- Welcome to the Huberman Lab Podcast, where we discuss science
and science based tools for everyday life. [upbeat rock music] I'm Andrew Huberman, and I'm a professor of
neurobiology and ophthalmology at Stanford School of Medicine. Today, my guest is Dr. Paul Conti. Dr. Conti is a psychiatrist who did his training at
Stanford School of Medicine, and then went on to be chief resident at Harvard Medical School. He now runs the Pacific Premier Group, which is a collection of
psychiatrists and therapists focusing on solving
complex human problems, including trauma, addiction, personality, and psychiatric disorders. Today, we discuss trauma in detail and the therapeutic process in detail. For instance, we discuss what is trauma? How do you know if you have trauma? Dr. Conti shares with us, for instance, that not every experience
that we think is traumatic is necessarily traumatic and yet many people might have trauma without even realizing it. We also talk about the
therapeutic process generally, for instance, how to pick a therapist, how to best approach
and go through therapy and how to evaluate whether or not therapy and your relationship to the
therapist is working or not. We also talk about self
therapies because we acknowledge that not everyone has access
to or can afford therapy. And we talk about drug therapies, for instance, antidepressants,
antipsychotics. We talk about alcohol, cannabis, ketamine and the psychedelics,
including psilocybin, LSD. And we talk about the clinical use of MDMA and what the future of that looks like. The reason for bringing
Dr. Conti onto this podcast is because I see him as the person who has the greatest and most
holistic view of therapy, trauma, drug therapies, talk therapies, and how self therapy and work
with others can be integrated for both healing and growing
from difficult circumstances. Dr. Conti is also the author
of an exceptional book, entitled "Trauma: The Invisible Epidemic, How trauma works and how
we can heal from it." That book describes trauma and its many features and many tools, some of which we discuss
on the podcast today. So whether or not you have trauma or not, by the end of today's episode, you will have a much deeper understanding about what trauma is. In fact, I'm confident
that you will gain insight into whether or not
you have trauma or not, whether or not people close
to you have trauma or not and the various paths to
recovering and indeed growing from trauma that we can all take. As you'll soon learn Dr. Conti is an exceptional communicator
and has a unique window into the trauma and therapeutic process that I know that all
of us can benefit from. Before we begin, I'd like to emphasize that
this podcast is separate from my teaching and
research roles at Stanford. It is however, part of my desire and
effort to bring zero cost to consumer information about science and science related tools
to the general public. In keeping with that theme, I'd like to thank the
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with Dr. Paul Conti. Paul, thank you so much
for being here today. - Thank you so much for having me. - I've been looking forward to this and I've received a ton
of questions about trauma, about therapy, about how to assess
where one is in their own arc of problems and addressing familial issues and relationship
issues and so forth. If we could just start off very basic and just get everyone oriented. - Sure. - How should we define trauma? We all have hard experiences. Some of them, we might
ruminate on more than others, but what is trauma? - To make the definition relevant, I think we have to look at
trauma as not anything negative that happens to us, right? But something that
overwhelms our coping skills, then leaves us different
as we move forward. So it changes the way that
our brains function, right? And then that changes evident in us as we move forward through life. - So how do we know if
we have trauma or not? I've heard before everyone has trauma. For instance, I've heard that if we are a child
or when we are a child and we request love from
a parent or attention from a parent, if they dismiss us that
that's a microtrauma, is that overstating or unfair
to the real issue of trauma? Do we all have trauma? What are micro traumas? What are macro traumas? - Right, I think traumas that we might categorize
as disappointments, right? Or things that are are negative, but not deeply impactful, I think is not a helpful
definition, right? I think the helpful definition
is something that rises to the magnitude of really
changing us and something that we can see both in how we behave. We can see it in mood, anxiety, behavior, sleep, physical health. So we can identify it and we can also see it in brain changes. So the fact that we become, say more hypervigilant, right? More vigilant, and then we can see that
different parts of the brain are more active. So that definition, that definition captures how trauma, if it rises to a certain
level, like what we would say, trauma that makes a post
trauma syndrome, right? Leaves us different, I think is the helpful
definition of trauma because it's a clinical definition, right? It's changes in us as people and we can map those changes to identifiable shifts
in our brain function. - So how do we know if we've
been changed by something? I mean, I can think
back to childhood events where some kid on the playground or in the classroom said something, I didn't like, something
negative about me. I think most people can do that. We have a great memory for the kid that said something awful, or the parent or teacher
that said something awful that really felt like it hurt
us or at least stuck with us. So clearly one's brain, my brain in this example has been changed by that event such that I remember it, but how do we know if something has actually changed the way that we are? Because of course we don't
know how we would be otherwise. - Right, right. - That's difficult, right. It's doable, but it's
difficult because the response, so if the trauma rises to the
level of changing our brains and I don't just mean, like
we have a new memory, right? So we can have memories of something that was negative, right? And in that sense, it changes the brain because now there's something we can call to mind, but it doesn't change the
functioning of the brain, right? If trauma rises to the level of changing the functioning of our brains, then there's almost always
a reflex of guilt and shame around the trauma that can lead us and often leads us to bury,
right, to avoid it, right? To feel that now there's
something negative inside of me and it feels shameful or it feels like no one
else would accept it, right? So, what happens is people tend to avoid looking at the change in them, which is exactly the opposite of what needs to be done, right? The idea of in a viral pandemic, right? We want to stay away from one
another and isolate, right? But with the trauma epidemic we need, we need to communicate with other people. We need to communicate and
put words to what's going on inside of us. And very often a, a person knows, I mean, I've done so much clinical
work over about 20 years, that has focused on trauma. And a lot of the times
the person knows, right? But they're not admitting to themselves because they're afraid of it, right? They don't know what to do,
but if they start talking, then they'll talk about
the event or the situation. It could be something acute, or it could be something chronic, that really has been
harmful to them, right? And then they feel different afterwards. Like, oh, after that, I started thinking differently,
feeling differently, but that doesn't always happen. Sometimes it's a process of exploration through dialogue, right? Whether it's written
or whether it's spoken of the person, so of exploring the changes
inside of themselves, maybe changes to their self-talk inside, changes to their thoughts about the world and whether they can navigate safely and readily in it. And you know, it anchors
as I talk about this, the example I'll use at times
is the example of my own life, where, you know, when I was much younger in my early twenties, my younger brother took
his life by suicide. And the response of guilt and shame and hiding all of it inside of me was, it's very dramatic, but I wasn't acknowledging it, right? 'Cause I didn't know what to do about it. And I felt guilty and I felt
responsible and I felt ashamed. So there was an avoidance inside of me. And then I wasn't saying to
myself, hey, before this, like you thought that
you could be effective and you could make your way in the world. And you know, if you were a
good person and you worked hard, you could make a difference, right? And then afterwards, I
thought, I can't get anywhere. The world's against me. And I felt like, oh my,
my options are all gone. And you know, I was like 24 years old, right? So, I didn't see that
the change was in me, but I was taking care of myself poorly. Like there was enough
going on that was unhealthy that I couldn't avoid the
realization that like, hey, I'm different now and in
these ways that are automatic. My reflex to, can I make
my way in the world? Can I have a good life? Can I be happy? My reflex is to that we're all different. And they were coming through
the lens of heightened anxiety, heightened vigilance, a sense of guilt, a sense of shame and a
sense of non belonging in the world and was ultimately good and
helpful people around me and my own realization. And hey, things are not going well, right? That led me to then get some help and to be able to talk about it and realize like, oh my gosh, I need to face these things that are going on inside of me. - From a psychoanalytic psychological, and maybe even a neuroscience
perspective, two questions. Why do you think that
when we experience trauma, these things that we call
guilt and shame surface? Everything you're telling
me is that in the end, that's not adaptive. - Hmm. - [Paul] Why would we be built that way? - Right, right. - So that's the first question. And then the second question is, how should we conceptualize
guilt and shame? I think that we hear guilt. We hear shame. How should we think about it? I mean, those emotions must
exist in us for some reason, but in this case, it seems like they, they don't serve us well. So maybe it that order
or in reverse order, what is guilt, really? What is shame really? And why is it that we seem
to be reflexively wired to feel guilty and feel
ashamed when that's the exact opposite of what we need to
do in the case of trauma? - Right, right. No, I think these are great questions. And I don't think anyone
knows the answers for sure. But my read of all of that
is that there's something adaptive that has happened in us through evolution that
now becomes maladaptive in the way we live in
the modern world, right? So if you think of through
most of human development, people weren't living that long, right? And the idea was to survive and reproduce. So, traumatic things that happened to us, it would make sense for
them to stay with us, right? So if you ate a new food and got really, really sick, you better
remember that, right? If you see someone from
the group of people, a couple miles away, right? And one of those people
attacks you, right? It's like, you better remember that. So, the traumatic things that are sort of emblazoned in our brain are built to last, right? Things that are positive will generate some emotion inside of us, but things that are profoundly negative are much more likely to stay with us. And I think that that was adaptive, right? When all of that was
about survival, right? And I think the same thing is
true with say shame, right? So I think here, it makes
sense to talk a little bit and actually I'm interested
your thoughts about this, right? That the limbic system, right? So the system often is called
the emotion system, right? In our brains has actually of course varying function, right? And one aspect is affect, right? So affect is aroused in us, which I think the meaning then is it's created in us
without our choice, right? So if we're walking down the road and someone jumps in front
of us or pushes us, right? Then there's a response
of fear, anger, right? Heart starts beating faster, more blood to the muscles, we're getting ready to fight, right? Or run, right? And then we become aware of it, right? So, the aroused affect in
us is also about survival and it has a very deep impact upon us and shame is an aroused affect. So it can be raised in
us without our choice and it's very powerful, which if you think about that is an extremely strong deterrent, right? So if you had, you know, imagine a tribe or a
group of people, right? That are sheltered
together, and, you know, someone eats half the food
at night or something, right? And like there's a very
negative response, right? And that person feels shame
because shame is so powerful to control behavior, right? So the way that trauma
can change our brains and stay with us in a way
that says, be more vigilant, look at the world in a different way, act more defensively, right? And how that links to shame and to guilt, and then guilt in, guilt becomes what gets
called feeling technically where we relate the aroused
affect to ourselves, right? So, shame the aroused affect and guilt, the next step, right? When the shame gets related
to self are such profound behavioral interventions
and deterrents, right? That you can see, I think how evolutionarily
kind of all makes sense if we're fighting for survival and we're an elder statesman
if we make it to 20, right? This makes sense. But it doesn't make sense in a world where we live much longer, right? We navigate in all
sorts of different ways. And there's so much coming at
us that can be traumatizing. I mean, if you think
about the news, right? I mean, how many times have
I written a prescription for someone that says no more news, right? - You've actually written
those prescriptions? - Oh, yes, yes. So glance at the news,
look at the news for news, anything going on I need to know, right? But what are people doing is looking at it and they're clicking and they're clicking. And there's a sense of
being like enthralled in a very frightening way with the horrors that are in front of us. And it shows how yes, trauma can come through acute
things that happen to us. Trauma can come through chronic
things, chronic denigration, whether it's based upon
socioeconomic status, immigration status, race, religion, sexuality, gender identity, these
chronic traumas, right? Of being denigrated by
the society around us, or treated as less than
can change the brain. But vicarious experiences can too, right? And we know this is not theoretical. We know that the changes in the brain can come from vicarious experiences too, which is why people who
are glued to the news and then feeling like, oh my goodness, like what is happening? The mothers in the Ukraine who've lost babies in the war. And like, there are things
that are so terrifying that if we spend so much time with that, it has a similar effect. So our brains are built
to change from trauma, but not in the way we experience trauma and not in the way that we live life in terms of the nature of living life and the duration of life
in the modern world, where these traumas that happen to us are often so bad for us because they change how
our brain is functioning. And then our entire orientation to the world is different and that could be for, years and years and decades and decades. It brings so much misery and suffering and at times it brings death. If you think about a hundred
thousand overdose deaths in this country in a year, 100,000, I mean where is a, so much of that arising from
is a person who's treated addiction very intensively
over many years. I think that, well, I feel sure that the majority of addiction that I see and treat arises, ultimately the roots of it are
in trauma and are in trying to soothe something that's
stuck inside that the person isn't letting outside because
of the guilt and shame, but it's running around in their head and tormented by it. And now there's a pool for, for these drugs or sometimes
medicines to soothe. So, the opiates that were given after
a minor surgery, right? Are like, okay, yeah, they help the pain for the minor surgery, but what they're really helping
is the pain inside, right? But that very quickly turns
into addiction, danger, risk. And we see that over and over again and not in a theoretical way. Like I see that in people
who have been in my practice with addiction, arising from trauma who have subsequently died. So it's sort of, writ
large in our existence, in the modern world. - Incredible to me that
this is the way it works. What I mean by that is this idea that I've heard about before. I think it was a Freudian concept of a repetition compulsion. - Yes. - That this is what boggles my mind, as I'm hearing this, something happens to us or we
observe something traumatic. And instead of acknowledging that and trying to distance from it, there seems to be a
reflex of shame and guilt in many cases and stuffing it away and then a repetition of behaviors to continue to try and just stuff it away. - [Paul] Yes. - Like you're trying
to pack, I don't know, recently I was packing a home
and trying to get a sleeping bag back into the bag. it seems like it's always
trying mushroom out the top, this kind of thing. It takes a lot of ongoing effort. And at the same time that
if this thing really exists, this repetition compulsion, people will return over and over again to the kinds of scenarios
or at least the kinds of emotional states that
look just like the trauma. - [Paul] Yes. - Or resemble it in some way. So the question I have for you is, is the repetition compulsion a real thing? And why would we be wired that way? My understanding of this
concept of the repetition compulsion is that we all
want to solve our traumas. - [Paul] Yes. - And it allows us to put
ourselves into micro or again, macro versions of that
over and over again. We get to run the
experiment again and again. - Right. - In an attempt to solve it. - Right. - In the case of taking a drug that it's clear certain
drugs like opioids, it's clear how that would not allow us, to deal with it, right? - [Paul] Yeah. - It's just masking the emotional state. But why is it for instance that somebody who experiences sexual trauma, then places themselves into circumstances of more sexual trauma? Why is it that somebody who
is in an abusive relationship goes on to have a second and
third or fourth verbally, or physically abusive relationship? Yeah, I mean, on the
face of it, you just go, that makes no sense. And yet we see this over
and over and over again. - Yes, the first thing I would say about the validity of the repetition compulsion concept, right? Is a strong yes. Like, yes, we see that over and over. It's not necessarily in everyone, but boy, it is in a lot of people
who have suffered trauma. And I think there's a very
good reason on the face, on the surface of it, it's
like, it makes no sense. But then if we think,
well, how does the brain, how does our brains
actually function, right? We're sort of trained at
least in Western society, I think, to think of ourselves
as logical creatures, right? That like, oh, we're logical. And ultimately everything in
us can just boil down to logic. And if we think about it enough, we're going to understand how
to make the right decisions, which is completely not true, right? The limbic system, right? The emotion system so
to speak inside of us always Trump's logic, right? If you think about, does it ever make sense to
run into a burning building? I mean, logic says no, right? But if someone you love is
in the burning building, people run right in, right? Because the limbic system says, yes. So when logic and emotion
come head to head, emotion wins all the time. If emotion is powerful enough, it will always win. And so the limbic system is
so important and the limbic system does not care about the
clock or the calendar, right? And that's the answer. And also, say why to the repetition compulsion. So the limbic system doesn't know like, oh, it's now, it's today. It's may, it's 2022. It just doesn't care at all, right? So how I would relate that
to the repetition compulsion is when people are repeating, what they're trying to do is
to make things right, right? With the idea that if we
can repeat the situation and make it right, it will
fix everything, right? Which makes perfect sense if we think, well, where is that
concept coming from, right? It's coming from the
emotional part of the brain that wants relief from
suffering of the trauma and does not understand
the clock or the calendar. So if I can solve something now, I will also solve something
in the past, right? Which is why I can't
tell you how many times I've sat with someone and say, we're starting to do therapy, right? And a person will say, oh
gosh, like I know, look, you just can't help me, right? I mean, you know, my last seven relationships
have been abusive, right? And I'll say back something
sometimes like, well, if you tell me that you've
had seven relationships that have been abusive in different ways, I'll agree with you. Like, I only say that, 'cause that's never what
someone says, right? But I think what you're going
to tell me is you've kind of had the same relationship seven times. It's not seven things, it's one, right? And that's always, I
don't think one time yet that has failed to be the case. And that's how, so if you think about it, that's how we start to
elucidate what's going on. So they make the light bulb that goes off. Like I have not had seven
different abusive relationships. I have had one that I
have repeated seven times and now we start getting
to what's really going on and what needs to happen, that person needs to face
what happened in that original abusive relationship and it always comes down to
the same sort of concepts, of the person feeling terrified while the abuse was going on, feeling guilty, feeling
ashamed, feeling like, oh, they brought it on themselves. They deserve it. They don't deserve anything better, right? Because the brain is trying
to make sense of it, right? Or I thought I could make that
okay, but I couldn't, right? And then there's more
guilt and more shame. And if that's stuck inside of someone, like that's bundled up inside of someone, like a medical abscess inside a person, a walled off infection inside the body, this is the same concept in the brain, then of course the limb system
is going to want to fix that. And it fixes it by trying to
let's recreate that situation and make it right this
time and that's, I mean, I think that one of the best examples of how the right approach of
how like, let's look at that, let's talk about that, right? What's really going on there,
wait, who should feel guilty and ashamed is the person who is a abused or the person who is abusing, right? And we can get it what's
going on inside the person. And that's what changes that. And then the eighth relationship
can be entirely different than the first seven, right? And I see that all the time. I mean, this isn't esoteric or soft. Like I see that play out
clinically over and over again. And why do things get better? Because we go to the
trauma and we unlock it. It's not hidden inside where
it can control things, right? We bring it to the surface and we can take away its power. - I keep hearing in this narrative that so much of our
reflexive response to trauma, both emotional and in the
repetition compulsion in terms of behaviors is about
some very deep attempt to change the past. - Yes. - And in fact, in an offline conversation, I recall you saying
something about this, that, the number of behaviors
and thoughts and avoidance of behaviors and avoidance of thoughts that human beings put in to trying and change the past. - [Paul] Right. - Is remarkable and eerie and maladaptive, it sounds like. - [Paul] Yes. - And that really stuck with me because I think we all want
to feel like we're in control of our future and how
we feel in the moment. And to some extent, it
works for a brief while. There's this thing that
happened and it's just, it evokes some internal arousal
and then you have to know what to do with that arousal. And I think for many people, including myself, there's
this fundamental question. Okay, the thought about the
thing, the event or events, plural, evokes this arousal, this internal states, makes some people feel sleepy and exhausted. Other people feel really anxious. Other people feel angry. I mean that arousal has all
these different dimensions as you know, and then there's this question
of like what to do with it. - [Paul] Yes. And I'd love to hear a maybe even just a top contour prescriptive of
what do I, what does one do? I'll even just put myself
in it, what do I do? So I'm feeling upset about something. Should I feel like my options
are healthy catharsis. I could tell the story, feel it. I could. I can pack it down. We hear that it's bad to pack it down. But of course one has
to be functional in life and deal with things. And we have responsibilities at work and relational responsibilities, etcetera. We need to sleep at night. So catharsis, healthy catharsis, packing it down at the other extreme. Telling the story. And yet I think a lot of people
are afraid to tell the story because in that telling there is perhaps a
reemergence of the arousal. - Yes. - The arousal can become greater, I mean. - Yes. - Is that what people mean when they say things are going to get
worse before they get better? I mean, so I guess, the simple version of this
long-winded question is, it's clear we need to
confront these things. We can't change the past by, a reflexive response isn't
going to do that efficiently. And so how do we deal with arousal? How does one take what they feel inside about something shameful? What do you do with it in a moment? And does that have to be done
in the presence of a skilled trained therapist or
as I'm driving to work in the morning and something comes up, I can't deal with this
right now comes to mind, what do I do? Do I deal with it right then? I know this is a big
multidimensional question. - Yes. - But I think it's the one that a lot of people grapple with. We want to deal with things. How do we deal with that internal arousal? - Yeah, yeah. We so often try and change
the trauma of the past in order to control the future and what that really adds up
to is the trauma of the past dominates our present, right? And it doesn't have to be that way. And remember, we're talking about traumas that rise to the level
of changing the brain. So as you're saying, that involves re-experience,
it involves hyper vigilance, increased arousal. It changes in mood states, changes in anxiety, changes in sleep, changes in behavior. So these are all changes that in a sense, push towards dominating
our present, right? And then we're not really
living in the present, right. As we're trying to control the future. We're not going to do a great
job of controlling our future if we're not really living
in the present, right? And so the way to come at
that again in the moment, if we're saying, okay, in the moment, if I need to fall asleep, right? I might say, okay, let me try
and put that out of my mind. Let me try and thought redirect. So there's short term
strategies that can let us be functional in the
context of these changes. But the answer is to go look
directly at that thing, right? Look at that trauma, explore
that trauma, and sure. That can be done with a professional. And sometimes that's what makes sense, but not always, right? Sometimes it can be done by talking to another person, right? Writing it down, right? Look at what's going on inside of me, that my mind is so stuck to this. Let's explore that because
it's almost as if we're, we're so afraid, so often of looking at the
trauma that has changed us, that we'll look anywhere. But at that, right? It's like hidden in a closet and we'll shine the light everywhere else, but we're not going to open that door. And that's where people will say that same
as I've heard over and over. And I myself have thought
this at times like, oh, if I talk about that, I'm going to start crying
and never stop, right? Or I'm going to just fall apart, right? Which is never what happens. No one ever starts crying
and never stops, right? What ends up happening is when the person puts
words to it, right? It could be in writing, it could be talking to a trusted other or with a therapist, right? Things start to change. I mean, just the fact that
you can talk about it, you can put words to it and other people don't recoil, right? I mean, how many times has someone said something for the first time, right? And when they're telling
me about the trauma, there's such an anxious, like looking like as if I'm going to be, I'm going to recoil from it, right? Meaning I'm going to
recoil from them, right? And then there's a sense of
surprise if the person says, well, you know, I was abused by this coach when I was a kid, right? And there's not a, okay, there's not a response of recoiling. You can see the change and
people will say a lot, like, wow. Like, I can't believe like you can like, hear me say that and
be okay with it, right? I mean, so you think about
what's going on inside of them. Like how, what a sense
of shame, a sense of, this is something awful about
me for people to recoil from and it's just not true, but here's where trauma
is, it's insidious, right? And it's pervasive, right? Because if that convinces us
to continually hide it away, then how do we explore it? That example of the person who says, okay, I was abused by a coach
when I was a child. I mean, I'm thinking of a
couple, very real cases, right? People that I've taken care of. And once they start talking about it, then they start talking about how, , they were just innocent kids, right? And like, they didn't know. And like, they really
wanted to be on the team where this coach was
treating them as special. And now they can look at
themselves from the outside, right? They can look at themselves like they would look
at someone else, right? You think it's so easy for us
to see what's real and true, if it's someone else, right? If you ask someone, what do you think of someone
who's 10, 11 years old, who's abused and manipulated
and abused by an adult? And you say, oh my goodness, I feel compassion for that person, right? But if it's us right then, oh no, it's guilt and shame and
we have to hide it away. And when the person starts looking at it, they can sort of see it from the outside. And it starts to take the
energy out of it, right? Then, well, who should
feel guilty about that? Who's done something wrong? And like, so now the
conceptions come together, which is often a reflexive,
that was my fault. Oh, I did it. I went back to it. I still stayed on the team. I went back next season, right? I let it happen again, right? All the guilt and shame inside the person gets juxtaposed to like,
what really happened there? And then they say, right. I was a terrified child, right? I didn't understand at all. And they can come to
a place of compassion. And now we are working
against the guilt and shame. And if the person cries about
it, then it's great, right? I mean, crying is one of the best coping mechanisms we have. It doesn't hurt us. And it lets us grieve things. Yeah, we can't grieve if there's guilt and shame inside of us, it just blocks grief, right? We have to, there has to be a clean slate in a sense in order to feel sadness. And then you see that it
shifts from anxiety, anger, and frustration, usually
directed towards the self, the guilt and shame towards, towards being able to process
it and being able to bring to bear some compassion
and being able to direct the negative emotions, so to speak where they're
warranted and my goodness, the changes that happen. I mean, it's not like people
are miraculously cured, right? But it's remarkable how
just getting it out there and having like one hour
of talking like that, like what we're talking about now can leave a person
feeling immensely better. - It seems to me in hearing this, that there's this weird
wiring that we have, because what I'm hearing is
when traumas happen to us or we observe them, what we need to do most
is to confront those and the emotions around that directly. - [Paul] Yes. But instead our system
defaults to guilt, shame. - [Paul] Yes. - And trying to hide it. - [Paul] Yes. And this repetition
compulsion of placing us back into things similar to those traumas. Or even maybe even worse traumas. - [Paul] Yes. - In an attempt to resolve it. It's like the most maladaptive. - [Andrew] Wiring diagram. I could possibly think of. - Yes. - Emotional and presumably physiological wiring diagram. - [Paul] Yes. And this notion of trying to change the past by doing things now, when the exact opposite is
what's going to be beneficial also seems like the complete, the whole system seems
completely backwards. And I'm, I'm chuckling as I say this, not because I'm amused it's
because I'm just baffled once again at how our wiring can
often not serve us well. But it raises an, what I think is an important
and interesting question, which is earlier, you
were talking about how people will seek out media
that's really disturbing. They'll traumatize and
re-traumatize themselves on a daily basis. So that could be viewed as
the repetition compulsion or the person will have
the same relationship with seven different, same abusive relationship
with seven different partners in sequence seems terrible. And yet, as I say this, it also is becoming clear
to me how this almost seems like a poor, but desperate attempt to resolve it in some way. - Yes. - And so the fork in the road,
if I understand correctly, is to really get to the seed incident, really get to the thing
that started it all, as opposed to repeating it all. - [Paul] Yes. - Does that have to be done in
the presence of a therapist? Is there a benefit to
taking a walk and thinking about these things,
breaking down and crying, if that's what's necessary
or feeling angrier, if that's what comes up? The reason I ask it this
way is because I worry, I'll just speak to my own experience, I worry that in reactivating or touching into the
emotions around something that is itself a form of
the repetition compulsion, because you're feeling it all over again. - [Paul] Right. - You're not seeking out
something to evoke that feeling. So I realize this is a little bit of a circular argument, right? Or question. But I think it's one that
I really struggle with in trying to parse all the, the outcome based
therapies that I hear about and the recommendations that people make. I mean, how should we conceptualize this? Something happens. Sounds like we need to deal
with that thing directly. Do we need to do that with somebody else? Can we do that on our own? If we're, we don't have resources and
we have to do it on our own, can't hire someone, can't
pay someone to work with us. - [Paul] Right. - How do we do that in a way that isn't retraumatizing ourself in a major way, or in a minor way. How do we know where we
are in that landscape? - Right. Again, those are, I
think, great questions. And I think it starts
with real introspection. When things are bouncing
around in our minds, often, it's very, non-productive right? It's the same thing over and over again, and that's not helpful for us, right? So there's an idea which sometimes gets called an observing ego, right? The ability to stop and look at what's going on inside of ourselves. And so if we're just thinking about it and we're thinking in the same way, we sort of, in a sense,
always think about it, then all we're doing is
reinforcing the trauma, right? But if we can distance
enough to be like, huh, it's, I'm interested in what's
going on inside of me, right? I can think of a certain person who really loves music. I mean, and at some point
in our therapy work, I learned like she was taking long drives, but the, the radio wasn't on. And I was like, well, what what's going on, right? And I asked, and what was going on
is she was running over and over again in her head, like, I'm a loser, I'm a loser, right? And she didn't want the music
on because the music would drown out what she felt she
had to say to herself, right? And it was that like, wow,
that's interesting, right? And then her ability to
observe that and to think, why am I doing that when
it comes into her mind? Like, what does that trace to,
when did I start doing that? Like I say, you know, I'm saying it for a point
of exaggeration, we're like, nobody comes out of the womb programmed to think I'm a loser, right? So we don't think that
when we're born, right? So where does that come from? Then, we can think in ways that allow us to have new thoughts, right? That we weren't having, It's not just bouncing
around in our minds. And if we speak or write, there are even more mechanisms that come online in our brains, right? That are then sort of
monitoring mechanisms. We think in a different way,
if we're using words, right? And we are better able often
to bring in that observing ego, like what's going on inside of me? So it can be very helpful to think, it can be helpful to talk to someone, to a trusted other, you
know, friend, family, clergy to write, I mean, these are things that can be done without expending any resources, right? And sometimes it can make
really a big difference, right? It was a way, when did
I start thinking that? And like, interestingly,
in this case, okay, we did it in therapy, but it became very clear what
that was rooted to, right? And then in the therapy, which was still relatively young, but we'd done several sessions and we weren't talking at all about what we needed to talk about, right? But that's what got us to
what we needed to talk about. And when did that start, and now we're in that same
place of exploring that and what was the reflex to it and the sense of guilt and sense of shame. And it's where all of that came from that just got boiled down
to I'm a loser, right? Which this person didn't
even have in their mind. Like, I didn't think about
myself that way, right? And that's is so interesting, right? That our memories don't in
and of themselves have meaning it's like they're flat
or colorless, right? And they're colored in by the emotions that we attach to them, right? So, the idea that certain memories now, before the trauma were changed, right? By the trauma. So I tell the story, sometimes of a person
who like won an award when they were in high
school that they thought was, oh my gosh, like it shows, like I can do it, right? I get out there, that after trauma, they saw the award with the
negative emotion attached to it. That was like, oh, it was given to me and
I didn't deserve it. And almost it was mocking. Like, it was going to be the
greatest achievement in my life and I was 17 or so, and to
have someone think like, that's not how they felt
about that at the time. It's the trauma that
changed, the self talk, the internal state going forward and talking about miraculous
in a negative way, also changed that going backward, right? And when we can really look at that, like where did that come from? And we can start
unraveling it, it changes. So in those cases, you
know, often it's helpful to have a good therapist,
it's not always necessary. And it certainly, it's not
always possible, right? So we need other strategies. And some of those, I write about some of those in the book of how can we sort of get at trauma without those formalized mechanisms. And sometimes if the symptoms
are significant enough, like we really do need to
talk to somebody professional who can help us get to
the root of the trauma. And there's so many times, that's the answer to what's
going on with people. People I've seen have had
five residential stays. I'm not exaggerating this,
for mental health reasons, for substance reasons, and no one's ever taken
a trauma history, right? And then when you take a
trauma history, you say, well, that's obviously where
this is all coming from, right? Like that's when the drug
use started truly thereafter, the negative self talk
and the negative feelings that led to the drug use. Then you go after the trauma and you can change things. Whereas trying to change
things without looking, introspecting, talking about the trauma, I think of course was futile. - Do you think that people can start to have negative fantasies? I mean, you mentioned this woman who would take these long
drives to berate herself. I'm not familiar with that, but I'll, I'll give a little bit of
personal disclosure here. I've felt several times in my life that I will start to create a narrative about something that truly hasn't happened about something terrible
that somebody is going to do. - [Paul] Yes. - That's going to upset me. - [Paul] Yes. - And for the longest time, I wonder why am I doing this? And I have a couple ideas about why, one, is that I was attempting
to just avoid thinking about other things. It's just, you know, anger is such an attractive emotional force in this. It's an attracting, it's not attractive. We don't like it. And yet, oftentimes anger is a great way to replace feeling something else. - [Paul] Yes. - Feeling sad or having to come up or to do work or to do something useful. So it has this kind of a like
gravitational force to it. That was one idea. The other idea was in imagining
kind of worst outcomes, then actually that relationship were, could actually seem a
lot better in reality. - Hm hm. - [Andrew] It's almost like
creating this negative contrast. - Yes. It's like, oh, well
then it's not that bad. And then the third possibility
is I have no idea why, but it seemed like a reflex. And I spent some time thinking about it. I can't say I've resolved it completely, but why would somebody have a narrative or a default
narrative when driving or when walking of I'm just
going to spend some time and think about how terrible
this thing is going to turn out or how someone's going to upset me or harm me or how terrible I am. It seems, again, like
maladaptive thinking, maladaptive wiring. And yet I have to assume
that it serves some purpose. - Yeah, yeah. I mean, I think there are three factors there and they're all bad. And I think you spoke to at
least two of them, right? They I think speak so powerfully to how insidious trauma
is and how these are real brain changes inside of us. So I would say that the
three factors, punishment, avoidance and control, right? So the trauma inside of us, that makes guilt and shame. So often, so often leads to a desire to punish oneself, right? And the idea that, oh, that was my fault. Or I deserve that. Well, what do we do if something is someone's fault and someone now deserves punishment, right? I mean, we we punish them, right? We send 'em to jail, we
give them a fine, right? We punish them. And so what, what we do is
punish ourselves, right? And if we tell ourselves we're a loser or this awful thing is
going to happen, right? Then part of what we're
doing is saying to ourselves, see, right, you deserve that. You're not going to have
anything better, right? It's a negative. It's a very negative
way that the brain tries to make us in a sense, to do better by hurting
us more for the things that we couldn't and
shouldn't have been able to, weren't expected to control
in the first place, right? The second is distraction. As you said, anger, that kind of fantasy can distract us from affect feeling and emotion. That can be much more negative. Anger, it can be more gratifying than certainly than guilt or shame, although guilt or shame can
serve a punishment purpose. But if anger is directed also
towards ourselves, right, then it can serve punishment too. So punishment, avoidance, and the sense of control
that if you think ahead to something awful, that you're imagining is going to happen, well, maybe that will
let you avoid it, right? I mean, you can see the
brain here in a sense, really confused. I mean, part of the brain wants to punish. part of the brain doesn't
want to think about it at all and part of the brain
wants to make it better. And then how all of that resolves, if we're not aware that, hey, this is in the context of our brains being deeply impacted by trauma. So what's going on here
is all maladaptive, right? 'Cause these negative
fantasies of the future, they may help us feel better
about something in the present, but they don't help us make
anything better, right? They don't help us make anything better. So this is kind of the sequela. This is where trauma and
all this reflexive stuff that happens after trauma
ultimately lead us. And you can see how we get lost, how I've seen over and
over again in my own life, in the lives of other people, how man we get stuck in those situations and that's why I see people sometimes. This has been going on for
30 years, 40 years, right? And it's just been going on
over and over and over again because there's no natural
end to any of this, right? Unless we, we look at it in a different way, that we have knowledge and
information like, whoa, this isn't the way it has to be. Let me bring a novel perspective to this. It doesn't change on its own. - I'm struck by your statement that these thoughts or behaviors
can make us feel better, but they don't actually
make anything better. In that way, this mode of imagining terrible outcomes starts to immediately
seem like taking opioids. You feel better in the moment, but it doesn't actually
make anything better. And it probably makes things worse. - Yes. - And just a question of how much worse and in what direction, yes. And so I just want to just
pause on that concept, because I think that concept
of makes us feel better, but doesn't make anything better. I think it answers an earlier question about what seems to be a totally
maladaptive wiring diagram. We need to confront the thing, but we don't want to go into
the repetition compulsion. So it's a knife edge there, to navigate through trauma. - [Paul] Yes. - Working with a very skilled
clinician like yourself, I think is the ideal
circumstance for people. And of course there are people
who can't access support from somebody, for whatever reason. You've talked about journaling. - Hmm, yes. - As a useful tool. Could you maybe highlight some of the other things that
people can do on their own. And then I'd also like to talk about what makes for a good therapist. What should people look for for those that are seeking therapy, especially nowadays when a lot of therapy is being done remotely, but
let's just start with the, let's just call them self-generated or zero cost sorts of things, journaling being the first and then what are some of the others and what kind of structure
would you recommend someone put around journaling, carry a journal around all
day and jot things down as they come up or sit down and spend an hour writing
in complete sentences, for instance. - Yeah. If I could add something
to what you had just said before the question, right? That we have these short-term coping mechanisms in us, right? And in a way it makes sense, right? If we find ourselves in
just terrible situations, then a short-term coping mechanism can get us through them, right? So our brains are built that way and that's part of survival too, right? And whether now in the modern
world, whether it's food, it's drugs, it's sex, it's alcohol, right? Or it's negative thoughts, right? This is short-term soothing. Even the negative thoughts, And anger is short-term soothing at the expense of long-term change, right? And that's where addictive
pathways can come into play. And that's where, again, our, how we're built
evolutionarily for survival, doesn't help us, you know, in
the way humans have evolved. Like we haven't lived this way throughout, 99.9% something percent
of human history, right? So we're not adapted to this. So I want to just make a point of saying that about the short-term soothing at the expense of any of long-term change, And then the question you had
asked about say journaling or what can we do that's
outside of professional. I think the hallmark of it has to be bringing new eyes to it, right? Like thinking about self with a curiosity, instead of just a simple
automaticity or repetition, right? Like, why am I thinking about this? When did this start? Why is this in me? Right? Whether it's words or
whether we're writing, that's so important. So I think for journaling, it depends on the person. I mean, we don't want
somebody carrying around a journal all day, if then there's a compulsion to, I need to write about everything that's going on in my mind, right? Like that might be good to okay. Write a little bit at night, right? Or someone who might think, sometimes this really comes
into my mind in a strong way and it could be unpredictable, right? I want to have the journal with me. So, ah, that thing is back in my mind now, let me write about it, right? Because then putting words to it and then being able to
read those words, right? And when people read, even do a little bit of journaling and they read like, oh, I thought again about
how I'm a terrible person who can't have a good life, because I was in such a bad car accident or because that person attacked me or because when I was in school, I was bullied because I looked different than everyone else, right? Or acted different from everyone else. Wow, to actually see that written out. It's a little bit of that, it's a little bit of that. Like when you're saying it to someone as if it were someone else, right? Because now there's
enough distance from it. Like I'm looking at the
words I wrote, right? That we get some distance
and we can start to integrate some of the, not just the compassion, but integrating compassion
and logic, right? Of like, okay. I feel a sense of compassion
now, wait, what does this mean? What really happened here, right? And gosh, I did start thinking
differently after that. I started, that's where
this came from, right? That's why I'm saying this, it's those kind of
revelations that we can have through again, the written or spoken word. And I think again, that
involves a trusted other, or writing, right? And I think that those
are ways we can do this, where we bring some de novo
perspective to something that often has been bouncing
around inside of us. And it's amazing to me that, I can see such intelligent
empathically, attuned people who've had the same thing running over and over again
in their mind for years. And it just points out that our brains don't automatically
say, hey, wait a second. I've been spinning wheels
here for a long, long time. Like, was there another
way to look at this? We need something from the outside, which can just be knowledge, right? Which is why I think what we're doing here or the reason I wrote the
book that I wrote was like, apprehending this like
amazing surprise to me, right? Which is like, wow, like some huge percentage
of everything I'm treating is rooted in trauma and the
opacity of trauma, right? Which is why we don't see
that, oh, the depression, the panic attacks, the
life change, the addiction, the maladaptive choices like, oh, this is all coming from
trauma because it hides itself in that opacity. So we need a de novo perspective if we're doing it on our own. And we need that if we're
doing it in therapy, which might link like finding
the right therapist, right? Which is also part of your question. - Yeah, yeah I definitely want to know about how to assess and
find the right therapist. Before we cover that, however, something came up in the
course of your answer. I can immediately relate to this idea that certain behaviors are really maladaptive and are stuffing things
down or avoiding the topic is problematic and bringing a curiosity and an introspection and
almost a third personing of the experience that we've had in order
to try and address it from a new, truly from a new perspective. It occurred to me as we
were discussing this, however that some people, and yes, maybe I'm talking a little
bit about my own experience. We have a sense of our own identity and how people view us and
our ability to be functional in the world in ways that we like, effective at work or a good brother or a good mother or father,
human being in the world. We have relationships. And I think that one
thing that I have heard, and maybe I've experienced
is that sometimes those maladaptive thoughts or behaviors, the things that generate a kind of a repetition of anger
or of arousal or activation or sadness, that we have
some internal process where we funnel that into a
functionality in the world. So we I'll give a more concrete example. So in thinking about things
that have upset me in the past and in imagining bad
outcomes in the future, there's a certain
internal state of arousal that comes about. And for many years, I
was able to use that, not to feel angry, but rather to work an
extra three hours a day - [Paul] Right. - Or to pack my schedule with
work and social engagement. So I could show up in a way that I, hopefully was a very good brother
to my sister for instance. - [Paul] Right. - So in a way it was a, it was a transformation
of something negative inside of me. - [Paul] Yes. - Into a functionality in the world that was actually very
rewarding and beneficial. - [Paul] Yes. - And yet in describing it, I can immediately see how it
would be wonderful if I could source from something else. - [Paul] Hm- hm. - And yet I, you can imagine, and I can imagine how
one would be reluctant, maybe even terrified of
giving up that source. - Yes. - [ Andrew] It's a fuel. - Yes. and I think in knowing some
of the traumas of other people and their reluctance
to work through those, obviously I'm not a therapist, I sense this over and over again, that one's positive identity can often be linked to something
difficult in their past. - [Paul] Yes. - And so people are reluctant
to give up this fuel. - [Paul] Yes. - Because it it's in that
sense, it's functional. The only thing that allowed
me to kind of start to address this and why I'm still
so curious about this, 'cause I don't think I've worked through this process completely, again, a little more
self-disclosure there, is that I was told that these words, just imagine how much better it would be if you could source from a different fuel, a fuel that felt better. - Right. - Maybe it was on the, it was on this, this sentence. It was, maybe you could actually be much more effective. - [Paul] Yes. - Maybe you could be 10
times the better brother. - [Paul] Yes. - Maybe you could have 10 times more insight or work capacity, etcetera. So it's on that hint of a promise that I, at least I was inspired to
start looking into these things and reading about trauma
in your book and elsewhere, and start to think about this. So again, I realize this
is a long winded question and a somewhat complex idea, but I think, or I hope that people will
be able to resonate with this idea that sometimes we
want to stay attached to this short term soothing
that the punishment distraction or control
because it evokes this arousal and then we can apply that arousal. - Yes, yes. I think what you're describing maps I think clinically to what
gets called sublimation. So there's something
negative inside of us, but we sort of transfer that energy, we transfer that into something that is adaptive or
that is positive, right? So the idea of the anger, right? When I think of that thing
and it makes anger in me, I channel that into harder work, right? Or I channel that into like, I'm going to go be nicer
to my brothers, some right, something like that. And there's validity to that, right? But it can become like self
justifying if a person thinks, well, look at what this
is doing for me, right? I wouldn't work as hard without it. Right now we start to become
attached to the trauma. Whereas I think what you
had said is absolutely true that just because we can sublimate some of the negative
affect, feeling, emotion that comes from trauma into something productive doesn't mean
that that's best, right? I mean we can get to our destination by taking a very circuitous route, right? We might waste an hour getting
there, but we get there. That doesn't mean that that's best. And it also doesn't look
at all the negative, right? In this example, the wasted
fuel, the wasted time, right? We get somewhere, but
we are not optimizing. And I have yet to see one person who has addressed the trauma and become less functional, right? It's always either,
they're just as functional, but they're happier, right? Or more functional
because as you said, like, just because we may be
able to sublimate, well, maybe what's going on will
be 10 times better, right? If we weren't sublimating because the sublimation limits us, right? It limits our perspective
to only what we can see and do through the lens of the trauma. And that is never better
than the alternative. - Thank you for that. - Yeah, you're welcome, yeah. - Let's discuss how one could or should go about finding
a really good therapist. Typically in my experience,
this is done by word of mouth. There's this person you
might want to work with them and they're really great, but what are some of the characteristics that one should look for? And should we take into account whether or not we are a person who for instance, I've heard this from listeners,
although I'm clearly, I'm definitely not talking about myself here in cloaking something. Some people will say, I want to work with a somatic
therapist because I've actually heard someone say, I think in fields, I feel stuff in my body. So I want to work with someone who can really acknowledge that or someone else will say, I want to work with somebody
who has this orientation or that orientation or is open
to my particular lifestyle, or isn't going to tell me that
I have to leave my relationship. I feel like people already
show up to the question of who to work with with
all these, you know, things internally, some of which are voiced
and some of which aren't. So I'd love for you to talk
about maybe some of the, the core features of a
really good therapist and then how to look for a therapist. And also how to think about oneself in looking for a therapist. - [Paul] Right. - Because of these kind
of predispositions. - [Paul] Right, right. Well, there's a lot of data about this over the years, if you look at what are the top 10 important factors to find in a therapist, just repeat rapport 10 times, right? I mean, that's the key. And if you think about that, it's pretty amazing, right? Because therapeutic modalities
can be so different, right? And I think what that's
telling us is, in a way, something very obvious, right? Like what does rapport mean? Like, you know, it's somebody that's paying attention, right? It's trust, it's a back and forth. It's like, yeah. even though
I'm doing something difficult, I'm doing it with someone
who's really helping me, someone who's in it with me, right? Someone who's really paying attention. Wants me to be better. That's indispensable, I mean,
it's just indispensable. And I write in the book is someone, a therapist not making eye contact or this is the way they do it, right? And you know, you got to fit into the
box of the way they do it. That is not going to be helpful. And then what I, what I think about that is
the different modalities. It doesn't actually tell us that, oh, the modalities are irrelevant. I think that's not true. I think that good therapists
are not pigeonholed by a certain modality. They may come at the world largely through a psychodynamic
or a CBT or a DBT lens. There's lots of different, ways to do therapy. But when you really talk to those people, really good experience therapists, it's all coming through
the vehicle of the rapport, but they're practically shifting
to what the person needs. I don't understand the idea that like, oh, I just do this, right? I don't do that. And when people are pigeonholed that way, I don't think they help their
patients very well, right? We have to be diverse enough to say, hey, I want all the arrows
in the quiver, right? And even though there might
be one that I favor and that's the lens I see things through, no, I can be versatile, I can shift, I can adapt to what this person needs. And I think if you have
that, you've got to, if you have that, you've
got a winning combination. - Great, so people should
perhaps try a few therapists and maybe have a session or
two or three to see if they, the rapport feels like it's taking root. Is that? - [Paul] Yeah. - Do you have that right? - Yeah, and I think that's why word of mouth is important, right? If someone you trust tells you, hey, this is a good person
that says a lot, right? It already makes the pretest probability, is quite high. But yes, it's interesting to see when like people have a therapist or they called their insurance and they're assigned a therapist. This thought that like, oh, that's the person I have to have now. And it's like, no, you should look at that like anyone you'd be interviewing, right, for a job, right? But you got to bring again, the right set of thoughts
to that to be helped, right? Which is that I want someone
who has rapport with me. I don't want someone who's
going to make it easy, right? Who's like, well, it's,
gosh, it's kind of pleasant, because then that means
they're not talking about the difficult things, right? So if one brings, like, I know
this isn't going to be easy. I got to talk about
difficult things, right? Even if one doesn't recognize or I got to talk about
the trauma in me, right? But to go to therapy
thinking, no, it's, I mean, sometimes it's enjoyable,
but a lot of times, right, it's not, right? It's hard work. It can be excruciating. We can cry during it, but to say, right, that that's how
I'm going to be helped. And I want someone who's
going to do that with me, who's really looking at,
what's going on inside of me, how do we help me? And I can feel sort of
the robustness of that. If one brings that approach
and then looks at the therapist through that lens, you're very likely to
then move on from someone who's not a good choice, right? And really stick with someone who is, even though that doesn't mean
it's always like pleasant and enjoyable. I mean, it has to not be that sometimes. - Right. Maybe we could drill a little deeper into the mechanics of therapy. I put out a few questions to
audience asking what they want to know about therapy and it was amazing. I got hundreds, if not
thousands of responses saying, how should I show up to therapy? So for instance, should people take a five minute
meditative drop in before? Or should they just show
up cold and let it emerge. During therapy, is it a good idea to take notes or to not take notes
and then post therapy, how should clients, patients as they're sometimes
called, one or the other, I never know which, how should they process that information? Should they take some
designated time afterwards and in an ideal world, take a 30 minute walk
afterwards and think about the material or should they set it aside and come back to it? Of course there are constraints,
work and family, etcetera. But you know we, there's a lot of knowledge out
there about how to best show up to a workout, warm
up for five, 10 minutes, then do this, etcetera
and then the cool down. I mean, here, we're talking
about hard psychological work aimed at bettering oneself. So to my knowledge, I've not ever seen this
information anywhere. It'd be very useful to hear,
hear your thoughts on this. - Yeah. Well, I'm not trying to duck the question, but I think it varies so much by person. So if you think about the
first part of your question, I think was how to show
up to therapy, right? And I think the answer would be whatever lets you be fully present
when you're in therapy. Now for some people that's
going to be, I show up early, I say it, I call myself,
I meditate a little bit. I mean, that's how then
they're present, right? For other people, you know,
they just, they show up, walk into the room, they can
stop another present, right? So it's whatever works for that person. So that they're really
there, their thoughts, their energy is really in what's going on. And the same thing
applies on the other end. There are people who are
really well served by, going for a walk if they can, or sitting quietly after therapy, kind of putting that in order, right? Otherwise they lose some of it, right? Or like some of the ahas, right? Or the, oh, that's an interesting thought that they really need to put it in order. Maybe that involves taking some
notes during therapy, right? For other people, they need
to do the exact opposite. They need to like leave,
not think about that at all. And then they can reflect on
it later and learn from it. So we're so different. Human beings, there's
such a diversity in us that there's no hard answer to that, but it's like being present
when it's happening, then being able to sort of consolidate and retain what's been
gained is most important. And I think we have to figure
that out person by person. I mean, I try and do
that in the work of like what's serving this person best. And sometimes we, sometimes it evolves and
sometimes we talk about it, but it varies so much. - Hmm. - If someone were thinking about embarking on therapy or more therapy to address trauma or just
general issues of life, what is the frequency that you recommend? I could imagine two extreme models. One is, okay, I'm going to finally tackle this trauma. I'm going to do therapy
three times a week, but for a shorter period
of time, six months, over and out versus this open
ended model of once a week, typically for as long as it takes. - Right, right. I think that also varies. And I work with people
in varied ways from oh, someone who's doing well and like we meet for a half
hour every six months, right? To doing week long, hourly sessions, to
spending three intense days with someone in a row, right? So I think as far as like
kind of guiding principles, what I have found in my own life, 'cause I value my own
therapy tremendously. So I found in my own life
and in my own clinical work that if it's less than once a week, then it's hard for us to retain really. We spend a lot of time
kind of catching up, okay, what's happened? Let's get back to the place
we were at before, right? Which is why I think if we're
really going to get somewhere, we're not just trying to
maintain something, right? Then I think once a week for an hour is really kind of the minimum, right? But more intensive work. It's like the more I intense it is, it's not linear, right? It's an exponential gain. Like we do a lot of intensive work, right? where someone will come
and do 30 clinical hours with us over the course of a week. So five or six different
clinicians, 30 clinical hours. And you know, we've found that the benefits
of doing that are immense. It's like let's say a year's worth of therapy consolidated and
you take well, 30 hours, let's say, we go almost every week, maybe that's 45 or 50 hours, but 30 hours with that kind of intensity is worth probably 60 hours, done in a different way, because then it's in us
in an active way, right? It's in the therapist in an active way, it becomes very, very dynamic. So I think turning up the intensity, if there's something that
we really need to process, absolutely makes sense. And I do that in my own life is something now's
like, whoa, it's really, somebody is really distressing me and it's linking into prior trauma and I can see what's going on in me. Now I start to have
ruminative thoughts, you know, with negativity, I'm like,
I got to go more, right? Because I got to do that processing. So I can get to the place that I am, which is not that, it's not that the trauma
has no impact on me, right? It' that the impact is much
less than it was before the therapy and that I most often and more often than not
have an ability to see when it's now intruding into my thoughts. And it's taking me away from like what I really think and believe, or being able to draw
logic and emotion together and make good decisions. Turning up the intensity
then absolutely makes sense. - This very deep, intensive
work of 30 hours in a week. What brings somebody to some,
the type of work of that sort? Is it a suicide risk or a
severe addiction situation? I mean, how does one
gauge how much therapy they ought to be doing
and should it always be on the therapist to decide that frequency? What would bring someone to a situation of five
therapists in 30 hours a week in one week? - Right, right. Yeah, it's usually a person
who is really distressed by something whether that's, it's so negatively impacting their life or sometimes a person
comes to realization. I just can't take this anymore, right? I'm sick of the cyclical depression. I got to stop having panic attacks. I need help, right? But it's usually some, crisis point with the idea
of crisis in the meaning of, okay, something comes
to a head and after it, things are going to be different, right? Not a crisis and things are
going to be negative afterwards, but a point where, where then
that cognitive flexibility comes to the fore of like, well, I need to do
something different, right? So that's often what brings us. Sometimes it's other
people pointing it out or somebody's had an
intervention somewhere or yes, that person's been hospitalized
after a suicide attempt or they've gone back to rehab again for the third or fourth time. And their life is really in danger. Sometimes it's that. And sometimes it's a person
realizing, yeah, I just want to, I want to look at myself, I want
to understand myself better. I know that what's going on in me, isn't as good as it can be, right? So I think people can come to it for all sorts of different ways. And I think, yes, I think a lot of times it
would be the therapist to say, more work, more intensive
work or can make a difference. But I think the person also needs to, take ownership, right? Of their own therapy and say, if I don't feel helped enough, well, I have to think about that, right? And talk to the therapist
about that, 'cause it, maybe that therapist isn't a match, right? Or maybe you talk to the
therapist and the therapist can change his or her approach, right? Or maybe you talk to the therapist and increase the frequency, right? But the idea is to be aware of it, right? And if one's needs, aren't being met to
acknowledge that, right? 'Cause people can get
into a rhythm of therapy where it's really not helping them, right? But they either feel sort
of nihilistic about it. Like, oh, I'm no better and
I'm going to therapy, right? Or sometimes there's a sense
that while I'm in therapy, so I'm kind of checking
that box of doing something for myself, but it's not
really getting me anywhere. And then the part of the
brain that's controlled by the guilt and shame and avoidance thinks that's a great idea, right? So again, this ability
to observe ourselves and like what's going on, am I being helped in the way, do I feel helped, right? Am I in some ways, even like happy that
I'm not feeling helped. 'Cause I don't have to face this thing I don't want to face, right? Or am I too afraid to say
I need more help, right? Do we really need to look at ourselves? And this is where the insurance systems often are very difficult, 'cause it's hard sometimes
for a person to say, I need more therapy 'cause that
may not be possible, right? So there are sort of negative factors in the world around us. But ultimately I think the
answer to the question comes down to observing ourselves
and taking ownership of like what's going on in
us and how we're feeling. And then feeling that, that commitment to self
or to self-care to say, I need to go change this. - And for those that
maybe don't have the means or insurance or access to do even one day a week therapy in the journaling model. - [Paul] Yes. - Could one perhaps take an entire day as awful as it might seem, to do a lot of journaling
and thinking and walking, do a self-generated intensive. Do you think there's utility to that? - I mean there could be, but again it depends by person 'cause there could also be
something negative about that if it's someone who's not at the point, not ready for that, right? I mean we don't come at, we don't come directly at
the trauma immediately, at least most of the time
we don't do that, right? And we often don't explore it in depth. Like this idea that, oh, that person now has to go through
every second of the trauma is actually not true. I mean sometimes it is, but that's, that's not the common situation, right? So more often that
person has to acknowledge like the example of like
I was sexually abused and have to acknowledge
that and to, and say, okay, like, gosh, what has that done to me? That doesn't mean, well let's parse out every moment of like how that was and
the terror of that, right? So that can lead people
to a worse place, right? So, I think the idea of
biting off small pieces, so to speak where a
person is writing, right? Or is talking. But I think if one is writing, it is good to communicate
with another, right? Another trusted person. And if there's not someone
in one's personal life, there are clergy members, even if one isn't a affiliated
with an organized religion, you could probably go places and get clergy to want to help you, right? I mean, there are people out there who want to help other people. So we say, what if someone
has no one, I mean, almost never do we have
no one here, right? 'Cause we could probably go find someone, but we need to kind of
take that in pieces. So there's some risk like trying
to do the intensive thing, you know, on one's own. And that's where I would put in, if a person's having suicidal thoughts or even thoughts of death,
of not wanting to be alive, I don't deserve to be alive. I mean, these are warning
signs for really getting help. So there are some signs that say, hey, don't try and do that on your own, right? Go try and find a resource. And it's things that get to
that level of severity of, and often a person knows that. I mean, am I in a place where I know I'm not healthy and I'm having kind of scary thoughts, then we need, that's a person who
really shouldn't be doing that on their own. - Great, thank you for that. - Yeah, you're welcome. - So we've been talking
a lot about talking. - Huhm. - And now I'd like to talk a
little bit about chemistry. - Yes. - Drugs. - [Paul] Yes. - So maybe first we could
talk prescription drugs. I mean you're a psychiatrist,
so you're approved to, and presumably do prescribe
medication where appropriate. I mean, this is a vast
landscape of course. We've got ADHD and I should just tell you, I get more questions about
ADHD and the drugs related to ADHD and dopamine than any
other topic, any other topic. So there's ADHD, there's
OCD, there's depression, there's antidepressants and so forth. Is there some way that we can, wrap our arms around all of that as a way of waiting into this, this drug question and just address, how does one decide when
medication is useful? Because in the end, the dissection tool that the psychiatrist or therapist has is language. And at some point, one has to make an assessment
about dopamine or serotonin or whether or not a given drug would help. And most therapies, I believe don't involve putting
someone in a brain scanner. And to my knowledge, there still is not a very
good blood test to assess, oh, is this person's dopamine low or high, correct me if I'm wrong. And ultimately that, and I know there are companies out there, so I'm not trying to
undermine those companies. But if I happen to do
that in this statement, if you take a blood test
and find that your serotonin metabolites are low, my understanding is it's
possible that you are too low in serotonin in the brain, but that's a very indirect window into what's really going on. So how does, how do you think about
prescription drugs in the context of treating trauma and other
conditions and then maybe we'll drill into some of the
more specific conditions? - Sure, I mean, I would first comment that
right there aren't tests for these things. And I think the tests for metabolites, I mean, things are so different. By the time, what we're talking
about has been metabolized, often to some very significant extent. Left the brain, now it's in the peripheral blood that we really don't
learn from that, right? I think that we tend to over
utilize medicines in this country because we have
a healthcare system that often that's so based
on throughput that we want to polish the hood when there's a
problem in the engine, right? So we overutilize medicines
often as an end point, right? Oh, we're going to make that
person's depression better with an antidepressant. Well, I mean maybe, right? But most of the time for
the person's depression to really get better and stay better, they need to unravel what's
driving the depression, right' So the first step is I think they're cut two steps to it, right? The first assessment step is, is there a diagnosis that, that the vast majority of the time, if not sometimes, all the time,
really warrants a medicine? So the bipolar disorder, OCD, ADD, right? These are diagnoses that we, we understand more about
them and what's going on in the brain and how medicines
can treat or stabilize them, which doesn't mean the
medicine is necessarily, it's not a substitute for therapy, right? But sometimes the medicine and
therapy can go hand in hand. So for OCD, for example,
warrants therapy, but it almost, not always, but it almost
always warrants medicine too, so that you can ease the
systems that are making the rigidity and the
repetition in the brain. So the first kind of branch point can be, what is the diagnosis? What is the level of severity, right? And I think that's very, very important where I
think it's a little more, maybe even interesting is using medicines to help the person engage in the therapy as productively as possible. And here's where I think we're so limited by how we categorize medicines and this sort of pharmaceutical insurance driven medical system we have that I think throws
us off in tremendous ways. So you think about how
medicines are categorized, so antidepressants. And the vast majority of people who are helped by antidepressants, they're not, they don't have clinically severe depression, right? Those medicines create more
distress tolerance in us, right? And if you think about
how helpful that can be, if you're going to go, now you're going to do
something difficult, right? You're going to bring that
trauma or the stressors to the surface and you're going to process and you're going to try
and make life change. If we can make more
distress tolerance in us, that can be so, so much better, right? And think about the category
of medicines that are called antipsychotics, which really
puts people off, right? But most of the prescriptions
for antipsychotics are not for psychosis, right? And there are ways in which
low dosing of some of those medicines can help intervene
in negative pathways, right? In pathways that are about distress. And sending out those tendrils of neurons that are about hyper vigilance and avoidance, right? In in our brain. And we can often get at that. And if you can improve
someone's distress tolerance and you can use medicines that take away what clinically
is rumination, right? Not the standard meaning of that word, but the clinical meaning of it, where there are distress
centers in our brain that are overactive. And then we get stuck in these
maladaptive negative pathways where we think about something
over and over and over again, with no real chance of solving
it because that's not what's going on inside of us. So medicines can help that, but we have to have some flexibility around their conception and the modern medical system
of like 15 minute visits, to a psychiatrist that are weeks apart. I mean, I don't understand
how that goes well, right? In the vast majority of times, I think it doesn't go well
because it's not enough time to do the therapy, even
generate the understanding. So then medicines get
thrown into the person. This is how, we use, I think approximately
five times as much medicine, I think across the board as say
the Dutch population, right? Then you think, well,
why is five times more, is a lot more medicine, right? And you know, they have
a healthcare system and a cultural system that to
the best of my understanding is more rooted in taking
responsibility for oneself, right? So if a person comes in and
cholesterol is high, right? The first order of business is, hey, you could take better
care of yourself, right? Like this person really needs to lose some weight exercise more, right' They're not just jumping to like, let me give you a medicine and you know, and shift you through
the healthcare system and out the other side of the door, right? And the same thing is
true in mental health, and I'm not trying to be critical to the psychiatrists or the
nurse practitioners or people who are practicing in that way, because oftentimes there
is no choice, right? If they're working in a
healthcare system that, that the standard is highly
spaced or spaced apart, 15 minute visits, what
alternative is there, right. But to look at, okay, I'm going to use medicines
because I don't have another tool to bring to bear. So I think the healthcare system
and its focus on throughput and it's short term talk about, we talk about short term response, right? Short term soothing at the
expense of long-term health. And I think that is the metaphor for, that applies to our
healthcare system, right? Where if we, if we are going to try and
treat a symptom in a short term, we're going to do it in a 15 minute visit, that we're going to do it in a way that maybe it soothes a symptom, maybe it doesn't, but it
does not get at the problem. We need to invest more
resources to get at the problem and I think that's
where a sort of protest, if people, as a society, we say, look, we don't like the way
our healthcare is going. Like, we need more focus
on what the actual problems are that yes, we would spend more money, to treating people and
taking care of people 'cause it's more human time, but ultimately about less
suffering, less death, right? And ultimately more productivity. I think as an economy, we would save so much money
if we spend money on the human aspects of mental healthcare, because people would be more functional. They're spending less time
in the hospital, right? They're more productive
when they're working. There's less entry into the
criminal justice system. So I think medicines get overused in part for systemic reasons, in large part, for systemic reasons. And also for some of these
categorization reasons, oh, that person meets
some technical criteria for depression. We got to give them this medicine
instead of really thinking, wait, what's going on in this person. And I see this over and over again. I see one who is on seven medicines and they're on seven medicines to treat seven different symptoms. And now they have side effects from all those seven medicines. Maybe two of them are to
treat the side effects from the other five, right? And that's bad, right? And if you really get at
what's going on in them, now they're doing much better and maybe they're on two medicines, right? So I dunno if that's a
helpful answer to that. - It is, it's a very helpful answer. I mean, I think at least in the spheres that I run these days, I hear a lot of negative
statements about antidepressants. I think, I'm old enough to remember the book, "Listening to Prozac." I remember when Prozac and its and things like it
first started showing up and the excitement. And then nowadays I hear more
about the problems with all these drugs and maybe that's just, 'cause I have arms in
the, both the scientific, but also in the kind of wellness community where people think a lot
about behavioral change. Fortunately I think
that's that they do that. But of course these
drugs, as you mentioned, can have enormous utility as well. - [Paul] Yes. - I'd like to just pick up on one theme that I haven't heard a
lot about anywhere else, which is the short term versus the long term use of these drugs. 'Cause I could imagine, someone feeling like they're
finally going to tackle something that's been inside them
for a long time either because they're really struggling or because they're just done with not working it through and they decide to start a medication that would give them higher
levels of distress tolerance for a short while. I mean, is there anything to say that someone couldn't take a
properly prescribed medication for a week or for the first
three months of the work? - Yes. - And then know that they can come off it because I think that the black
and white model of, okay, you're either going to start
this drug and stay on it forever or be taking some drugs forever. - [Paul] Right. - Or you're not going to take anything. I mean, that just seems to, life doesn't have, does life have to work that way? - [Paul] Right. Is there a short term use
that can be effective? - Yeah, absolutely, yes. In American medicine we are
so much better at starting medicines than we are at
taking them away, right? And part of that I think
is driven by such a strong presence of the pharmaceutical industry and the pharmaceutical industry does a lot of very good things, right? But you know, there's such thing as too
much of a good thing, right? And then as a society, when
something seems positive, this I think also is human nature. We can overinvest in it, right? So you think about when Prozac
and those kinds of medicines came out, they were safer medicines, they're billed as antidepressants
and the thought was, well, they're going to
fix depression, right? And it's not how that works, right? So if we look at them as tools, right, then we can deploy them
sometimes for the longer term 'cause sometimes that's necessary. But absolutely for the
shorter term, absolutely. If we thought of Prozac and
those kind of medicines, not as, oh they're
antidepressants, we think, look, what they do is they, they seem to make there be
more serotonin in certain circuits that are important
for mood regulation, anxiety regulation, distress tolerance. So those medicines can
really help somebody if they're very severely depressed and we want to sort of
get them feeling better. They can also help someone if
they could use more distress tolerance in a discrete
period of time, right? When we think about them that way, we think about them as
tools that we could apply for short term or long term. We don't see them as fixes, right? And we don't see them as then substitutes for the human to human work that needs to be done. I mean, I've been sort of in my training at times in healthcare systems and I've seen in many other circumstances that look at medicines as
answers and this idea that, that person is a, and a lot of times there'll be a number, right, right? And the number is the diagnosis and that number gets this medicine. And I'm not sure we could
be more misguided than that and that's what leads to adding
medicines, adding medicines, it's not working. Of course it's not working, because no one's really paying
attention to what's going on. So add more medicines and then
medicines for the medicines. And I mean, we know this is true. We know this is true, but we haven't had the
wherewithal as a society to say like with a lot
of things in society, to say like this isn't okay, right? I mean, we need more. Like give these people
who are trying to help us. They need more latitude to help us. We need more human to human contact to get at what's really going on, and yes, that's an investment of
time and energy and money in the short term and
sometimes that's money from the systems, right? But if we do that, my
goodness, look at the, look at the payoff of that. - What is your thought about anxiety and ADHD as a separate phenomena, in terms of medication. Again, ADHD is the thing that seems to come up most in questions. I can't tell you the number
of especially students, but also young working professionals and even people who are outside those categories
who are interested or taking Ritalin, Adderall, Modafinil
or Armodafinil or Vyvanse, because they seem to
struggle focusing without it. Or, and I don't know, 'cause I'm not one of those individuals, or because they seem to just
like how well they can focus when they do take those compounds. And so my understanding is
these compounds mainly increase dopaminergic transmission in the brain, also adrenaline, epinephrine in the brain. So they're more or less stimulants. They look a lot like, at least chemically, they look a lot like
cocaine and amphetamine, although they're not quite
cocaine and amphetamine. So should we be concerned about this? Is this a different sort of epidemic? Can these drugs be used to train the brain to focus and then people can
withdraw from these drugs? I mean, I think this is a huge topic and one that maybe warrants
its own episode entirely, but as long as we're on the topic, what are your thoughts
about medication for ADHD? - Sure, I think medication for ADHD can be extremely effective and the studies show us that, right? They show us that if there is ADD, then medication for ADD, is very, very helpful and
that's true in youths, it seems to be true if adults
have adult ADHD or ADD, we kind of know that's true, but all attention deficit is not Attention Deficit Disorder, right? And there we go to the
reflexive 15 minute visits, throw medicines at things, right? Attention deficit can come
from many, many places. And one of them is anxiety, right? There's so many other reasons
depression affects attention, poor sleep affects attention, poor diet can affect attention, stress in life can affect attention. So, and, and certainly trauma. And the thing, the problems that trauma spins
off can affect attention. So this is really the, this is really the truth that
while teaching once about medicines and pharmacology, I was frustrated about how
the answer to everything was like, what medicine do we use? What medicine do we
use, as opposed to like, this is just one piece of the puzzle. And I told an anecdote, which, I think it was a clinical anecdote, like what do you think is going on? And I think that if I
told that to, I dunno, middle school students or something, they would probably say, you just told a story of a
person with a rock in their shoe, which is what I, the story that I was actually telling, right? But several people I was talking to, they're physicians, right? ADD, right? It's like, no, every time the person
steps down the rock hurts and they're not able to
maintain attention, right? Like that's what's going on. But we're so programmed
to think about medicines and inappropriate use of
ADD medicines, as you said, there's dopaminergic impact. There's epinephrine,
norepinephrine impact. We're affecting what are called prefrontal alpha 2 receptors that like really need to be
helped if there's real ADD but if there isn't, that
is not a good thing to do, which is why it is quite fascinating that when people have ADD, they tolerate generally
stimulants very well, without the other problems
that can come of stimulants. And again, I don't know, I
don't claim to know why that is, but we see that phenomenon. But when people are being treated for ADD and they don't have ADD, which sometimes they
know they don't have ADD, but the stimulants make
them function better. So they go to somebody
and get the stimulants. That's not a good thing to do, right? 'Cause stimulants, when
they're not needed over time, they do affect our physical function. They affect our judgment, right? There are a lot of negative
things that come from that. They can affect the
vigilance inside of us. So, yes, it's a valid diagnosis, but it gets made when it's
not present very often, which we see with a lot of diagnoses that you can throw medicine at. We see the same thing
with bipolar disorder. True bipolar disorder
is extremely important to utilize medicines effectively, but how many people are
diagnosed with bipolar disorder who have, they absolutely
don't have bipolar disorder, but it can be a catchall diagnosis because there is in a sense, "something to do for it," right? And you can throw medicine at it, right? So I mean, what do we expect, right? If we have a healthcare
system where you get 15 minute visits with your psychiatrist, of course we're going to
throw medicines at everything. And then the training paradigms are going to look at it through that lens. And then very often again, I give the example of seeing
somebody on seven medicines. I mean the first thought I
have is how many of those medicines are actually counterproductive? And a lot of the time it's not like, oh, every now and then one
is counterproductive. No, that's the case. That's the case a lot of the time. And again, I come back to, if we're not putting thought into it, what other result would we expect? - Thank you for that answer. I'm very curious what
constitutes negative effects of stimulants. So if somebody's taking
Adderall or Ritalin in order to work longer hours or focus because they have attention deficit, but not necessarily ADHD. And again, I'm not
recommending anyone do this. I've just heard the numbers
that have come back at least from surveys and discussions with colleagues at Stanford and elsewhere, other college campuses that
upwards of 75% of college students use semi
regularly, these drugs off, not by prescription, just
to study and to learn. - [Paul] Yes. - I can imagine sleep
issues because people, because these are stimulants, what sorts of other issues
can they create for people problems that they can create? - Sure, I mean, I think a touchstone maybe that's running through
our conversation, right, is prioritizing the short term benefit over solving a long-term problem, right? Which we might say is a human tendency and we see it across the
topics that we're discussing. So, short-term use of stimulants. Sure, people are more alert. They can stay awake more, they can study more intensely and longer. Okay, there's some
short-term benefit of that, over there, even there,
there can be problems, right? But we can say, let's just say for sake of
argument that in the short term, there's something to be
gained by doing that, right? But oh my goodness,
there's so much that is, there's so much risk to that, right? And how many times have I seen someone who they're doing that and they're just doing
that to study, right? And now they're addicted
to the amphetamines and their behavior changes
and they don't know it. Talk about shifting our brain
towards a more defensive, sort of suspicious, outward look, view of the world that
we see a lot of that. So we see judgment impairment, we see heightened levels of anxiety. We see more impulsivity
in decision-making. And sometimes we, it can get to the point
of seeing Frank psychosis. Now, that's not common, but have I seen young people who've done exactly what
you're describing, right? They're using Adderall or
they're using Ritalin to study. And then I see them when they're
coming into the hospital, they're screaming about how
someone's trying to hurt them. Boy, it's the worst case scenario, but it shows like that's
where that can go. And how much is there between the, oh, I'm just using it to
study and that severe, outcome that is actually
quite negative for a person and it might change how they think about that friendship or
that relationship, right? A lot negative happens
when we change our brains without an ability to see like, what is it actually doing to us? So, which is part of my whole
theme about trauma, right? It changes our brains and
we don't know it, right? Well the same can be, the same is often true of
amphetamines used inappropriately. It shifts our brain. And we don't realize that we're
a little bit more impulsive in our decision making, a
little bit less trusting. These are significant negative things that if we don't know it, the person will just say, yeah, oh, I'm just using it to study. I'm using it to work more. That's not, you know, that's not without it's
high level of risk. - What are your thoughts on cannabis? I've said it many times on this podcast before and I'll say again, I feel fortunate that I've
never really been attracted to alcohol or drugs of any kind , so much so that if all the
alcohol and all the marijuana and all the cocaine
amphetamine disappeared, I wouldn't notice any
change in my life, right? And I feel lucky in that way, 'cause I know a lot of people feel an attraction to these things that it is almost a gravitational force. - [Paul] Yes. - From their first drink, they just feel, I once heard it described in this, I think it was an Augusten
Burroughs book, "Dry" where he was an alcoholic. He said that the first drink he had, it felt like this magic elixir that meshed with the
physiology of his blood in the most seamless way and as I was reading this, I thought, oh my goodness, first of all, that's the most foreign experience for me in terms of alcohol. And second gosh, that must be terrible. And you can, but at the same time you
could really understand why someone would be drawn to that. - Yes. So cannabis nowadays is legal or decriminalized in
many areas of the U.S. A lot of people seem to use the argument, it's better than drinking or they only do it for
sleep or anxiety management. I'm not looking to demonize
or support the cannabis. So what are your thoughts about cannabis for anxiety management, depression? And maybe even for ADHD for that matter. Sure. - If I could make an
alcohol comment, right? The number of times I've seen alcohol like having been a good idea for coping with something approaches zero, right? Like the alcohol for
coping is just never good. And there's an additional risk
factor that there's certain genetic profiles where people
respond strongly to alcohol. Like, as you're saying, it's not just, oh, there's a little bit of
short term relief of distress, but there's this sort of euphoric response and those genetics, we don't understand them completely. They seem to be in Northern
European populations, more prevalent as you head
west in Northern Europe. So we understand where risk
factors are demographically, but we can't pinpoint
that for any one person. And there's a tremendous risk of that, when a person responds so
strongly to alcohol or habituates coping to alcohol. Cannabis is a little bit
of a different story. I mean, how I have seen that play out, and again, this isn't
coming from any expertise around the neuro the
neuropharmacology of it, like how is this really
working in the brain? But it comes from an observation that what it seems to do is
to narrow our attentional perspective, right? So it's why people will
say, well, they want to, they want to use cannabis before like watching a movie with friends or something, right? And, and I think, okay, I think why people are doing that is because our cognitive spectrum narrows. And then instead of worrying
about that thing at work or that relationship issue,
one can just be present, right? It gates out other
attentional intrusions, right? So in some ways, I mean, I've absolutely seen it
be helpful to people. I mean, it's been legalized
in Oregon, which is where my, I spent a lot of my time and it's not where all of my practice is, but what I have seen is
it is at times helpful, safe around sleep, right? Because a person can gate
out other intrusive thoughts and they can just relax and go to sleep. But there can be another side of that too, that at higher levels of distress, at higher levels of tension, what it can do is narrow the focus of cognition to the thing
that is negative, right? So the idea that, oh, like,
oh, this is a treatment for, depression, anxiety,
trauma, is not true, right? Can it be helpful under
certain circumstances? Like I think the answer to that is, yeah. I mean, I know the answer to that is yes. 'Cause I've seen it play
out clinically that way, but think it can also be harmful too. So there, again, like
anything that has any power, power to influence our brains, we want to be thoughtful
and careful about it. I mean, do I think that
it's safer than alcohol? Yes, I mean, I mean, like we, we so clearly see that. Does that mean? Or it's just uniformly safe? No, right. So we want to be respectful of anything that can change how our brain is working and I think that includes, certainly includes alcohol. And I think it certainly
includes cannabis too. - I'd love to talk about
psychedelics for two reasons. One, there seems to be a
tremendous amount of interest in psychedelics as a
therapeutic clinical tool. I know there's also recreational
use and I'll just preface all this by saying that
my stance is we absolutely know for sure that these
are controlled substances, they're illegal to possess, sell or use in most of the country. There are few areas where
it, they are decriminalized. - [Paul] Yes. And psychedelics is a
broad category, of course. And we can touch on some of
the different, different ones, but whereas five years or so, five years ago or so I
was truly afraid to say the word psychedelics in
any kind of public venue, there are laboratories at
Stanford working on ketamine, psilocybin, MDMA, mostly in animal models. There's terrific work going on at Johns Hopkins University
School of Medicine, Matthew Johnson's Lab, and others looking at the
clinical applications, mainly of high dose psilocybin and LSD. There's the maps trials with MDMA. - [Paul] Yes. - So nowadays it's safe
for an academic like me to say the word psychedelics. And I'm, I'd love to
approach this question of psychedelics from a place of true exploration and curiosity. But with the preface that
we're talking about this in a legal clinical setting. - [Paul] Yes. - And the legality is something
that's now in process. I don't think it's completed,
but that's my understanding, but there are trials. You can go to clinical
trials.gov and put in MDMA, and you'll see a bunch of clinical trials that are happening in
the recruiting subjects. So I think it's safe to
have the conversation now, and I'd love your thoughts
about psychedelics. Maybe we could start
with psilocybin and LSD as a broad category of drugs, that at least my
understanding is they touch on mainly the serotonin system, some specific receptor
activation and modulation, tend to change notions of space and time, adjust internal state. Maybe we would start there. - [Paul] Yes. - And then maybe venture
into some of the other ones. So what are your thoughts on
these drugs for therapeutic potential also potential
hazards, etcetera. - Yeah, I think if we look
at the true psychedelics, so psilocybin and LSD, right? Because ketamine and MDMA, they're different categories of medicine. They're these sort of novel
tools to bring to bear. But if we start with psilocybin,
LSD, true psychedelics, I think why it is, why they have gained so much momentum over the last several years is
because the data coming from the labs and the academic centers is so powerfully positive. And as someone who's, I'm interested in anything that's potentially helpful, right? And I want to learn and understand that because a lot of things that
are potentially helpful, you know, you go and look at the data and you see that that's not
helpful, that's harmful. I think what we have
seen with psychedelics is that they're so helpful, right? And the trials are bearing that out. And of course these are
used in professional hands and with the right kind of guidance are extremely powerful tools, but used in the right way by someone who knows how to utilize them in the right setting can have
an immense positive impact. And that's why I think that the thought is there
across people and more and more people feel comfortable saying
it and talking about it, I mean we're in the state of Oregon now where the thought is, we're moving towards
legalization of psilocybin early in 2023. And it's part the new data, right? And how it meshes with
the older data, right? How it meshes with data
from the 60s and 70s that showed such a strong, powerful impact of these medicines. And I have a whole set of
thoughts about what's happening there and they're just
their conjectures, right? But my read of, you know, as best I can try and
understand the neuroscience and the clinical applicability
and the changes is, what happens is we see less communication or less chatter in the outer
parts of the brain, right? the the outer parts of the cortex. And I think that as human beings, we sort of glorify the parts
of the brain that only we have. I mean, certainly in my growing up, right? I mean, what did I learn? Even if you think about like, learning about the brain
in high school, right? I learned that like, wow, we're great as humans
'cause we have language and other animals don't and we can use tools and
like aren't we so great because we have this part of
the brain that other animals don't and it lets us function, right? Okay, there's some truth to that. That we can do things others can't do. But we get lost often in the
outer parts of the cortex, which I think are about survival, right? So we come back to the things you and I talked about early on of like, why are these trauma
mechanisms in us, right? So like so much of what's going on in our brains is about survival. And I think living so to
speak in the cortex, right? And the outer part of the brain is consistent with a focus on survival. So if you think that's where language is, that's where vision is, that's where executive function is. So planning and task execution, so much of that is about making our way in the world around us. So we tend to glorify
that and think, well, that's in a sense where
our existence is, right? And I believe that is not true, right? And again, can I say that for
sure, of course not, right? But my read of 20 years
of doing clinical work and thinking about all sorts of medicines and thinking about the psychedelics in a lot of depth, I think that what they do is they take us out of the cortex, right? Because that's where we
run into these problems. That's where we bounce
things over and over again that the distress centers deepen our brain and the brain stem kind of
align with the outer parts of the cortex and they say, right, we we're in distress. We want to stay alive. Often a lot of us have had
trauma that makes these changes in the brain and then we're
thinking all the time, like what would I do
if, if there were war, what would I do if there's
civil war, if someone bombs us, what will I do if the
economy collapses, right? What will I do if somebody gets sick? We're thinking all this future projection that is all coming from
a place of fear, right? It's all coming from a
desire to think about things and control the future
with this part of the brain that is so uniquely human, right? And I think when we take
the neuro transmission out of those places, right? And we set it in a part of the brain and say the insular cortex, right? The parts of the brain that are sort of in the middle, right? Which I think, I believe is
where our humanness really is. So the psychedelics make there
be less chatter communication in these other parts of the brain. And then we become seated
in the part of the brain that I believe is most
about our experience of true humanness, which is why, when you read about, people who have experiences
and I've heard about them and people talk to me about this, right? They've utilized it. They talk with me. So whether it's someone
telling me their story or it's coming from research data, it's why people can sort
of see with clarity that, oh, that trauma, that thing
is not my fault, right? Like we feel a sense of
compassion for ourselves. We relieve ourselves,
release ourselves from guilt and you say, why is this
so helpful to people? And I think it's because it can do what we are trying to
get at in good therapy, but it can really catalyze
that by just putting a person in that part of the brain that can see it for what it is, without all that chatter
in the cortex about, hey, got to think it's your
father, you won't avoid it again and that makes the repetition compulsion. How do I think ahead to the
next thing that might happen and what else bad might happen? I mean, we don't get anywhere doing that. And I think where we get somewhere
is when we seed ourselves deeper in the brain,
which I think we do if, if we're like doing really
good therapy and we're, we're in the deep parts
of the brain, but these, these psychedelics, the medicinal value I believe
is putting us in that part of the brain where a person
can really find truth. And that's why I think that, that's come so far in these few years because I think that is
very clinically evident. And I think we're going to
see more and more of the value of that and how, what the
psychedelics do can become, I believe a heuristic for
understanding like wait, how are our brains really functioning? And what are the parts that really matter to our experience of being human? It's those parts of the brain, right? The deep parts of the
brain, the insular cortex and the areas around it that
say light up when a person has an experience of spiritual ecstasy or an experience of connection
with another person, right? We kind of have these telltale
markers that something is going on there that's very
important and very special. And I think we're more
attracted to the outer parts of the brain in part 'cause
they're easier to study, right? I mean, as you know, better than I do, we started studying the brain
through lesion studies, right? 'Cause it was easy to, or to see if a person got
hurt in this part of the brain or had a stroke in that part
of the brain, what changes? So we look at the cortex 'cause one, it's easier to study and
we tend to glorify it. And I think that has been misguided. And I think that we're learning. about how that's been misguided through the study of these novel modalities from
Western perspectives, would of course they've
been used for a long, long time in other cultures, but novel from our perspective. - Yeah, I'm fascinated by this idea that in these middle brain structures is, is where our humanity lies and as you said, I also wonder whether or not
other animals experience life more from that orientation
with less chatter. We can only guess, but. - [Paul] right. You know, that a dog lover and being in the presence of
animals that seem to just be present in what's happening in
their immediate environment, not too much anticipation. - Right, I mean, through sentient right? I mean what you're talking about is sentience, it's important. And sentience is extremely
important, right? And if we're going to
overvalue say language, then I think we undervalue
sentience, right? Which is why I think we tend
to undervalue animals, right? And their suffering, we say, well, they're not saying
anything about it, right? And you know, they're not
writing about it, so, okay. It's easy to ignore and we think about, again the hubris of that right though, because we can think and talk and write, like we must be feeling more than species that don't do that. I mean I think, I think that that is so true and that we're going to
understand more about sentience in other species and how, that's at the core of existence. And my hope would be that we value more humans and animals, right? Through the evolution
of that understanding. - The hallucinations that
accompany psychedelics like LSD and psilocybin have
such an attractive force to them as a concept and as an experience. And so I think most often when
people hear hallucinogens, they think, and psychedelics, they think about hallucinating. - [Paul] Right. - It makes sense why they would. - [Paul] Right. - But what's so interesting to
me is nothing in your answer about psychedelics,
psilocybin and LSD focused on hallucinations, per se. It was more about feeling states, accessing a feeling state or a relation to an event or to a person or to oneself. Maybe even I, I caught hints of maybe
even empathy for one's self. - Yes. - [Andrew] For the first time. - Yes. - None of that had to
do with seeing sounds or hearing colors and these kind of cliche statements about hallucination. So I am aware of laboratories, one at a University of
California Davis in particular, but a few others that are trying to generate chemical variance of psychedelics that lack the
hallucinogenic properties, but maintain these other
properties as therapeutic tools. And as I say that, I realize that I, people in the psychedelic
community are probably thinking, oh, that's horrible. That's the dismantling of the core thing. But the simple question is, do you think the hallucinations
are valuable for anything? - And I think we're really
getting into the philosophical, right, the ontological, right? There's this sort of trying
to understand being, right? And I don't claim to
know the answer to that. I think that at times it
seems like the hallucinations have a metaphorical or a symbolic way of being helpful, right? Because people will come
to understand things that they hold dear and true
after the experience, right? That often, not always,
come through the lens of the hallucinations. So are the hallucinations necessary? Are those hallucinations
sometimes important sometimes not? I mean, I think we don't understand that. And I think we want to be respectful of the sort of mystery of that. But what I think is fascinating
is when you think about like substance abuse and
what that means is, well, one aspect of that is that
a person has experiences, thoughts, conceptions of self in the world with the substance that
without the substance, they know are wrong, right? People talk about, you
know, liquid courage, right? And okay, I feel better about myself and I feel courageous 'cause
I've had a couple of drinks. Now, when I, when I, after that, I feel like normal about myself
and that was false, right? And we see that like, that's part of what substance
intoxication means, right? But what we see with the
psychedelic medicines is something that's
incredibly different, right? That people are having
experiences that are so delinked from our normal experience of reality. And then when they come in a
sense back online with right, in a normal cognitive way,
they realize like, wow, now I'm applying all those mechanisms of trying to understand truth and to that, and what I see is that it's
true and wow, it's true. Like, I mean, we hear that
all the time, which tells me, hey, something different
is going on there. And of course these are powerful tools so misused like very
bad things can happen. But you think about the clinical
utility and what does it mean that so many people
change for the healthier or even change their
lives after an experience because it so resonates as like, oh, now I understand
something that's true. And it's not something bizarre. It's like, I wasn't responsible for
being raped that time or I'm not less than even
though my sexuality or my gender identity's different from some
silly binary concept, right? Like people kind of often
get it and they feel differently about themselves and guilt and shame are impacted. So I think we're likely to
see that they are powerful anti-trauma mechanisms again, used clinically in the right hands. And I think that we're also going
to see that they're heuristic for understanding our brain
that goes against what I see as some of the reflexive hubris of, well, the outer parts must be the best because that's what makes us human and other animals don't have it. And we're better because we're human. I mean, it makes no sense, you know? - I'd like to talk about MDMA and I'll preface this by saying I was a participant actually, technically I'm still a
participant in a clinical trial. So I have experience of doing it twice at the trial involves three
separate dosings of this. I was reluctant to do it
outside of a clinical trial, mostly because I was aware there can be some cardiac effects. And I liked the idea there
would be a clinician on hand. And I'll just say that
I found the experiences to be profound, beneficial
and very different from one session to the next. The first one felt a whole collection of ideas and relational
things came up that felt very powerful and transformative. And I do think that I learned there, I exported a number of things, my particular experience
isn't relevant here, but the second time I expected
it to be the same way. And it was very mellow and relaxing and was deeply tied to kind
of notions of acceptance. So there weren't all these
revelations and wow new insights. It was very much about sort of grounding into a kind of a calmer state. So I have the personal experience of benefiting from these in
ways that I think still benefit me and was very struck
by the power of MDMA. And my very crude understanding
of the pharmacology and the state that is being under MDMA is that it encourages or increases dopaminergic transmission, but also serotonergic transmission. - Yeah. - Which is to my knowledge, a kind of a rare state
for the brain to be in that typically it's more
of a seesaw dopaminergic drive towards external goals or more serotonergic drive towards more plasticity or comfort
with what one already has. And so with both those systems amplified, the only way I can describe
it subjectively is that it, everything sort of funneled back in, and it was almost like a
pursuit of inner landscape. And I can only imagine what it
would be like in the context of doing this with somebody
else also taking MDMA. I have no idea what that's like. That's my report of the experience. I know that the experience can vary. What are your thoughts about the chemistry and what sorts of states do you think MDMA is creating that can explain why it's
a useful therapeutic tool in some cases and what sorts
of cases those might be. - Sure, sure. To clarify, I think part
of what we're starting with is this is very different
than the psychedelics, right? Which are seeding our
consciousness in these deep centers of the brain, right? Whereas what MDMA is
doing is sort of flooding with positive neurotransmitters, right? In certain parts of the brain. And I think what that creates
is a greater permissiveness inside to entertain or approach
different things, right? So I think where we see it's tremend, my read of the data is around potentially and we're seeing in some
of the trials, right? Tremendous benefit for trauma, right? And you think about what we
were talking about earlier, how this reflexive, guilt, shame, hypervigilance, avoidance, right? And when these systems are flooded with these neurotransmitters, it's more permissive to sort
of think about that, right? And to think about that without again, all the chatter of that's your fault, or you're never going to get
anywhere because of that, or you know what that means, right? They could kind of go away
and then we can think about it in a way that isn't through
the lens of fear, right? And I think that's, the power there is that it's permissive of approaching something, contemplating something, a different, a novelty as we
talk about a de novo approach. And I think that's also why the experience can vary because you could also see how, if you're not thinking
about something, right? So there's not a clinical guidance to it, you could be in a state where like, hey, I just feel good, right? And I'm thinking about good things. And like, that can feel good, right? But it, but that's not necessarily
problem solving, right? So the clinical guidance says, hey, let's take that state and
do something with it, right? Let's Now that you're in this state, let's make hay while the
sun is shinning, right? You're in a state where we can look at things that are traumatic, right? We can approach them from
a de novo perspective. And I think it's part, I think that explains why
you had these different experiences from one to the other, because your brain is just in a state that's conducive to something, right? But if there's not the mechanism to have that thing happen, like conducive to something therapeutic, then you might go there on your own. Or you might just be in a state where you have a sense of wellbeing and you sit with that. - Which sort of seems like a waste to me. I mean, this is what I tell
people when they ask about MDMA. I said, at least from my experience that the potential hazard
there is that in that very high dopaminergic, serotonergic state, there were moments where I
felt like I could get excited about any one specific concept
that I might even just think about, for instance, water and how nourishing it is, and really just go down the path of water and the world and all
the water and you can, you're in a state that is
very prone to suggestion. - [Paul] Yes. - Internal suggestion. And so the guidance turned out, the guidance from the clinician
turned out to be immensely valuable in allowing me
to go into my own heads for bits of time, but
then also to resurface and share and exchange in a way to, I'm trying really get something out of it that was useful and that I could export because of course water is wonderful, but I'm not really interested in growing my relationship to water. - [Paul] Yes. And I really felt like in,
I could understand for the, I never went to raves
or anything growing up. I never did MDMA recreationally, but I understood for the first time how people could get really attached to an environment
and feel connected to things. Because I think with all that serotonin, you just feel connected
to everything around you. So I think it's a slippery slope there. - Yes. - And I don't know what the future of the clinical use of MDMA looks like, but I would hope that whoever's thinking about I'm guiding these sessions is really thinking carefully, also about evolving the practice to help people really move through in a sequential way so they can leave with something valuable. - Yes, 100%, 100%. These are such powerful tools. And again, if they're powerful tools and we're using them without
respect for them, right? Without clinical guidance,
we incur risk, right? I mean, you know, getting obsessed with water
while it probably isn't going to hurt you, right? But if someone is out using it,
they're around other people, what one can feel positively about or become sort of obsessed
in the short term about can be very counterproductive, right? It can be a lot of risk to that. So I think it anchors back to
these are very powerful tools. We're coming to understand
them much, much more. And we're coming to understand
that they have immense potential to be helpful to us. But I think and hope that
that only also increases our respect for those
modalities and what can come, what negative can happen
if we're not respectful. - It's going to be very interesting to see where all of this goes in the next few years, not
just in Oregon, but elsewhere. One way or another it's happening. It seems to have a momentum
that is not going to stop. So very exciting area to be sure. - I agree. - I have a question about language. In your book, you talk about how we need to be careful about the use of language around trauma. - [Paul] Yes. - Maybe problem solving and
problem describing in general. At one extreme, you hear that your
brain and your body hear every word you say, and, you know, we have to be so careful with language. And that actually frightened
me for a number of years, 'cause I would hear that
and I thought, gosh, if I just think that something is bad now it's going to hurt me worse, which itself is part of that whole, packing down of an issue. Very hard to avoid thoughts
without distraction. - [Paul] Yes. - So that's one extreme,
on the other hand, I can say, I can tell somebody, I love them with a tone of hatred. I can tell somebody I hate
them with a tone of love. - [Paul] Yes. - So how should we think about
language in parsing trauma? And in your book you talk about, you give some cautionary notes about talking about depression, trauma and PTSD in terms that that might diminish their real severity in some cases. And I was really struck by that. So maybe just touch on how should we talk about these
things in a way that doesn't diminish them for ourselves
or for other people. And at the same time honors the fact that there's a lot of trauma out there. - [Paul] Right - And there's a lot of
depression out there and we need to talk about it. - Yeah. I think this a very complicated and in many ways convoluted topic, like I think it's wonderful
that we have language, but boy, language leads
us astray often too. You think about how we, how people define words? Someone says a word, what is it? Does that person know
what that word means? What nuance are they taking from? it We just have to be very
careful what we're saying and what we're communicating. And I think this doesn't mean because, there's a sort of phenomenon now where people are trying
to control language I think too much, like you can't say anything
that someone else might find hurtful or you have to refer to people in ways they choose to be referred to, even if those are ways that
others don't understand, or ways they themselves have
decided or ways that might be psychologically or clinically unhelpful. So I think the over control
of language is not good, but I think the specificity of language of what are we trying to
say, how are we defining it? Or even the word trauma, right? We're talking about trauma. So we want to define
what that means, right? It doesn't just mean like, oh, anything kind of negative, right? Because then that dilutes it
down to meaning nothing, right? It also doesn't just mean, injury and combat, right? Like we have to talk about what that is. So I think anchoring it
to something that rises to the magnitude of
overwhelming our coping skills and changing us, like then at least I define
it that way and I can communicate that to you
and we can understand what we're talking about, right? I think that another aspect
of language, while again, we need this middle ground and
I don't think that it is okay for the over control of language
to shut down expression, but we also have to acknowledge, how we're so much less
distanced from each other through social media. And I think social media can do very, very good things as hopefully
we're doing now, right? But it can also be used to harm people from a distance, right? And how much hatefulness
is there out there that I think comes from anger and frustration in people, back to trauma, right? Where people just want to be angry and it's not really issues
that they're talking about, but then there's a target of that anger and people feel beleaguered by that. And the words that people use sometimes are so awful that someone reading that, like if you're in the demographic that's being targeted, right? And you're reading that, I mean, how does a person not feel, not feel, be set upon vulnerable, right? And then I think that also fuels, things like we just had this terrible shooting in Buffalo, right? Like just hate motivated, right? And I think that, because that kind of language
becomes very real to people who may take it in, it fuels their hate and then
they do something to enact it, which of course creates greater feel and fear and vulnerability. And I think there was
some civility and decorum that was in our world,
not that long ago, right? I mean, you know, I'm in my early fifties, I'm not that old, right? But I remember a time when in political discourse, say people were civil
to one another, right? Now so much, I mean, it's
not all of it, right? But there's an acceptance of things that are just bombastic, right? It's a circus side show sometimes of people being just angry and aggressive and it's not really linked to anything, although it's allegedly
linked to something, but then other people's
anger can attach to it. And it's not about what it's about, but it's about aligning with the anger and I think that there is so much damage that comes from that. And I think, should we have, should it be okay that
people sometimes are talking, communicating, using language in ways that would like get us suspended
from middle school, right? Ways I don't want my
eight year old to see, I mean, is that really okay? Or do we need to take a stand for like rational use of language? I don't want my use of
language to be over controlled by someone who thinks
they sort of understand better than the rest of us
how to communicate with us. Okay, I don't want that. What's stereotypically a sort of idea of the left say, right? At least in our society,
but I also don't want, language, it can be so angry and so aggressive that it is perpetuating or spreading vulnerability and
that it facilitates trauma. And I think we could set
standards as a society where we say, look, I
don't want anybody in power who's going to behave that way, right? I don't care if their
whole agenda is like, make Paul Conti's life better. I'm still not going to
vote for you, right? If you're behaving towards others in a way that's denigrating, you're behaving in a way that I feel essentially ashamed of, right? And I feel that a lot, right? I see the politics, you
know, I see things play out. It's not always political, of
course not always political, but I see things play out
and I think, oh my gosh, I feel embarrassed. Like we we're somehow okay with this. Well, it doesn't matter which side of the political spectrum it's coming to. And I think that's an
indicator that what we're doing is really hurtful to us. People become more angry. They attach to the anger. People feel more beleaguered. There's more divisions between us. And it seems more and more like, well, we can only really
identify with people who are just like us and like, what does that really mean? I mean, the divisions
that it creates between us and that promotes so many
negative things, right? I mean, think about ways
in which it promotes white supremacy, right? It's just one example, right? And we've seen that play out
that this is really bad for us. And we've got to look at that. I mean, if we don't look at that, I don't think something
is going to happen. Like something is happening, right? It's happening now. - Yeah, and I'm, it really, to my mind, it really seeps down into the soil of everything that we're talking about. - Yes. - On all sides. - [Paul] Yes. - People are activated. People are upset about
one thing or the other. - Right. - No one is immune from upset regardless of political affiliation. - [Paul] Right. - Everybody seems to be upset nowadays. - [Paul] Right. - As I was hearing you talk about this, I feel a lot of resonance
with what you said and I also am hoping you run for office. - Thank you. I don't think I have the gumption for that but thank you for. - [Andrew] Well, that would be wonderful. - Thank you. I'd like to talk about a concept of taking care of one's self. This comes up in the book. - [Paul] Yes. - This is something we talk
a lot about on this podcast. I mean, I think people have
heard me blab endlessly, and I'll probably go into the grave telling people to get sunlight
in their eyes when they can and to try and get proper
sleep and to have a few tools for reducing their anxiety in real time and on and on and on. - [Paul] Right. - We hear about this concept
of taking care of oneself and I think at a surface level, it can sound a little bit
light, you know, oh, take care, take care, take good care. But to me it's a deep
and powerful concept. - [Paul] Yes. - And I was very happy
to see it in your book and also to learn a lot of ideas about what that really looks like, because whether or not
somebody is in the early stages of considering whether
or not they have trauma or is in the deep stages of working that through or has made
it through the tunnel some distance taking care of oneself is an ongoing process. - [Paul] Yes. - I'd love for you to just describe what taking care of oneself
means to you as a clinician. And of course the practices and things that you encourage people to do. But how should we think about taking care of oneself because on one extreme, you could imagine massages
or treats vacations and chefs for hire that
take care of everything for ourselves. And on the other extreme, you could say, leaning into life in a way
that you're paying attention to small things while
working very, very hard. So it's such a big concept, how do you think about
taking care of one's self? How should I take care of myself? - [Paul] Sure. - How should people
take care of themselves? - Sure. - I see here, what I think is a very fascinating dichotomy, right? That in some ways, like, think about how complex
our brains are, right? How complex our psyches,
our unconscious minds are. There's so much complexity
there, but on the other hand, psychological concepts that are consistent with health are often very simple, right? Which I don't mean light, right? But simple, straightforward, right? And I think self-care is
absolutely one of them. I mean, how much is talked about, how to take care of one self that just skips over the basics that are necessary as a
building block for all else. So it doesn't matter how many
chefs or vacations or whatever a person has if the basics of
self-care aren't squared away. And it's not a light concept to say like, are you sleeping enough, right? Are you eating well? Are you getting natural light? Are you interacting with people who are good to interact with, right? Are you accepting negative
interactions in your life? Are you living in circumstances that make you feel okay or not? They're very basic premises, but so often we're not
looking at them at all, right? We're not looking at them at
all because we tend to skip over them and we tend to
skip over them either, because, again, in some automatic way that sometimes is trauma driven or we're not going to look at that, right? And often not taking care of ourselves can have the punishment
distraction, right? There's so much that can come into that. Or our sense of power is, is tied to not taking care of ourselves. I mean, I'll give you
an example is I tend to, for whatever reason do reasonably well with very poor self care, right? And like, that was very adaptive when I was into medical training, right? And I'm like, okay, I can eat a lot today. I can not eat, right? I can sleep two hours. I can sleep eight, right? I mean, overall, that's not good. And it hasn't been good
for me as I've aged. But then I realized some look, I'm doing all these things
to make myself healthier, but like what, I ignored that, right? And why am I ignoring it? That was a key question. Why am I ignoring it? Because somewhere inside of me, as it was, and still to some extent is, this idea that my ability to
be really functional, right? To generate success in the world around me is tied to my ability to do that, right? That, oh, but if I stop
doing that and now I'm like, I'm eating and sleeping regularly, then I'm going to lose some edge. So even I think about this all the time, but I realize, hey, I'm also, I'm not
doing it inside, you know? And I think it's really grounding to the basics that really help us of like, what are the basics of what I'm doing and not doing in my life, diet, exercise, sleep, people, circumstances, leisure activities. I mean, sunlight. I think immensely important
and dramatically undervalued. - Well, I want to thank you for that. And I want to thank you
for today's discussion. I found it to be incredibly informative and I know our listeners will also. I also want to thank
you for the work you do. I mean, you obviously run an incredibly robust clinical practice that I'm aware that you're
constantly trying to improve, even though it's operating at
the highest levels already. - I appreciate that. - I really, the reason
why you're here today is because I've done
a wide and deep search for people in these areas. And there are so few who have
the background in medical training and physiology, in the psychoanalytic
and psychiatric realm and also have a grounding
toward the future, of what's coming and who can encapsulate so many different orientations and bring them together
into a coherent piece. So I really thank you. - I so appreciate that. - Yeah, and for your
book, which is incredible, I will go on record saying, I think this is the
definitive book on trauma. - Wow, thank you. - And I really encourage people to read it and will continue
to encourage people to read it. It has so many valuable takeaways and insights and tools there. So on behalf of the listeners and myself, thank you so much for joining us today. - You're very welcome. And I take that to heart
and I'm very appreciative of being here, so you're very welcome and thank you as well. - Thank you. Thank you for joining me for my discussion with Dr. Paul Conti. I also highly recommend that
you explore his new book, which is "Trauma: The Invisible Epidemic, How Trauma Works and How
We Can Heal From It." It's an exceptional resource, both for those that have trauma and those that don't have trauma or those that suspect
they might have trauma. Again, it's a deep dive
into what trauma is and offers many simple
tools that anyone can apply with a therapist or not, in
order to heal from trauma. And if you'd like to
learn more about Dr. Conti and the work he does
directly with patients, please check out his website,
pacificpremieregroup.com. We've also provided a
link to both the book and pacificpremieregroup.com
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