumps over small talk and right into soul wrenching sobbing while walking to my office. So, psychiatrists become accustomed to not doing any of the work of small talk.

Alan: I feel you may be oversharing.

alan: Actually, this is so true of Sarah. We have a friend who used to bring by his girlfriends and Sarah made them all uncomfortable. It would go like:

Unnamed girlfriend: “Nice to meet you, I heard you are a doctor.”

Sarah: “Nice to meet you too. How do you seek joy? How do you connect to your inner strength?”

Unnamed girlfriend: “…”

At the end of the day, it was nice for me to get a reminder on the value of small talk. It also forced me to brush up on my skills and, in the end, I met some very interesting people and had some very lovely conversations. And, I have to remember, that all of those conversations started with, “What cruise have you done?”

Alan: I’m currently teaching my son to drive a manual transmission. The key is the clutch. The engine and the wheels are rotating at different speeds, and you use the clutch to synchronize them. I see small talk as serving much the same purpose.

When people engage in small talk, one of the brain’s key tasks seems to be figuring out how the other person is doing. More specifically, among other regions, the medial prefrontal gyrus — located right behind your eyebrows, between the hemispheres — becomes active during these interactions. This region is important when we are at rest. Primarily because it is, I think, running simulations. Essentially, what people appear to be doing in small talk is trying to figure out where the other person is “at” and aligning to that “speed.” Much like the clutch linking the engine (talker) to the wheels (listener) to a shared speed.

alan: and that makes us feel slightly less alone…

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I was working on a grant on MDMA in the brain (super fun! but I’m not going to talk about today) and I got obsessed with Kalman filters. Kalman filters are really cool. Basically, you build a model to predict something based on prior experience and this model can evolve overtime. I wanted to test out my code and so I thought to myself what can I try and predict? How about income inequality?

Sarah: So, no brain stuff today?

In his book Capital in the Twenty-First Century, Thomas Piketty of World Inequity Database (WID) really gets into the effect of acquired capital. Admittedly, a dry read/listen, but good stuff. An important point is there is a rate of return on capital (aka owning stuff) and when this goes beyond the growth of the economy then the inequity become problematic (aka S>G).

Piketty’s second fundamental law of capitalism is: β = s/g. Where β (beta) = the capital/income ratio; s = the savings rate; g = economic growth rate.

Sarah: Wow. Really no brain stuff. OK, I’m going to have to do some brain inserts so we stay on brand…

Now those wonderful people at the WID provide super wonderful data for us to look at in an attempt to understand the trends and effects of income inequality. But we need to have a good measure of inequity.

Sarah: The brain generates enough electrical current to power a 25-watt bulb. 1.

After a little time with wikipedia, I decided a good way of understanding income inequity is the Gini Index. This gives a single measure that we can use to describe the distribution of income. (Note: there is a good argument that wealth not income is a primary concern. But income is potentially a more responsive measure) (Also Note: Piketty has strong feelings again the simplification of Gini, but I wanted a single index so….) I think a picture is worth many words in this case.

Picture form wikipedia: By Reidpath - The original file was on WikiMedia Commons

Now imagine ordering people along the x-axis and cumulative share of income on the y-axis (as above). If 1 person had all the income then B essentially disappear.

So we can calculate the Gini:

So if 1 person has all the income then Gini~1. If every person has approximately the same income then each increase in x is an increase in y of the same percent. In that case A~0 and Gini~0.

Sarah: London cab drivers have a significantly larger hippocampus, the brain's memory center, likely due to navigating London's 25,000 streets daily. 1.

So back to WID’s wonderful data.

There are a few countries where they have some decent data over 100 years. We can see notable impact of some key events. For example, World War II really hit many of the countries involved and pulled the rich back to the bunch. You can also see the massive jump in Russia when the iron curtain fell. So the effect of history on Gini is pronounced.

I made a couple graphs just because I could using datawrapper. They’re interactive so I just couldn’t stop myself.

Sarah: Alan, the lines are all about the same color. How can I tell which countr—Oh. Interactive. Now I get it.

These are a few countries where we have nice detailed data and can look at trends over the last 100 years. You can see the impact of World War II near 1940 and the fall of the USSR near 1990. These are just fascinating. You can also see the growing inequity in the last 40+ years.

We have more detailed data for the last 40 years which lets us look at trends in different countries over time.

Interestingly, this gives you what looks like two worlds — where over the last 40+ years the Gini Index has moved in a rather similar direction in South Africa, Central + West Asia, North America, Russia, and Europe (mostly increasing). While in much of Africa, the middle east, Latin America traveled separately (mildly decreasing).

Sarah: According to the Laboratory of Neuro Imaging at the University of Southern California, the average brain generates 48.6 thoughts per minute—amounting to about 70,000 thoughts per day. 1.

Here is a heatmap where the correlations of different regions can be observed [exact number in the box, red behaves more similar, and blue behaves more differently).

This is the binning of two primary groups (largely the G7 in the upper group —blue) and African and East Asia (red).

There is also really fun stuff by Guido Alfani where in a few cases this is extended further back in time and he also has a nice book (which I haven’t read yet) called “As God among Men”

Which got me thinking does the gross domestic product (GDP) of a country affect inequity (Gini) or is it the other way around? For this we can use granger causality and investigate if the prior year of Gini influences GDP. Which is true for a number of countries (56 of the 214 I had data on had significant i.e. would happen at random 1 in 100 attempts). Interestingly, increasing inequity was linked to increasing GDP 35 of 56 times.

But, interestingly, about 40 countries had a significant effect the other way where increasing wealth in the country effected inequality. Here GDP increase lead to decreasing Gini 28 of 40 times.

But I’m looking at the relationship over ~200 years and that’s not that helpful to what about today. So, to the rescue …. Kalman filters!

Sarah: Neural signals in the brain travel at a speed of 268 miles per hour.

To build a good model let’s go back to Picketty’s second law. β~s/g Where β = the capital/income ratio. We can use the share of capital of total GDP as a proxy for β. Back in prior centuries this was a constant of the economy as the Picketty (apparent bibliophile/cinephile) points out in his book. But that has changed notably since the emergence of the stock market and the investment class. So let’s look at these in the US:

As you can see Capital took a big hit with the great depression and inequality dropped dramatically with World War II, but both are now back with a vengeance.

A little bit of fancy math and we can actually predict Gini pretty well (92% explained) so, after the Great Depression increasing capital drove inequality and following WWII increasing GDP drove down inequality.

But these days… I got nothing! So, for our current inequality, we may need to look for something else.

Out of interest, we can look if the tail is wagging the dog. Does inequality increase GDP? Short answer is yes. Especially recently (Note: This is true over the span of our data for Saudi Arabia above — so that’s not great). This means we may be learning that the more unequal our population becomes the more it looks like our country is prospering. We also see that very often increased capital/GDP ratio also increase GDP. This is pretty concerning really. For people, Gini matters, not GDP. This means that if we look at GDP as our prosperity, it could encourage us to push more money to the rich to get that prosperity. By the way, the model is still pretty good (88% explained).

What does all this mean to me? Careful using a single number to describe a complex thing. We can chase GDP or money at our own peril (and Piketty warns that the Gini is also an abstract, sterile, and misleading synthetic index and compresses income from labor with income from capital).

After over 1000 lines of code and countless hours messing with immense amounts of data, I think I learned a few things. 1) trickle down has ‘worked’ occasionally as increasing inequality can lead to increases in GDP (e.g., 1970-1990) — if that is called working. 2) I really like playing with data and could do ten or more posts on this alone from the data. 3) I would like to pretend I learned “money buys everything, except morality and citizens” (Rousseau, First Discourse) but the actual me just thought “money can buy you many things, but money can’t buy you love” (Beatles, Can’t buy me love).

Sarah: Well, this was a whole new tour for me. But it got me thinking about the wellness of an individual and how we view our success. My area of specialty is helping physicians. It’s not uncommon for me to see a physician who chooses to work impressively long hours. They’re raking in money. They’re zipping up the leadership ladder. They appear to have everything figured out and, boy, do they know how to maximize electronic medical record efficiency.

Then why are they so miserable? The number of hours worked by a physician (or their paycheck) might imply prosperity, success, and productivity. But that productive physician might also be sad, lonely, and exhausted. Likewise, the GDP might imply success for a country while the Gini could tell another story. We need to think about what personal success actually looks like— and it’s different for different people. It’s too long for me to get into here, but here is the post on how to cultivate wellness and personal success (it’s for physicians, but it’s true for everyone.)

1. Alpert JS. A selection of fascinating facts about the brain and heart. Am J Med. 2025;138(6):921-922.

First of all: what an excellent goal. Truly. As a psychiatrist, I can say this is a good way to spend your time—creative, cognitively demanding, future-oriented, and (ideally) fun. You’re engaging executive planning, emotion regulation, narrative construction, and meaning-making all at once. That’s a rich mental ecosystem.

It’s also… a lot.

Writing a book and running a Substack are both big goals, and they lean heavily on the same brain circuitry. When that circuitry gets overloaded, things can go sideways.

This past year:

• Alan and I launched this Substack.

• A non-fiction book, he co-edited was published (It was on time. Uh. That is, on the construct of time, not that he met a deadline. Although, he met the deadline, too. I think.)

Alan: It was mostly on time. But honestly that is really thanks to Marc Wittmann, he is an expert on time. The construct of time that is. But he is actually really organized.

• Alan and I wrote a neuroscience book proposal.

• And I finished a sci-fi novel I’m about to send into the world (wish me luck).

Alan: Fingers crossed!

These are good problems to have—but they’re still sources of stress. So let’s break this down in a way that’s clinically realistic for anyone trying to do both.

Mental health and goals

I ask patients about their goals constantly. Goals tell you a lot about someone’s internal state.

No goals at all can signal depression or burnout.
Goals that are frantic, sprawling, and impossible can point to anxiety, overwhelm, or ADHD. Goals link the present to the future. That future orientation can be protective—even lifesaving.

But certain goal-setting styles almost guarantee failure.

The most common examples of problematic goals I hear around health look like this:

• Abstract goals: “I want to get healthy.”

• Planning fallacies: “I’ll exercise an hour every day,” from someone for whom a 15-minute walk twice a week would be a genuine win.

• Intention–action gaps: No start date, no schedule, no environmental cue.

Alan: Delusional: “I want to get a grant funded in this funding environment.”

Most goal failures—clinically and personally—aren’t motivation problems. They’re translation problems. The brain is terrible at converting abstract intentions (“write more,” “post consistently”) into action without concrete cues.

Vague goals live on vague to-do lists. Vague to-do lists don’t get done.

Writing a book and a Substack

A lot of people on Substack are writing books: novels, memoirs, nonfiction. Some are building visibility for publishers (“just get 6,000 subscribers”—sure). Others write because if the thoughts don’t go somewhere, they’ll combust.

Alan: A few write because they just love spending as much time as possible on projects with the love of their life.

So how do you actually do both?

The first step is identifying how your book and your substack are different. Maybe they’re unrelated (For example, this substack has nothing to do with my sci-fi novel) or maybe they complement each other. Complementing each other is fine, but they should be adjacent and separate. Your book is your book and requires privacy (so you have the freedom to completely suck sometimes). Your substack is by nature public, has an audience, and is under scrutiny.

Alan: For the record, I was complimenting you while being both adjacent and separate — if that’s not love…

If you’re writing a substack to gain an audience for your fiction book, then consider a substack that’s about the writing process, what you’re grappling with, the obstacles, the wins, the themes you like to explore. It could also be on what you’re reading or watching these days and your thoughts on plot/meaning. Lean on your expertise. For example, I have a friend who works as a security guard. They could write posts explaining the behind-the-scenes to fellow authors who want to include a security guard in their book.

I’m going to explain the next few steps using a very cheesy brain metaphor that will make Alan cringe. Hahahahahaha.

Alan: It would. So very much.

1. The neurons (the basic units)

The basic unit here is writing. And writing takes time—real, scheduled, defended time.

“I want to write” and “I should write” are not plans. They’re wishes.

Schedule book writing time. Schedule Substack writing time.

Decide:

• when you start

• how often

• for how long

• and whether it actually fits your life

I don’t write during work hours. After work, I’m tired. But I don’t go straight home. I stop at a coffee shop for one hour.

That hour is for writing. Mondays and Wednesdays might be book time. Tuesdays and Thursdays might be Substack.

Alan: She actually does this! It is crazy!

Why a coffee shop? Environmental cueing. My brain knows what happens in that space. At home, there are kids, dinner, laundry, and the dog redistributing socks throughout the house. Context matters. Don’t underestimate how much easier it is to overcome inertia when the environment is doing some of the work for you.

Alan: And they have caffeine… just saying for some of us that matters.

For book writing, this is the time to satisfy measurable goals: word counts and deadlines certainly. But also schedule working on certain domains. “Today I’m working on voice.” “On Wednesday, I’m making sure that that character is consistent across chapters.” Break out the domains (plot tent poles, character development, research, voice) and identify when you’ll be working on them.

For Substack, it means not only writing posts, but also sticking to your identified posting frequency (you should have a consistent article drop date), posting notes at a certain frequency (this increases visibility), finding your voice/brand, and learning how the platform actually works (yes, including tags).

Alan: Yes, thanks for posting. That’s not just me talking but the brand thinks so too.

2. Neural circuits (things working together)

Writing doesn’t happen in a vacuum.

Alan: They are too small and full of dust.

For book writers, you need beta readers, writing groups, conferences, and people who can tell you what’s not working—and still encourage you. A good group gives you deadlines, feedback, and moral support. You need all three.

And don’t forget to read widely in your genre.

For Substack, you need your people. The ones who comment, heart, re-stack. This is a two way street. Invest back. Read others. Amplify voices you care about. Writing on Substack is social writing. Accountability to readers—and at least one person who gives you honest feedback—matters.

Alan: Honestly, good point…. Boom! I just communitied all over your post.

How does this work in real life?

For book writing, find those beta readers. You can find them through a variety of ways. For me personally, I like in-person writing classes/groups and then look around the room to recruit readers. I went to a writing conference recently and someone stood up and announced they were looking for beta readers and a bunch of authors made a bee-line to them because they were on the hunt, too.

For Substack, in the one hour carve out, write for 45 minutes (the neurons). For 15 minutes attend to connections: re-stack, like another writer’s work (The circuitry), build the community.

3. The brain (zooming out)

“Get a book published” or “Get this # of subscribers” are outcomes, not values.

Alan: I would suggest that getting a grant funded is a value… a dollar value that is.

If the book doesn’t sell, was the time wasted? If you’re hanging in there with low subscriber counts, was it all useless? Or did you learn, connect, create, and grow?

From a mental health perspective, goals that only count if you “win” are brittle. They spike stress, invite shame, and collapse when circumstances change. Goals grounded in learning, connection, and creative engagement are far more resilient.

Write down both your external goals and your internal ones. Then ask: if the external goal doesn’t happen, am I still allowed to feel successful?

Alan and I are accountability partners. When one of us says, “This is pointless,” (usually me, by the way) the other reminds us: this is supposed to be fun. The real goal is time spent creating together.

Alan: Mission accomplished! Well, not on the grant lately, but on the substack.

A few special cases

Attention drift:
When I was deep in novel writing, Substack felt like an interruption. Commit to a schedule, not perfection. Substack can be forgiving and if you have to miss a deadline. It’s okay. Just forgive yourself and do better next time. Compassion plus structure works better than guilt.

Alan: Wait are you telling me that this post isn’t going out Tuesday?

When the muse disappears:
Inspiration is unreliable. Outlines, fragments, half-written notes—these are cognitive scaffolding. Keep them. Use them.

Imposter syndrome:
Some self-doubt is adaptive. Too much is paralyzing. When visibility feels like threat, the amygdala goes a little nuts and perfectionism can sabotage your goals.

Write the post. Write the book. Publish the note. Don’t appeal to everyone. And, certainly don’t write for an agent— that’s way too much stress. Imagine one reader (a kind friend) and write for them (I have different imagined readers for my fiction and Substack).

To all my fellow Substackers out there. You’ve got this. You can do this. And we’re looking forward to reading your work.

Now for the Brain part of Boots and the…

Alan: In my day job, I try and make games to understand how people think. One of my favorite creations is also one of my biggest failures. I called it “The Cookie Monster.” The idea was you had two doors. One was unlocked and you could grab some cookies (e.g., 4). The other started out locked but it had more cookies (e.g., 8) and if you didn’t get to it soon the cookie monster would sneak in and eat the cookies. Then you wouldn’t get any cookies.

If you try a few times and the risk/locked door does not open then you should switch. I did a bunch of math to workout the right point to switch.

My initial goal was to look at what happened in the brain by fMRI when people decided to switch. But that’s not what happened. People would choose a door and almost never switch!

Reading this post I was reminded of goalposts and how to juggle two goals. Realize when your behavior is helping you get what you want. Realize when that changes. It’s often important to think about it ahead of time and have a plan.

One of my mentors (Murray Stein) is so very very good at this. Realizing when he’s being effective. Realizing what projects to work on, and when that project is no longer the right choice.

As the resident neuroscientist, I would love to tell you the part of the brain that handles this (I would call it the Murray Gyrus). But I can’t …

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Sarah: Ah, you’re still really cool to me.

My friend Samir and I had a radio show in college. Between 12 and 2 a.m. on Friday nights, we would do our thing—usually an hour or two after the real DJs went home.

At first, it was a pretty legit show. After a while (probably after too many F-bombs by my charismatic co-host) they started changing the door code. But Samir always figured it out, and our show would go on.

We had access to the latest music. There was a box of suggested bands—Cibo Matto, Soul Coughing, and the like. Never before, and never since, have I had my fingers so firmly on the pulse of the music scene.

Sarah: And I was dating a DJ—now that’s cool!

Fast forward 30 years and I am no longer cool. I’ve been reliving the ’90s for so long that my tastes and clothing have gone from current to retro. Not cool, but retro.

Sarah: Wait. My ‘90s spaghetti strap dress, choker, and flannel tied around the waist is back?!

I no longer have access to the box of selected music. No longer a finger on the pulse. I am set adrift, needing to forge my own path forward as a reckless rogue rambling the music landscape.

When I open Spotify, I feel like my 21-year-old version of myself standing in the wine section of a supermarket: faced with hundreds of options, armed only with labels and names, and feeling overwhelmed. (As a side note, back then I bought myself a book on wine, read up on the five main aspects [sweetness, acidity, tannin, alcohol, and body], and nobly forged on to figure out my “taste.” Specifically, I learned that pinot noir is trash and that Sideways ruined wine for my entire adult life.)

Sarah: Oh, we thought we were so cool. Hosting wine and cheese nights…memories.

Eager to learn from Spotify how to understand my music, I downloaded my listening data for the last year (Well, at least the songs I could also find in a Kaggle dataset of 12 million tracks). These songs are rated on seven to nine dimensions meant to capture musical qualities. I found about 41% of my music in this list and plotted it across the year. I thought this might be a nice way to see how my music tastes actually run.

But this was just too many dimensions for me to follow. The 50-year-old version of me never fully mastered the five-factor approach to wine. Seven or more dimensions was not going to work.

Thankfully, thanks to those luminaries at Sporkful, I don’t need to. I only need three factors: forkability, sauceability, and toothsinkability.

Let’s get to it with the easiest construct to apply to music: forkability!

Forkability is the ease with which pasta can be collected on a fork, or, how easily something can be picked up. The forkability of the three Sporkful factors is much higher than that of the five factors of wine tasting. Interestingly, the forkability of the concept of forkability is higher than the forkability of the other Sporkful concepts.

For now, I’m going to talk about modern music with lyrics. I have strong opinions on jazz (I’m listening to Charles Mingus as I write this) and heretical opinions on classical music, but to understand what has changed over the last 30 years, I needed to put those on the back burner and focus on popular music.

Forkability, as I view it, asks:

• How easy is it to dive into?

• How quickly does it jump into your ear, and how much do you need to shove it in?

This can range from ABBA to Mr. Bungle. I consider music like Lana Del Rey (music you can gradually turn up without anyone batting an eye) as highly forkable. But try to subtly play Busdriver or Skinny Puppy and people will notice.

Music becomes less forkable as it becomes less predictable and contained, and more hectic. Fun fact: I once worked with Shlomo Dubnov looking at brain imaging related to this characteristic (something I really need to get back to and publish). For fun, below is my brain, where musical novelty activated my prefrontal cortex (upper hand) and anterior insula (lower hand), compared to boring changes in tempo.

I often like my music less forkable—more Mingus than Coltrane. There are many ways to operationalize forkability, but it’s a defining characteristic in how I understand and appreciate the songs I listen to on Spotify.

Sauceability is up next up, which I see as:

• The degree to which the pasta picks up the sauce

Pasta, like bread, is both the vehicle and the driver, the destination and the journey. If we see lyrics as the pasta, then they carry the music with them. As you connect to the words, the surrounding music becomes part of the listening experience.

My kids are convinced that I don’t pay attention to the music (once you see my section on toothsinkability, you can see there they’re coming from). Sauceability is where I appreciate Queen’s Bohemian Rhapsody as it shifts styles, themes, and moments, or Stevie Wonder’s Superstition, whose competing beats remind me of Mingus’s bustling style.

Toothsinkability is the last part and my personal favorite:

• How thick is this pasta, does it have substance?

This might come from a rich metaphor, like Atmosphere’s Became, or a raw emotional moment, like Johnny Cash’s cover of Trent Reznor’s Hurt. When Pink Floyd plays Comfortably Numb, they’re giving me their grief for a lost bandmate, the corrosion of drugs, the breaking of a band, and the connective tissue of a life shaped by isolation. When Coolio sang Gangsta’s Paradise, he spoke to loss, entrapment, loneliness, and self-destruction.

Sometimes I experience songs as toothsinkable if they make me feel. Sometimes they are toothsinkable because they make me think, like Lupe Fiasco’s Little Weapon or Ani DiFranco’s Lost Woman Song. At the end of the day, in music, as in pasta, as in conversations, as in life, I think it is the toothsinkability of the thing that compels me most.

I tried to link the three dimensions of Sporkful with the many dimensions of Spotify. I was reasonably happy mapping forkability onto danceability, but after that things broke down. So I did the obvious thing: I rated a random sample of 100 songs using the Sporkful framework and trained a random forest regression model to predict the rest.

Sarah: But of course! Who wouldn’t train a random forest regression model?

The models were undoubtedly overfit, and even then they only predicted about 60%, but they give a sense of how Spotify and Sporkful align. With instrumentalness matching well with sauceability and toothsinkability remaining enigmatic.

And you can see my musical taste splitting a bit into melodic on the right side and more energetic on the left (6149 songs shown).

The process of defining things is the process of understanding them. But such things come at a cost.

“The day you teach the child the name of the bird, the child will never see that bird again” — Jiddu Krishnamurti

Sarah: “My cat’s breath smells like cat food.” -Ralph Wiggum

So do we want to name it? Do we want to measure it?

In writing this post and evaluating my music, I find that measurement does not diminish my experience. If anything, dimensionality helps me see the songs more clearly. As much as I evaluate the music, I am evaluating myself. What do I find catchy? What is musically compelling? What is lyrically important?

Sarah: How else can we apply Sporkful?

In pairing my opinions with the music, I’m not rediscovering music, I’m rediscovering myself as a listener. I’m rediscovering the 20-year-old version of me who cared deeply about music.

And as I think back on what I learned from all of this, one thing jumps out immediately: in many ways, I’m still that young man, still stuck in the ’90s, and still convinced that pinot noir sucks.

Now for the Boots part!

Sarah: Reading Alan’s article got me thinking about why people reach for different kinds of music in different moments. For me personally, I’m not really a toothsinkable-music kind of listener—I might play a song a hundred times and still not know the lyrics (very tricky when I want to sing along and end up just humming or loosely fudging the words). I’m more drawn to sauceable music: songs that shape my mood, help me hold onto a feeling, or provide a backdrop for what I need to do.

Music can be a tool. It can help with the motivation to exercise and distracts from fatigue (cardio tracks tend to be 128–135 BPM; warm-ups are best around 120–126 BPM). Trying to focus on work (or writing your Substack)? Familiar or structured pieces—classical, or songs you know well—help attention stay anchored. Listening to certain music can be the key to remaining calm and centered (aim for 60-80 bpm; consider Claude Debussy’s Clair de Lune or Marconi Union’s Weightless).

Different head spaces require different kinds of music, not because taste has changed, but because needs do. Listening to music can be a valuable strategy for regulating attention, motivation, and emotion, and helps a person stay grounded in the moment.

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Sometimes, humans encounter magic. Sometimes we encounter things that simply can’t be explained by neuroscience or physics or chemistry. I’m lucky to say that I recently had an encounter with magic and luckier to say that I’ve lived to tell the tale.

Alan: The opinions described in this blog do not reflect the official opinions of bootsandthebrain (aka, “what! Are we talking magic now? Oh, I can explain magic with science — bring it”).

Last year I was very fortunate to find myself on a boat in a Norwegian fjord called Troll Fjord (Thanks for the trip, mum!). This is a very narrow finger-shaped body of water where gray craggy mountains rise up dramatically on both sides of the ship. Trolls, they say, live in the mountains.

Trolls are ancient Norse creatures—quite dangerous to humans. They live in dark mountain crevices where magic still dwells. Fortunately for us, trolls turn to stone in daylight and, as we were sailing during the time of the midnight sun, we were safe from being roasted alive on their campfire spits.

Alan: Unfortunately, around the turn of the century someone foolishly ran cable to the Fjords — forever changing the internet (source: reddit).

As we silently drifted over the dark water with the mountains looming over us, eyeing us, I began to the see faces in the craggy rocks. An open-mouthed troll in that slab of granite over there. A troll hand cupping a small birch tree in its palm here. Gray stone eyes watched from the cracks and crevices. The more I searched for trolls the more I saw—all frozen in stone

Magic descended over the boat. Passengers quieted as we trespassed on the ancient. Goosebumps prickled flesh. Cold mountain air crept around us, penetrating our REI layers.

Alan: Passengers quaking in fear of cyberbullying so cruel it classifies as war crimes.

I suppose a jaded neuroscientist would start talking about pareidolia right about now. Pareidolia is the (very common) neurological condition of finding meaning in unrelated stimuli.

Alan: Oops. I’m letting down the neuroscientists out there! So, yeah, what you said.

We find soaring dragons with large open mouths in fluffy clouds. Beautiful Madonna faces in tortillas. Fierce lions and demons in the wood grain of a kitchen table. And, of course, I can’t leave out the number one celebrity of the pareidolia world—the man in the moon.

Why do we do this? It’s suggested that humans, being very social creatures, gravitate toward seeing faces in random stimuli (interestingly, eye gaze studies suggest that rhesus macaques—also very social creatures—demonstrate pareidolia, too). The historical biological success of humans depended on a great number of things, not least of which was the need to recognize people, feel drawn to people, and to recognize their emotions at the distance greater than a spear’s throw.

Studies show that parts of the brain light up (I’ll hand this over to Alan) when a face or a face-like non-face are revealed. The recognition of a face happens at a faster speed than normal cognitive processing. So, for example, “I sense being watched. Can I see a face? Why yes, yes, I can.”

Alan: Okay, admittedly, I could write a book on the hand off. But with uncharacteristic restraint, I will just mention the fusiform area. If you put your hand at the back of your head, that’s the primary visual area of the cortex. If you slide your hand up then that’s the “where” stream of understanding. If you then went along the under surface of the cortex that is the “what” stream. That’s the fusiform area and where you get object recognition.

Pareidolia is not limited to visual stimuli. We hear human voices in music played on low speeds or in reverse. Our brains construct melodies from the white noise of air conditioning. In a cruel trick of fate, new parents hear the cry of their baby in the sound of the water streaming from the shower only to rush out and stand dripping wet and shivering on the carpet to see their baby sleeping soundly. Hearing voices, music, or seeing faces in this way isn’t to be confused with hallucinations. In pareidolia, the brain isn’t conjuring visions or sounds (hallucinations), but rather misinterpreting the world that exists in front of us (illusions).

Alan: This is not in the fusiform, but each sensory input of the cortex is layered such that the further you move from the sensory input area the more abstract the reinterpretation of the information becomes. These abstract regions can have complimentary communication.

Sometimes, the ability to see meaning in meaningless blobs is used in psychology to help with diagnosing, and to understand a person’s personality and thought processing. Some neuropsychologists—the ones who are very proud of themselves, I think— subject people to Rorschach tests. These neuropsychologists speak about this test in hushed awe-induced tones, fiercely guard the images as if they were national security secrets, and (I suspect) actually have no idea what they mean but can talk a great deal about it at great length. In this simple psychiatrist’s opinion, any information the Rorschach provides can basically be better gathered by asking a patient, “Are you depressed?”, “Do you like to set things on fire?” and “Do you hear or see things other people don’t hear or see?”

Some things, like trolls, can’t be explained by neuroscience, physics, or chemistry. Sometimes, very old and dark magic is simply the answer— at least that’s what I’m going with. The nice thing about my encounter with the Troll Fjord is that it woke my senses to other magic and from that point on, every hike I went on, I encountered fairies, sprites, and goblins (which I photographed, and will share throughout the week.) Which brings me to the boots-on-the-ground part of this post…

After going to Norway and spotting faces in the rock faces, I’ve found myself doing the same thing back home.

I’ve always loved my morning walk with Alan in the canyon. I usually make a point to pause for a few seconds and notice the fog, the sunlight catching on the blades of grass, the eucalyptus in the air. I do this because 1. mindfulness is important, and 2. because we’ve all heard (and read) that being in nature is good for the mind, body, and spirit.

But lately, I’m looking for faces too. A quick scan of the patterns in tree bark, the leaves overhead, the mud at our feet. It feels like a different kind of mindfulness—a different way of evaluating the world, and, for a moment, pushes everything else out of my mind. There’s also a game-like quality to it: you know a face is there; the fun is finding it.

So next time you’re in nature—or anywhere, really—look around and see if you can spot a face. Maybe it’s the grill of the car in front of you. Or the bubbles in the foam on your coffee. Or the way the couch cushions sag. Give your tired brain a break from its worries and to-do lists and take a moment to appreciate and see the world around you in a different way.

Alan: Okay, there is so much stuff I want to talk about here. Is it multivoxel pattern analysis? Is it deep neural networks? Attentional blink? Is it working memory? Prosopagnosia? Ahhh. Why am I wasting my precious space just listing things? Why am I wasting space asking rhetorical questions like this? Get it together, Alan.

Okay, I’m going to talk amygdala. While with vision we mostly talk about the occipital lobe/visual cortex, there are other paths and areas in the brain that handle visual information pertinent to specific information (Note: humongous simplification!). There are people who, through disease or surgery, have lost most or all of their amygdala. They retain most of their visual processing but seem to specifically loose capacity to implicitly infer emotion from otherwise accurate perception of the whites of the eyes.

This provides fascinating evidence regarding the level and complexity of the brain’s specific tuning to decoding the emotional content of faces. It makes one thing clear: at the end of the day the true magic is just how awesome the brain is….

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*Addendum to prior admittance: For the introduction, I wrote a pretentious Camus quote. But then the strangest thing happened…

I was sitting at a café with Sarah and the kids (we go sometimes because we all enjoy writing). I had written an introduction to this post and wasn’t sure it was working. So, I asked my kids to read it and give me feedback (they give excellent and unfortunately honest feedback).

Sarah: Scathing feedback. But to their credit, I take out everything that they tell me is “cringey” and I’ve never had a reader comment that our posts are cringey, yet, so it must be working.

But getting their attention was difficult. They were listening to music on their earbuds. One was playing Spooky Scary Skeletons. The other was playing Comfortably Numb by Pink Floyd. For some reason, they had interchanged the earpieces and the two of them were listening to both songs at the same time in different ears.

Sarah: They were on a mission of finding the most painful combination of music possible. Ah, youth.

They let me and Sarah

Sarah: Made me and Sarah

give it a listen. It was pretty awful. It didn’t bring me to tears but I couldn’t last an entire minute before pulling the earbuds out. There was something so much more painful about listening to a song that I embrace playing in one ear while simultaneously hearing one I couldn’t stand in the other.

Sarah: much more painful that listening to either one alone.

My brain was telling my ears to listen so all my normal gating around listening to noise was removed, and then this awful noise mashup was just allowed to gain purchase of my brain and my attention.

That being said, it made me think about the thermal grill illusion.

Our body and our brain are constantly trying to re-balance and find homeostasis. When hot, a cold drink refreshes. When cold, a hot drink hits the spot. This isn’t just at the cortical level, our body has systems that actively work towards homeostasis, too. A lovely example of this is Thunberg’s thermal grill illusion (no relation to Greta Thunberg).

Sarah: A thermal grill consists of alternating cool and warm bars. An unsuspecting person places their hand across the bars and anticipates, well, feeling cool and warm bars, but they get a nasty surprise...

When you place your hand on the alternating cool (~20C) and kind of warm (~40C) bars this gives the impression of “burning pain.”

Heat is carried by C-fibers. These are unmyelinated fibers meaning they are slow to propagate signal to the spinal cord and brain. Meanwhile, cold is carried by A-delta fibers. These are myelinated and send the signal quickly. Usually these both send similar signals and we can estimate a temperature.

Sarah: I’m going to step in and Mumsplain because I can see my Mum scratching her head right about now. Hi Mum! So what Alan is getting at is the nervous system picks up data from the environment and sends it to the brain for processing. Different nerves carry different information at different speeds.

For example, suppose you wanted to get a hold of me at work. You could text, call, email, or even fax me. Some of those methods are better than others considering what kind of message you want to get to me and how fast you need me to get it. The nervous system works a similar way. Some nerve pathways are slow and bulky (C- fibers; carry info about heat) while others are very quick (A-delta; carry info about cold).

This information is pathed up spinothalamic pathway, down the length of the insula, and finally integrated in the anterior cingulate cortex. The thermal grill messes with this system. The usual inhibition doesn’t take place because both are activated and think their message is unique and true and they hit the anterior cingulate with their competing pieces of information.

Sarah: Gonna mumsplain what Alan means by “usual inhibition”…

Normally, cold suppresses some of the sensory processing in the brain (it suppresses some pain signals). But, in this case, the heat info in the brain inhibits this normal cold suppression and a pain signal gets through. Suddenly, everything is reinterpreted as neither warm nor cool but something different.

Mum, think of it this way...if you called me to say you’re hungry and then texted me your lunch order, everything makes sense: it’s the similar gist of a message come through in different channels. But, if you told me you were full, so very stuffed, and thinking about food made you sick and then texted me a bunch of demands for raised glazed donuts, I wouldn’t think you were full or hungry. I’d get a completely different message: that you were teetering into dementia.

The normal inhibition that occurs to stop or modulate the strength of the neural signal is removed and the unsuspecting person feels burning pain. Bud Craig and Kathy Bushnell described this as “unmasking of burning cold.” Our body is always trying to get that homeostasis. Most of the time it figures out a way.

But there are moments in life when we can experience Thunberg’s illusion in other ways. It can be when you have a truly excellent song playing in your right ear and a terrible song playing in your left. It can happen when you get in a car crash and but see glass poetically scatter on the road like a thousand diamonds.

Most of the time we figure out our life through a singular experience. Our implicit homeostatic predictive systems give us a clear message. Sometimes we lose this gating capacity, and something that usually you can ignore invades your attention.

The Boots on the Ground part of Boots and the Brain…

Sarah: Many of my patients struggle with the holidays for familiar reasons: past trauma, grief, financial stress, family dynamics, and the pressure to make everything feel perfect. December can become something to endure. I often hear, “I hate the holidays.”

But the holidays aren’t simple. There can be sadness and stress here, yes—but also warmth. People tend to be kinder. Lights soften dark streets. Gingerbread smells good. Coffee shops make fun drinks. The food is indulgent.

This complexity reminds me of the thermal grill illusion: warm and cold coming together and being perceived as intolerable. But it also affords something else— an opportunity to question the reality of the feeling. Are the holidays actually intolerable? Is everything awful? Is there really burning pain or are the holidays more nuanced than that?

A mantra of “The holidays are the worst” can soften into something more accurate:
“There are parts of the holidays I don’t like (the cold bar), and parts that are okay (the warm bar).” That shift doesn’t deny the hard parts—it just keeps them from dominating the whole experience.

If you hate the holidays, get specific about why. Then ask what you enjoy, even a little. The holidays return every year. The goal isn’t to love them—but to lean into what’s tolerable or good, and loosen your grip on the rest.

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I recently gave a talk at a conference. I’d been on the planning committee for nearly a year, so the talk had taken up an outsized footprint in my mind long before I ever stepped on stage.

Rationally, I can say it went well. I forgot a few things, sure. But people seemed engaged. Fewer people were on their phones. People laughed in the right places.

And then it was over—and I was a bit of a disaster, actually.

I had a two-hour drive home and used every single minute of it to beat myself up. I should have said this. I should have said that. Why can’t I ever remember to use presenter notes? I completely forgot that one part.

I could have been better.

I could have been better.

I could have been better.

This happens after every talk, but this one was amplified. The audience wasn’t bigger than usual, but the emotional stakes were enormous because of my time investment. And if I’m being honest (and I am, because that’s the point of this post), I am embarrassingly needy after talks. I want people to tell me, “Good job.” Immediately.

Alan: This one is really good so far. So: “Good job.”

A few days later, I went to dinner with a friend—an absolutely delightful psychologist—and I told her about the post-talk spiral. She looked across the table and said, “I’m going to give you some unsolicited advice.”

My shoulders tensed. Oh no. Was she about to tell me I talk too fast? That I needed to dress better? That I should stop gesturing with my hands so much? That for the love of all things holy I should actually stick to the slide deck?

Alan: my guesses were: “Measure twice, cut once.” “Slow is smooth, smooth is fast” or “plastics.”

Instead, she said, “You need to tell your inner critic to shut the hell up.”

I sat up a little straighter. “What?”

She said, “You’ve invited your inner critic to the talk. That part of you is always going to have an opinion. But you need to say, ‘Yes, I hear you. Thank you for the feedback. But you’re just one voice—and I’m the one in charge. You don’t get to dominate the conversation.’ And then you move the hell on.”

Not to sound completely cliché, but her words hit me like a ton of bricks.

Alan: Oh, her advice was better than ours.

Suddenly, this wasn’t me being my thoughts. It was me hosting an internal meeting with a very loud, somewhat obnoxious attendee whose agenda was sabotage. And if this were a real meeting, I wouldn’t let that person run the room. I’m actually the one in charge. I’ll listen to feedback—for a while. But I also need to understand where it’s coming from.

Which brings us to the real fear: What if the critic is right?

Alan: My inner critic has an English accent so it is easier to think he’s smarter than he is.

Here’s the thing: the inner critic usually has good intentions. It’s not evil. It’s trying—very clumsily—to protect from shame, humiliation, and failure. Understanding that makes it easier to stop treating it like an all-knowing authority and start seeing it as a misguided helper.

Alan: My inner critic has an English accent and is a neuroscientist so I’m pretty sure he’s evil.

I didn’t know it at the time, but my friend was drawing from classic parts work, most famously described in Internal Family Systems therapy, but also present in psychodynamic and narrative models. The idea behind Internal Family Systems therapy is that you, the core self, manages and integrates different aspects of the self or sub personalities.

She was also borrowing from Acceptance and Commitment Therapy (ACT), which asks a very different question than, “Is this thought true?” ACT instead asks: Is this thought helpful?

On that long drive home, I realized that I had decided—without really noticing—that I might stop public speaking altogether. Not because I’m bad at it, but because the punishment afterward didn’t feel worth it.

I actually love public speaking. I love coming up with ideas. I love practicing. I love connecting with other humans. I even love the pounding heart on stage—that feeling of being fully alive.

Alan: And I like yelling at drivers that should never have been given a license. Oh, Sweetie, we are peas in a pod.

What I didn’t love was the two-hour emotional flogging afterward.

ACT would put it this way: Is allowing the inner critic to dominate the meeting helping me live the life I want? Definitely not if it leads me to quit something I love.

So I asked myself a different question: Who said this fool could carpool with me?

Alan: Who even gave them a license!

Next time, I’ll allow the inner critic to come to the talk. She can even have opinions. But she’s absolutely not getting into the car for the ride home.

So here’s the Boots on the ground part of Boots and the Brain…

The next time you’re at risk for getting pummeled by your inner critic try this things:

1. Schedule feedback:

   Give yourself a set window (10–15 minutes, max) to reflect on what you’d change next time. Write it down. When the timer ends, you’re done. No bonus rounds in the car.

2. Name the critic:

   Seriously. Give it a name or a job title—The Reviewer, The Saboteur, The Needy-Annoying One. Naming it creates distance. And allows you to manage the meeting in your mind better.

3. Thank it, then demote it:

   “I hear you. You’re voice has been noted. In the interest of time, we’re moving on.”

   There’s no need to argue with the critic or prove it wrong. Just take away the opportunity to speak.

4. Ask the ACT question:

   Instead of “Is this thought true?” ask:

   “Is listening to this thought helping me do more of what matters to me?”

   If the answer is no, you’re allowed to disengage—even if the thought has a grain of truth.

5. Change the environment:

   If rumination is your pattern, interrupt it physically. Call a friend. Put on loud music. Listen to an audio book. The goal isn’t insight—it’s not letting the critic hijack the next two hours.

6. Save the car ride:

   Make a rule: the inner critic doesn’t get to come home with you. No carpooling.

The Brain part of Boots and the Brain…

Alan: I’m going to let down the neuroscience fans out there and not talk much of the brain today. But, when I was in graduate school I was given the chance to specialize in all sorts of therapy, psychodynamic, cognitive behavioral, behavioral therapy, etc.

I choose Gestalt Therapy. Why? Gestalt Therapy focuses on the current moment, and how the body feels. It focuses on the concepts of self and these are all good reasons on why I choose it, but I’d be lying if I said that’s why I picked it.

It was the empty chair.

In Gestalt Therapy, you’re supposed to imagine putting a person, problem, thought, concept into a chair and talk to them/it out loud.

I thought this was going to be hilarious.

But in honesty, it was really uncomfortable for me as a therapist to ask people to talk to an empty chair. This discomfort seemed to add to the emotional impact of the moment. The whole chair thing actually worked really well to thoughtfully inspect a situation.

One thing that Gestalt focuses on more than ACT is body awareness. In Gestalt, when you’re addressing a thought, it’s common to also focus on what your body feels and what it does regarding this. I should point out, however, that Gestalt doesn’t give you a skill set or a road map like ACT.

I really like the idea of focusing on the body. I’m from the William James school of thought that the way our body feels comes first and the emotion follows. I like the idea of addressing the body state as soon as possible in order to short circuit those responses by early attention to the body (like interoceptive exposure therapy).

But, back to Sarah’s point, one important thing to know: when you put your inner critic in the chair, it doesn’t mean you can take the carpool lane.

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I dislike sleep.

I work with a number of people who do research in sleep. They are lovely people. But sleep? Sleep is lame. I find it extremely unproductive and immensely uninteresting.

Sarah: I find it quite noisy…when you sleep, that is.

I’ve never gotten anything accomplished during sleep — it’s the nefarious time loss that regularly steals from my life in a forgettable mist of mental numbitude — like a departmental meeting.

Sarah: Window rattling. Honestly, it’s like a chugging locomotive is in bed next to me.

Compared to many people, I don’t sleep much — but I still lose 4-5 hours a day on a regular basis.

Sarah: The roof loses 4-5 shingles a night…

But, as much as I would like to eradicate all sleep (and organizational meetings) from my schedule, I can’t. I’ve come to terms with many bodily limitations — eating, drinking, breathing — as necessary to provide exogenous material needed to maintain functioning. But sleep is different. First, it takes a lot of time (and, if I spent 4-5 hours eating, I’d be really frustrated). Second, it doesn’t seem to provide an exogenous resource to the body.

Sarah: It’s an exogenous resource to my ears.

Why is this temporal yoke so unavoidable? The lovely sleep researchers that I talk to would give you a lot of science about this (really, they are some of my favorite colleagues) but between you and I, I like to think about sleep in terms of grocery shopping.

Sarah: I like to think about sleep in terms of the Noise Reduction Rating (NRR) of various earplugs.

At my local grocery store — let’s call it von Ralpherson’s — at a certain point in the evening they shut the doors but the workers are still working hard. They’re re-organizing, re-shelving, and cleaning. Some of this they do during the day but the shoppers get in the way. So, it’s at night when things are calmer that the real work can be done. It’s not like VonRalpherson’s can just shut the doors in the middle of the day to do some re-shelving. If we were to observe the worker’s movement at night, we would see that they phasically engage in different activities be it cleaning or restocking.

Sarah: This reminds me of some very cool studies showing the connection between sleep and learning. People were tested on remembering certain word pairs 12 hours after learning them. If they had slept during the 12 hours, they had better recollection than the people who stayed awake. I always liked the idea of learning something before bed knowing it was more likely to stick. I’d wake up the next morning and congratulate myself on a job well done. And now I also have a fun image of my little von Ralpherson homunculus worker unpacking the info and storing it on my brain shelf.

If the night crew skips a night the store is going to be fine. But the longer their vital work doesn’t occur the worse the store operates during the day. Similarly, when I’ve skipped a few nights of sleep I tend to notice little things — usually visual illusions of parallel lines of light appearing to move.

Sarah: By the way, a common visual hallucination from sleep deprivation is seeing dark shadows or shapes out of the corner of your eye.

But I can write a grant despite some minor visual illusions so it’s no biggie. But if I were to stretch longer and longer without sleep then the symptoms would start getting more and more invasive.

Sarah: like seeing people or animals, hearing voices, and maybe even feeling a hand on your shoulder—this is what happens after more hours of sleeplessness.

Phases of sleep are often separated into REM and non-REM sleep. These phases have characterological frequencies as measured by EEG (see the handy dandy table).

Recent research has indicated that we can also have localized micro sleeps. This is especially true for those in sleep deprivation states. Unlike sleep that occurs at night, this is transitory and localized. Think: “spill on aisle prefrontal cortex.”

Sarah: Well done, Sweets. Nice line!

So, if the re-stocking and cleaning needs to happen then the body does what it has to when it can. It throws down a few cones and may disrupt a couple shoppers but not for long. But it’s not really a sustainable situation.

Which brings me to Trader Joe’s™. Trader Joe’s is always stocking during the shopping day. I know this is to make sure that if shoppers need any help an employee is usually nearby. But I see this as something more. I would like to think that this means that people at Trader Joe’s don’t need to do so much in the night shift. I’d like to think that means all of the lovely employees at Trader Joe’s can go back home to their loved ones/puppies/kittens. I aspire to be Trader Joe’s: my brain will provide me optimal customer service but mostly also because I hate to sleep.

Sarah: And I’d buy all your colleagues earplugs.

Time for the Boots on the Ground part…

As a psychiatrist I treat a lot of sleep difficulties. Desperate, exhausted patients beg for sleep medications to get a night of blessed relief. Unfortunately, sleep medications are not that great and aren’t the first line of treatment. Why so problematic? They’re often not effective, or they’re too effective (still around for the morning commute), or create dependence resulting in nasty rebound insomnia when trying to go medication-free.

The primary treatment for insomnia is sleep therapy otherwise known as CBT-I (Cognitive Behavioral Therapy for Insomnia) and features the following elements:

• Sleep restriction: Match bed time to sleep time; Awake, but lying in bed? It’s time to get up.

• Stimulus control: The bed is a powerful visual cue for sleep; avoid doom scrolling, eating, TV, or reading between the sheets to retain the power of Morpheus.

• Cognitive restructuring: Exploring and challenging unhelpful sleep lore—there’s some interesting concepts in this one that’s too much to expand here. Future post, I think.

• Mindfulness strategies: Be here and now, let go of the day, and sleep acceptance

CBT-I is great for both improving sleep quality and quantity. Like all types of therapy, it’s most effective if delivered by a trained therapist and takes about 4-8 sessions.

Pleasant dreams!

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