Dr. Paul Conti: Therapy, Treating Trauma & Other Life Challenges

00:00:00.000 | - Welcome to the Huberman Lab Podcast,

00:00:02.280 | where we discuss science and science-based tools

00:00:04.880 | for everyday life.

00:00:05.900 | I'm Andrew Huberman,

00:00:10.240 | and I'm a professor of neurobiology and ophthalmology

00:00:12.920 | at Stanford School of Medicine.

00:00:14.880 | Today, my guest is Dr. Paul Conte.

00:00:17.260 | Dr. Conte is a psychiatrist who did his training

00:00:19.720 | at Stanford School of Medicine,

00:00:21.280 | and then went on to be chief resident

00:00:22.960 | at Harvard Medical School.

00:00:24.320 | He now runs the Pacific Premier Group,

00:00:26.360 | which is a collection of psychiatrists and therapists

00:00:28.820 | focusing on solving complex human problems,

00:00:31.520 | including trauma, addiction, personality,

00:00:34.040 | and psychiatric disorders.

00:00:35.960 | Today, we discuss trauma in detail

00:00:38.360 | and the therapeutic process in detail.

00:00:40.920 | For instance, we discuss what is trauma?

00:00:43.320 | How do you know if you have trauma?

00:00:45.440 | Dr. Conte shares with us, for instance,

00:00:47.340 | that not every experience that we think is traumatic

00:00:49.580 | is necessarily traumatic,

00:00:50.920 | and yet many people might have trauma

00:00:53.360 | without even realizing it.

00:00:54.800 | We also talk about the therapeutic process generally,

00:00:57.280 | for instance, how to pick a therapist,

00:00:59.160 | how to best approach and go through therapy,

00:01:01.500 | and how to evaluate whether or not therapy

00:01:03.600 | and your relationship to the therapist is working or not.

00:01:06.460 | We also talk about self-therapies

00:01:08.040 | because we acknowledge that not everyone has access to

00:01:10.740 | or can afford therapy.

00:01:12.620 | And we talk about drug therapies,

00:01:14.880 | for instance, antidepressants, antipsychotics.

00:01:17.920 | We talk about alcohol, cannabis, ketamine,

00:01:21.240 | and the psychedelics, including psilocybin, LSD,

00:01:24.840 | and we talk about the clinical use of MDMA

00:01:27.440 | and what the future of that looks like.

00:01:29.200 | The reason for bringing Dr. Conte onto this podcast

00:01:31.680 | is because I see him as the person

00:01:34.200 | who has the greatest and most holistic view of therapy,

00:01:38.260 | trauma, drug therapies, talk therapies,

00:01:41.040 | and how self-therapy and work with others can be integrated

00:01:44.520 | for both healing and growing from difficult circumstances.

00:01:47.860 | Dr. Conte is also the author of an exceptional book

00:01:50.800 | entitled "Trauma, the Invisible Epidemic,

00:01:53.440 | "How Trauma Works and How We Can Heal From It."

00:01:56.440 | That book describes trauma and its many features

00:01:59.180 | and many tools, some of which we discuss

00:02:01.820 | on the podcast today.

00:02:03.320 | So whether or not you have trauma or not,

00:02:06.100 | by the end of today's episode,

00:02:07.340 | you will have a much deeper understanding

00:02:09.160 | about what trauma is.

00:02:10.760 | In fact, I'm confident that you will gain insight

00:02:12.760 | into whether or not you have trauma or not,

00:02:15.000 | whether or not people close to you have trauma or not,

00:02:17.240 | and the various paths to recovering

00:02:19.280 | and indeed growing from trauma that we can all take.

00:02:22.400 | As you will soon learn, Dr. Conte

00:02:23.960 | is an exceptional communicator and has a unique window

00:02:27.520 | into the trauma and therapeutic process

00:02:29.780 | that I know that all of us can benefit from.

00:02:32.240 | Before we begin, I'd like to emphasize that this podcast

00:02:34.760 | is separate from my teaching and research roles at Stanford.

00:02:37.520 | It is, however, part of my desire and effort

00:02:39.540 | to bring zero cost to consumer information about science

00:02:42.000 | and science-related tools to the general public.

00:02:44.720 | In keeping with that theme,

00:02:45.860 | I'd like to thank the sponsors of today's podcast.

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00:03:02.940 | I spent a lifetime working on the visual system,

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00:06:58.180 | And now for my discussion with Dr. Paul Conte.

00:07:01.820 | Paul, thank you so much for being here today.

00:07:03.780 | - Well, thank you so much for having me.

00:07:05.500 | - I've been looking forward to this,

00:07:07.580 | and I've received a ton of questions about trauma,

00:07:12.220 | about therapy, about how to assess where one is

00:07:15.660 | in their own arc of problems

00:07:18.560 | and addressing familial issues

00:07:21.580 | and relationship issues and so forth.

00:07:24.620 | We could just start off very basic

00:07:26.060 | and just get everyone oriented.

00:07:27.700 | - Sure.

00:07:28.540 | - How should we define trauma?

00:07:31.180 | We all have hard experiences.

00:07:33.340 | Some of them we might ruminate on more than others,

00:07:36.780 | but what is trauma?

00:07:38.740 | - To make the definition relevant,

00:07:42.620 | I think we have to look at trauma

00:07:44.380 | as not anything negative that happens to us, right,

00:07:47.660 | but something that overwhelms our coping skills

00:07:50.980 | and then leaves us different as we move forward.

00:07:54.200 | So it changes the way that our brains function, right,

00:07:57.780 | and then that change is evident in us

00:07:59.780 | as we move forward through life.

00:08:01.560 | - So how do we know if we have trauma or not?

00:08:04.900 | I've heard before, everyone has trauma.

00:08:07.820 | For instance, I've heard that if we are a child

00:08:11.740 | or when we are a child and we request love from a parent

00:08:15.180 | or attention from a parent,

00:08:16.920 | if they dismiss us, that that's a microtrauma.

00:08:21.220 | Is that overstating or unfair to the real issue of trauma?

00:08:25.360 | Do we all have trauma?

00:08:27.900 | What are microtraumas?

00:08:29.140 | What are macrotraumas?

00:08:30.540 | - Right, I think traumas that we might categorize

00:08:34.460 | as disappointments, right,

00:08:35.940 | or things that are negative but not deeply impactful,

00:08:40.220 | I think is not a helpful definition, right?

00:08:43.240 | I think the helpful definition is something

00:08:45.220 | that rises to the magnitude of really changing us

00:08:48.760 | and something that we can see both in how we behave,

00:08:52.420 | we can see it in mood, anxiety, behavior,

00:08:54.820 | sleep, physical health, so we can identify it

00:08:58.020 | and we can also see it in brain changes.

00:09:00.540 | So the fact that we become, say, more hypervigilant, right,

00:09:03.860 | more vigilant, and then we can see

00:09:05.980 | that different parts of the brain are more active.

00:09:08.540 | So that definition, that definition captures how trauma,

00:09:13.540 | if it rises to a certain level,

00:09:16.460 | like what we would say trauma

00:09:17.780 | that makes a post-trauma syndrome, right,

00:09:20.140 | leaves us different, I think is the helpful definition

00:09:23.540 | of trauma because it's a clinical definition, right?

00:09:25.900 | It's changes in us as people and we can map those changes

00:09:30.660 | to identifiable shifts in our brain function.

00:09:33.940 | - So how do we know if we've been changed by something?

00:09:38.300 | I mean, I can think back to childhood events

00:09:42.420 | where some kid on the playground or in the classroom

00:09:45.380 | said something I didn't like, something negative about me.

00:09:48.820 | I think most people can do that.

00:09:50.060 | We have a great memory for the kid that said something awful

00:09:54.100 | or the parent or teacher that said something awful

00:09:56.100 | that really felt like it hurt us

00:09:57.740 | or at least it stuck with us.

00:09:59.500 | So clearly one's brain, my brain in this example,

00:10:03.460 | has been changed by that event such that I remember it.

00:10:08.040 | But how do we know if something has actually changed

00:10:10.560 | the way that we are because of course,

00:10:12.600 | we don't know how we would be otherwise?

00:10:14.620 | - Right, that's difficult, right?

00:10:18.500 | It's doable, but it's difficult because the response.

00:10:22.100 | So if the trauma rises to the level of changing our brains,

00:10:25.300 | and I don't just mean like we have a new memory, right?

00:10:27.700 | So we can have memories of something that was negative,

00:10:30.300 | and in that sense, it changes the brain

00:10:31.980 | because now there's something we can call to mind,

00:10:34.600 | but it doesn't change the functioning of the brain.

00:10:37.740 | If trauma rises to the level of changing the functioning

00:10:41.740 | of our brains, then there's almost always a reflex

00:10:45.140 | of guilt and shame around the trauma that can lead us

00:10:49.700 | and often leads us to bury it, to avoid it,

00:10:53.900 | to feel that now there's something negative inside of me

00:10:57.420 | and it feels shameful or it feels like no one else

00:11:02.160 | would accept it, right?

00:11:03.740 | So what happens is people tend to avoid looking

00:11:07.200 | at the change in them, which is exactly the opposite

00:11:10.580 | of what needs to be done, right?

00:11:11.800 | The idea of in a viral pandemic, right?

00:11:13.940 | We wanna stay away from one another and isolate, right?

00:11:16.740 | But with the trauma epidemic,

00:11:19.340 | we need to communicate with other people.

00:11:22.140 | We need to communicate and put words

00:11:24.020 | to what's gone on inside of us.

00:11:25.900 | And very often a person knows, I mean,

00:11:28.900 | I've done so much clinical work over about 20 years

00:11:32.760 | that has focused on trauma and a lot of the times

00:11:36.380 | the person knows, right?

00:11:38.280 | But they're not admitting it to themselves

00:11:40.100 | because they're afraid of it, right?

00:11:41.260 | They don't know what to do, but if they start talking,

00:11:44.540 | then they'll talk about the event or the situation.

00:11:48.260 | It could be something acute or it could be something chronic

00:11:51.140 | that really has been harmful to them, right?

00:11:53.260 | And then they feel different afterwards.

00:11:55.380 | Like, oh, after that, I started thinking differently,

00:11:57.820 | feeling differently, but that doesn't always happen.

00:12:00.460 | Sometimes it's a process of exploration through dialogue,

00:12:04.900 | right, whether it's written or whether it's spoken

00:12:08.060 | of the person sort of exploring the changes

00:12:11.300 | inside of themselves, maybe changes to their self-talk

00:12:13.780 | inside, changes to their thoughts about the world

00:12:16.300 | and whether they can navigate safely and readily in it.

00:12:19.780 | And it anchors, as I talk about this,

00:12:22.200 | the example I'll use at times is the example

00:12:24.700 | of my own life where, you know, when I was much younger,

00:12:28.620 | in my early 20s, my younger brother took his life

00:12:31.900 | by suicide and, you know, the response of guilt and shame

00:12:36.220 | and hiding all of it inside of me was,

00:12:41.140 | it's just very dramatic, but I wasn't acknowledging it,

00:12:46.140 | right, 'cause I didn't know what to do about it

00:12:47.820 | and I felt guilty and I felt responsible

00:12:50.340 | and I felt ashamed, so there was an avoidance inside of me.

00:12:54.460 | And then I wasn't saying to myself, hey, before this,

00:12:57.500 | you thought that you could be effective

00:12:59.060 | and you could make your way in the world

00:13:00.460 | and, you know, if you were a good person

00:13:02.060 | and you worked hard, you could make a difference, right?

00:13:04.500 | And then afterwards, I thought, I can't get anywhere,

00:13:07.600 | the world's against me and, you know,

00:13:09.820 | I felt like, oh, my options are all gone

00:13:12.500 | and, you know, I was like 24 years old, right?

00:13:14.540 | So I didn't see that the change was in me,

00:13:18.020 | but I was taking care of myself poorly,

00:13:20.420 | like there was enough going on that was unhealthy

00:13:22.940 | that I couldn't avoid the realization that like,

00:13:25.100 | hey, I'm different now and in these ways

00:13:28.100 | that are automatic, you know, my reflex to,

00:13:30.780 | can I make my way in the world?

00:13:31.900 | Can I have a good life?

00:13:32.940 | Can I be happy?

00:13:33.780 | Well, my reflexes to that were all different

00:13:36.260 | and they were coming through the lens of heightened anxiety,

00:13:39.260 | heightened vigilance, a sense of guilt, a sense of shame,

00:13:42.780 | and a sense of non-belonging in the world

00:13:45.300 | and was ultimately good and helpful people around me

00:13:49.480 | and my own realization and hey,

00:13:50.940 | things are not going well, right,

00:13:52.540 | that led me to then get some help

00:13:54.500 | and to be able to talk about it and realize like,

00:13:56.700 | oh, my gosh, I need to face these things

00:13:58.820 | that are going on inside of me.

00:14:00.940 | - From a psychoanalytic, psychological,

00:14:04.520 | and maybe even a neuroscience perspective, two questions.

00:14:08.340 | Why do you think that when we experience trauma,

00:14:11.980 | these things that we call guilt and shame surface,

00:14:17.260 | you know, everything you're telling me is that

00:14:20.220 | in the end, that's not adaptive.

00:14:22.500 | Why would we be built that way?

00:14:25.280 | So that's the first question.

00:14:27.460 | And then the second question is, you know,

00:14:30.500 | how should we conceptualize, you know, guilt and shame?

00:14:35.160 | You know, I think that we hear guilt, we hear shame,

00:14:38.220 | you know, how should we think about it?

00:14:39.580 | I mean, those emotions must exist in us for some reason,

00:14:44.580 | but in this case, it seems like they don't serve us well.

00:14:48.300 | So maybe in that order or in reverse order, you know,

00:14:53.020 | what is guilt really?

00:14:54.580 | What is shame really?

00:14:56.060 | And why is it that we seem to be reflexively wired

00:14:59.760 | to feel guilty and feel ashamed when that's

00:15:03.900 | the exact opposite of what we need to do

00:15:05.460 | in the case of trauma?

00:15:06.860 | - Right, right.

00:15:07.700 | No, I think these are great questions.

00:15:09.120 | And I mean, I don't think anyone knows the answers for sure,

00:15:12.220 | but my read of all of that is that there's something adaptive

00:15:16.860 | that has happened in us through evolution

00:15:19.900 | that now becomes maladaptive

00:15:22.820 | in the way we live in the modern world, right?

00:15:25.460 | So if you think of, through most of human development,

00:15:27.940 | you know, people weren't living that long, right?

00:15:29.540 | And the idea was to survive and reproduce.

00:15:32.320 | So traumatic things that happened to us,

00:15:35.560 | it would make sense for them to stay with us, right?

00:15:38.580 | So, you know, if you ate a new food

00:15:40.580 | and got really, really sick,

00:15:42.140 | it's like, you better remember that, right?

00:15:44.540 | You know, if you see someone from the group of people,

00:15:47.500 | you know, a couple miles away, right?

00:15:49.240 | And one of those people attacks you, right?

00:15:51.260 | It's like, you better remember that.

00:15:53.160 | So the traumatic things that are sort of emblazoned

00:15:56.860 | in our brain are built to last, right?

00:15:59.740 | Things that are positive

00:16:01.140 | will generate some emotion inside of us,

00:16:03.260 | but things that are profoundly negative

00:16:05.400 | are much more likely to stay with us.

00:16:07.700 | And I think that that was adaptive, right?

00:16:10.220 | When all of that was about survival, right?

00:16:13.020 | And I think the same thing is true with, say, shame, right?

00:16:17.740 | So I think here it makes sense to talk a little bit,

00:16:21.140 | and actually I'm interested in your thoughts about this,

00:16:23.100 | right, that the limbic system, right,

00:16:25.640 | so the system often is called the emotion system, right,

00:16:28.300 | in our brains, has actually, of course, varying function,

00:16:32.260 | right, and one aspect is affect, right?

00:16:35.500 | So affect is aroused in us,

00:16:38.300 | which I think the meaning then is,

00:16:40.740 | it's created in us without our choice, right?

00:16:43.700 | So if we're walking down the road

00:16:46.180 | and someone jumps in front of us or pushes us, right,

00:16:49.220 | then there's a response of fear, anger, right?

00:16:52.260 | Heart starts beating faster, more blood to the muscles,

00:16:56.320 | we're getting ready to fight, right, or run, right?

00:16:59.940 | And then we become aware of it, right?

00:17:02.440 | So the aroused affect in us is also about survival,

00:17:07.440 | and it has a very deep impact upon us,

00:17:10.060 | and shame is an aroused affect.

00:17:12.980 | So it can be raised in us without our choice,

00:17:16.300 | and it's very powerful, which if you think about that,

00:17:19.220 | is an extremely strong deterrent, right?

00:17:22.200 | So if you had, you know, imagine a tribe or a group of people

00:17:25.660 | right, that are sheltered together and, you know,

00:17:28.960 | someone eats half the food at night or something, right?

00:17:32.180 | And like, there's a very negative response, right,

00:17:35.020 | and that person feels shame because shame is so powerful

00:17:38.420 | to control behavior, right?

00:17:40.340 | So the way that trauma can change our brains

00:17:43.580 | and stay with us in a way that says, be more vigilant,

00:17:47.620 | look at the world in a different way,

00:17:49.460 | act more defensively, right?

00:17:51.500 | And how that links to shame and to guilt.

00:17:54.940 | So then guilt becomes what gets called feeling technically,

00:17:59.740 | where we relate the aroused affect to ourselves, right?

00:18:03.940 | So shame, the aroused affect, and guilt, the next step,

00:18:07.940 | right, when the shame gets related to self,

00:18:10.820 | are such profound behavioral interventions and deterrents,

00:18:15.120 | right, that you can see, I think, how evolutionarily

00:18:18.460 | kind of all makes sense.

00:18:19.680 | If we're fighting for survival, you know,

00:18:21.700 | and we're an elder statesman, if we make it to 20, right,

00:18:24.820 | this makes sense, but it doesn't make sense

00:18:27.920 | in a world where we live much longer, right?

00:18:30.560 | We navigate in all sorts of different ways,

00:18:33.080 | and there's so much coming at us that can be traumatizing.

00:18:36.180 | I mean, if you think about the news, right?

00:18:37.860 | I mean, how many times have I written a prescription

00:18:40.060 | for someone that says, no more news, right?

00:18:43.220 | - You've actually written those prescriptions?

00:18:44.540 | - Oh yeah, yes.

00:18:45.900 | So glance at the news, like look at the news for news.

00:18:48.940 | Anything going on, I need to know, right?

00:18:50.840 | But what are people doing is they're looking at it

00:18:53.860 | and they're clicking and they're clicking,

00:18:55.100 | and there's a sense of being like enthralled

00:18:58.620 | in a very frightening way with the horrors

00:19:01.760 | that are in front of us.

00:19:03.220 | And it shows how, yes, trauma can come

00:19:06.420 | through acute things that happen to us.

00:19:08.900 | Trauma can come through chronic things,

00:19:10.500 | chronic denigration, whether it's based

00:19:12.880 | upon socioeconomic status, immigration status,

00:19:16.660 | race, religion, sexuality, gender identity,

00:19:21.820 | these chronic traumas, right, of being denigrated

00:19:25.820 | by the society around us or treated as less than

00:19:28.580 | can change the brain.

00:19:29.600 | But vicarious experiences can too, right?

00:19:32.660 | And we know this, it's not theoretical.

00:19:34.620 | We know that the changes in the brain can come

00:19:37.780 | from vicarious experiences too, which is why people

00:19:40.660 | who are glued to the news and then feeling like,

00:19:42.620 | oh my goodness, like what is happening?

00:19:44.500 | You know, the mothers in the Ukraine who've, you know,

00:19:47.100 | lost babies in the war, and like there are things

00:19:49.180 | that are so terrifying that if we spend so much time

00:19:52.660 | with that, it has a similar effect.

00:19:54.740 | So our brains are built to change from trauma,

00:19:59.400 | but not in the way we experience trauma

00:20:02.380 | and not in the way that we live life in terms

00:20:04.660 | of the nature of living life and the duration of life

00:20:07.620 | in the modern world where these traumas that happen

00:20:10.100 | to us are often so bad for us because they change

00:20:14.460 | how our brain is functioning and then our entire orientation

00:20:17.380 | to the world is different.

00:20:18.900 | And that could be for, you know, years and years

00:20:21.780 | and decades and decades.

00:20:23.600 | It brings so much misery and suffering.

00:20:26.180 | And at times it brings death.

00:20:28.000 | If you think about a hundred thousand overdose deaths

00:20:31.420 | in this country in a year, a hundred thousand,

00:20:35.100 | where is so much of that arising from?

00:20:38.540 | As a person who's treated addiction very intensively

00:20:41.640 | over many years, I think that, well, I feel sure

00:20:44.700 | that the majority of addiction that I see and treat arises

00:20:49.700 | ultimately the roots of it are in trauma

00:20:53.340 | and are in trying to soothe something that's stuck inside

00:20:56.300 | that the person isn't letting outside because of the guilt

00:20:58.460 | and shame, but it's running around in their head

00:21:00.460 | and they're tormented by it.

00:21:01.820 | And now there's a pull for these drugs

00:21:05.180 | or sometimes medicines to soothe.

00:21:06.680 | So, you know, the opiates that were given

00:21:08.980 | after a minor surgery, right, are like, okay, yeah,

00:21:11.900 | they help the pain from the minor surgery,

00:21:13.540 | but what they're really helping is the pain inside, right?

00:21:16.700 | But that very quickly turns into addiction, danger, risk.

00:21:20.740 | And we see that over and over again

00:21:23.180 | and not in a theoretical way.

00:21:25.780 | Like I see that in people who have been in my practice

00:21:29.220 | with addiction arising from trauma

00:21:31.880 | who have subsequently died.

00:21:33.580 | So it's sort of writ large in our existence

00:21:36.940 | in the modern world.

00:21:38.540 | - Incredible to me that this is the way it works.

00:21:42.180 | And what I mean by that is this idea

00:21:46.660 | that I've heard about before,

00:21:47.900 | I think it was a Freudian concept of a repetition compulsion

00:21:51.860 | that, you know, this is what boggles my mind

00:21:55.140 | as I'm hearing this.

00:21:56.540 | Something happens to us or we observe something traumatic.

00:22:00.780 | And instead of acknowledging that

00:22:03.260 | and trying to distance from it,

00:22:04.800 | there seems to be a reflex of shame and guilt in many cases

00:22:09.180 | and stuffing it away.

00:22:11.160 | And then a repetition of behaviors

00:22:14.140 | to continue to try and to stuff it away.

00:22:16.760 | Like you're trying to pack, I don't know,

00:22:18.840 | recently I was packing a home

00:22:20.140 | and trying to get a sleeping bag back into the bag.

00:22:23.100 | It seems like it's always trying to mushroom out the top.

00:22:25.940 | This kind of thing.

00:22:26.780 | It takes a lot of ongoing effort.

00:22:28.660 | And at the same time that if this thing really exists,

00:22:32.500 | this repetition compulsion,

00:22:34.140 | people will return over and over again

00:22:36.140 | to the kinds of scenarios

00:22:37.620 | or at least the kinds of emotional states

00:22:39.240 | that look just like the trauma or resemble it in some way.

00:22:42.620 | So the question I have for you is,

00:22:45.380 | is the repetition compulsion a real thing?

00:22:48.880 | And why would we be wired that way?

00:22:52.420 | My understanding of this concept

00:22:54.180 | of the repetition compulsion

00:22:55.300 | is that we all want to solve our traumas

00:22:58.700 | and it allows us to put ourselves into micro

00:23:01.780 | or again, macro versions of that over and over again.

00:23:05.980 | We get to run the experiment again and again

00:23:08.020 | in an attempt to solve it.

00:23:09.900 | In the case of taking a drug that it's clear,

00:23:12.900 | certain drugs like opioids,

00:23:14.240 | it's clear how that would not allow us to deal with it.

00:23:17.340 | It's just masking the emotional state.

00:23:20.220 | But why is it, for instance,

00:23:21.980 | that somebody who experiences sexual trauma

00:23:24.220 | then places themselves into circumstances

00:23:26.600 | of more sexual trauma?

00:23:29.020 | Why is it that somebody who is in an abusive relationship

00:23:31.380 | goes on to have a second and third or fourth

00:23:33.860 | verbally or physically abusive relationship?

00:23:36.300 | Yeah, I mean, on the face of it,

00:23:37.140 | you just go, that makes no sense.

00:23:38.820 | And yet we see this over and over and over again.

00:23:42.540 | - Yes.

00:23:43.380 | The first thing I would say about the validity

00:23:45.540 | of the repetition compulsion concept is a strong yes.

00:23:50.540 | Like, yes, we see that over and over.

00:23:53.560 | It's not necessarily in everyone,

00:23:55.700 | but boy, it is in a lot of people who have suffered trauma.

00:24:00.380 | And I think there's a very good reason.

00:24:02.920 | On the surface of it, it's like, it makes no sense.

00:24:06.340 | But then if we think, well,

00:24:07.860 | how does our brains actually function, right?

00:24:11.140 | We're sort of trained, at least in Western society,

00:24:14.700 | I think, to think of ourselves as logical creatures, right?

00:24:17.900 | That like, oh, we're logical

00:24:19.300 | and ultimately everything in us

00:24:20.640 | can just boil down to logic.

00:24:22.060 | And if we think about it enough,

00:24:23.760 | we're gonna understand how to make the right decisions,

00:24:27.200 | which is completely not true, right?

00:24:29.760 | That the limbic system, right?

00:24:31.620 | The emotion system, so to speak, inside of us

00:24:34.520 | always trumps logic, right?

00:24:37.140 | If you think about, does it ever make sense

00:24:38.960 | to run into a burning building?

00:24:40.620 | I mean, logic says no, right?

00:24:42.640 | But if someone you love is in the burning building,

00:24:45.340 | people run right in, right?

00:24:47.000 | Because the limbic system says yes.

00:24:49.260 | So when logic and emotion come head to head,

00:24:52.580 | emotion wins all the time.

00:24:54.160 | If emotion is powerful enough, it will always win.

00:24:57.520 | And so the limbic system is so important

00:25:00.620 | and the limbic system does not care

00:25:03.900 | about the clock or the calendar, right?

00:25:06.440 | And that's the answer.

00:25:07.600 | And I'll sort of say why to the repetition compulsion.

00:25:10.540 | So the limbic system doesn't know like,

00:25:12.660 | oh, it's now, it's today, it's May, it's 2022.

00:25:16.300 | It just doesn't care at all, right?

00:25:18.220 | So how I would relate that to the repetition compulsion

00:25:21.380 | is when people are repeating, what they're trying to do

00:25:25.740 | is to make things right, right?

00:25:28.140 | With the idea that if we can repeat the situation

00:25:31.260 | and make it right, it will fix everything, right?

00:25:34.800 | Which makes perfect sense if we think,

00:25:38.360 | well, where is that concept coming from, right?

00:25:40.800 | It's coming from the emotional part of the brain

00:25:43.620 | that wants relief from suffering of the trauma

00:25:46.620 | and does not understand the clock or the calendar.

00:25:49.860 | So if I can solve something now,

00:25:52.220 | I will also solve something in the past, right?

00:25:55.160 | Which is why I can't tell you how many times

00:25:57.580 | I've sat with someone and say,

00:25:58.940 | we're starting to do therapy, right?

00:26:01.100 | And a person will say, oh, gosh, like, I know,

00:26:04.500 | look, look, you just can't help me, right?

00:26:06.020 | I mean, you know, my last seven relationships

00:26:09.020 | have been abusive, right?

00:26:10.620 | And I'll say back something sometimes like,

00:26:13.320 | well, look, if you tell me that you've had seven relationships

00:26:16.680 | that have been abusive in different ways,

00:26:18.920 | I'll agree with you.

00:26:19.760 | Like, I only say that

00:26:20.600 | 'cause that's never what someone says, right?

00:26:23.160 | But I think what you're gonna tell me

00:26:24.720 | is you've kind of had the same relationship seven times.

00:26:28.400 | It's not seven things, it's one, right?

00:26:30.860 | And that's always, I don't think one time yet

00:26:34.120 | that has failed to be the case.

00:26:35.920 | And that's how, so if you think about it,

00:26:37.720 | that's how we start to elucidate what's going on.

00:26:41.240 | So the light bulb that goes off,

00:26:43.260 | like I have not had seven different abusive relationships.

00:26:47.100 | I have had one that I have repeated seven times.

00:26:50.280 | And now we start getting to what's really going on

00:26:52.840 | and what needs to happen.

00:26:53.940 | That person needs to face what happened

00:26:56.800 | in that original abusive relationship.

00:26:58.720 | And it always comes down to the same sort of concepts

00:27:01.880 | of the person feeling terrified

00:27:04.320 | while the abuse was going on,

00:27:05.820 | feeling guilty, feeling ashamed,

00:27:08.080 | feeling like, oh, they brought it on themselves,

00:27:10.040 | they deserve it, they don't deserve anything better, right?

00:27:12.640 | Because the brain is trying to make sense of it, right?

00:27:15.440 | Or I thought I could make that okay, but I couldn't, right?

00:27:18.560 | And then there's more guilt and more shame.

00:27:20.820 | And if that's stuck inside of someone,

00:27:23.260 | like that's bundled up inside of someone,

00:27:25.600 | you know, like a medical abscess inside a person,

00:27:28.380 | you know, a walled off infection inside the body,

00:27:31.000 | this is the same concept in the brain,

00:27:33.740 | then of course the limbic system is gonna wanna fix that.

00:27:36.260 | And it fixes it by trying to let's recreate that situation

00:27:39.780 | and make it right this time.

00:27:41.560 | And that's, I mean, it's I think one of the best examples

00:27:44.220 | of how the right approach of how like, let's look at that,

00:27:47.280 | let's talk about that, right?

00:27:48.820 | What's really going on there?

00:27:49.920 | Wait, who should feel guilty and ashamed?

00:27:51.560 | Is it the person who was abused

00:27:52.840 | or the person who was abusing, right?

00:27:55.060 | And we can get at what's going on inside the person

00:27:57.840 | and that's what changes that.

00:27:59.160 | And then the eighth relationship can be entirely different

00:28:01.640 | than the first seven, right?

00:28:03.040 | And I see that all the time.

00:28:04.400 | I mean, this isn't esoteric or soft.

00:28:06.820 | Like I see that play out clinically over and over again.

00:28:11.380 | And why do things get better?

00:28:12.740 | Because we go to the trauma and we unlock it.

00:28:16.460 | It's not hidden inside where it can control things, right?

00:28:20.020 | We bring it to the surface

00:28:21.340 | and then we can take away its power.

00:28:24.000 | - I keep hearing in this narrative

00:28:28.620 | that so much of our reflexive response to trauma,

00:28:33.620 | both emotional and the repetition compulsion

00:28:36.580 | in terms of behaviors is about some very deep attempt

00:28:41.380 | to change the past.

00:28:42.940 | - Yes.

00:28:44.080 | - And in fact, in an offline conversation,

00:28:45.940 | I recall you saying something about this,

00:28:49.380 | that the number of behaviors and thoughts

00:28:53.160 | and avoidance of behaviors and avoidance of thoughts

00:28:56.200 | that human beings put in to try and change the past

00:28:59.460 | is remarkable and eerie and maladaptive, it sounds like.

00:29:06.460 | And that really stuck with me

00:29:07.940 | because I think we all want to feel

00:29:10.940 | like we're in control of our future

00:29:13.140 | and how we feel in the moment.

00:29:15.100 | And to some extent it works for a brief while.

00:29:19.260 | You know, there's this thing that happened

00:29:20.900 | and it just evokes some internal arousal

00:29:24.500 | and then you have to know what to do with that arousal.

00:29:26.980 | And I think for many people, including myself,

00:29:29.580 | there's this fundamental question,

00:29:31.940 | okay, the thought about the thing, the event,

00:29:35.740 | or events, plural, evokes this arousal,

00:29:38.780 | this internal state makes some people feel sleepy

00:29:40.940 | and exhausted, other people feel really anxious,

00:29:43.580 | other people feel angry.

00:29:44.700 | I mean, arousal has all these different dimensions

00:29:47.420 | as you know.

00:29:50.000 | And then there's this question about what to do with it.

00:29:52.260 | And I'd love to hear maybe even just a top contour

00:29:57.260 | prescriptive of what does one do?

00:30:00.340 | I'll even just put myself in it, what do I do?

00:30:02.260 | So I'm feeling upset about something.

00:30:04.140 | I feel like my options are healthy catharsis.

00:30:08.020 | I can tell the story, feel it.

00:30:10.960 | I can pack it down.

00:30:14.620 | We hear that it's bad to pack it down,

00:30:16.300 | but of course one has to be functional in life

00:30:18.320 | and deal with things.

00:30:19.620 | And we have responsibilities at work

00:30:21.900 | and relational responsibilities, et cetera.

00:30:24.720 | We need to sleep at night.

00:30:26.920 | So catharsis, healthy catharsis,

00:30:29.980 | packing it down at the other extreme.

00:30:34.040 | Telling the story.

00:30:34.880 | And yet I think a lot of people are afraid to tell the story

00:30:37.020 | because it's in that telling,

00:30:39.200 | there's a perhaps a re-emergence of the arousal.

00:30:42.320 | The arousal can become greater.

00:30:43.640 | I mean, is that what people mean when they say

00:30:45.780 | things are going to get worse before they get better?

00:30:47.580 | I mean, so I guess the simple version

00:30:49.760 | of this long-winded question is it's clear

00:30:53.000 | we need to confront these things.

00:30:55.040 | We can't change the past by a reflexive response

00:30:59.200 | isn't going to do that efficiently.

00:31:01.040 | And so how do we deal with arousal?

00:31:03.180 | How does one take what they feel inside

00:31:05.460 | about something shameful?

00:31:07.160 | What do you do with it in a moment?

00:31:09.440 | And does that have to be done in the presence

00:31:11.460 | of a skilled trained therapist?

00:31:13.520 | Or as I'm driving to work in the morning

00:31:16.500 | and something comes up,

00:31:18.240 | I can't deal with this right now, comes to mind,

00:31:20.640 | what do I do?

00:31:21.480 | Do I deal with it right then?

00:31:22.840 | I know this is a big multi-dimensional question,

00:31:25.720 | but I think it's the one that a lot of people grapple with.

00:31:28.040 | We want to deal with things.

00:31:29.000 | How do we deal with that internal arousal?

00:31:31.640 | - Yeah, yeah.

00:31:32.880 | We so often try and change the trauma of the past

00:31:37.880 | in order to control the future.

00:31:41.080 | And what that really adds up to

00:31:43.600 | is the trauma of the past dominates our present, right?

00:31:47.860 | And it doesn't have to be that way.

00:31:49.760 | And remember, we're talking about traumas

00:31:51.900 | that rise to the level of changing the brain.

00:31:54.080 | So as you're saying, that involves re-experience.

00:31:56.580 | It involves hypervigilance, increased arousal.

00:31:59.600 | It changes in mood states, changes in anxiety,

00:32:02.120 | changes in sleep, changes in behavior.

00:32:04.440 | So these are all changes that, in a sense,

00:32:08.440 | push towards dominating our present, right?

00:32:11.360 | And then we're not really living in the present, right,

00:32:14.600 | as we're trying to control the future.

00:32:16.380 | We're not gonna do a great job of controlling our future

00:32:18.780 | if we're not really living in the present, right?

00:32:21.720 | And so the way to come at that,

00:32:24.320 | and again, in the moment, if we're saying,

00:32:25.800 | okay, in the moment, if I need to fall asleep, right,

00:32:28.280 | I might say, okay, let me try and put that out of my mind.

00:32:30.040 | Let me try and thought redirect.

00:32:31.260 | So there's short-term strategies

00:32:33.220 | that can let us be functional

00:32:34.560 | in the context of these changes.

00:32:36.440 | But the answer is to go look directly at that thing, right?

00:32:41.440 | Look at that trauma, explore that trauma.

00:32:45.880 | And sure, that can be done with a professional,

00:32:47.640 | and sometimes that's what makes sense.

00:32:49.780 | But not always, right?

00:32:51.140 | Sometimes it can be done by talking to another person,

00:32:53.880 | right, writing it down, right?

00:32:55.480 | Look at what's going on inside of me

00:32:57.820 | that my mind is so stuck to this.

00:33:00.560 | Let's explore that.

00:33:01.720 | Because it's almost as if we're so afraid so often

00:33:06.720 | of looking at the trauma that has changed us

00:33:10.700 | that we'll look anywhere but at that, right?

00:33:14.480 | So it's like it's hidden in a closet

00:33:16.080 | and we'll shine the light everywhere else,

00:33:18.060 | but we're not gonna open that door.

00:33:19.980 | And that's where people will say the same as I've heard

00:33:22.380 | over and over, and I myself have thought this at times,

00:33:24.680 | like, oh, if I talk about that,

00:33:26.160 | I'm gonna start crying and never stop, right?

00:33:28.100 | Or I'm gonna just fall apart, right?

00:33:30.120 | Which is never what happens.

00:33:31.000 | No one ever starts crying and never stops, right?

00:33:33.520 | What ends up happening is when the person puts words to it,

00:33:37.320 | right, it could be in writing,

00:33:38.600 | it could be talking to a trusted other or with a therapist,

00:33:41.480 | right, things start to change.

00:33:43.080 | I mean, just the fact that you can talk about it,

00:33:45.840 | you can put words to it and other people don't recoil, right?

00:33:48.900 | I mean, how many times has someone said something

00:33:51.460 | for the first time, right?

00:33:53.680 | And when they're telling me about the trauma,

00:33:56.320 | there's such an anxious looking like as if

00:34:00.560 | I'm gonna recoil from it, right?

00:34:03.240 | Meaning I'm going to recoil from them, right?

00:34:06.040 | And then there's a sense of surprise if the person says,

00:34:08.480 | well, I was abused by this coach when I was a kid, right?

00:34:13.480 | And there's not, okay, there's not a response of recoiling.

00:34:19.000 | You can see the change and people will say a lot like,

00:34:22.000 | wow, I can't believe you can hear me say that

00:34:26.720 | and be okay with it, right?

00:34:28.420 | I mean, so you think about what's going on inside of them,

00:34:30.480 | like what a sense of shame, a sense of,

00:34:34.440 | this is something awful about me for people to recoil from.

00:34:38.440 | And it's just not true, but here's where trauma is,

00:34:42.200 | it's insidious, right?

00:34:43.840 | And it's pervasive, right?

00:34:46.140 | Because if that convinces us to continually hide it away,

00:34:50.640 | then how do we explore it?

00:34:53.040 | Like that example of the person who says,

00:34:56.480 | okay, I was abused by a coach when I was a child.

00:34:59.080 | I mean, I'm thinking of a couple very real cases, right?

00:35:02.320 | People that I've taken care of.

00:35:03.840 | And once they start talking about it,

00:35:05.760 | then they start talking about how,

00:35:08.760 | you know, they were just innocent kids, right?

00:35:10.920 | Like they didn't know.

00:35:12.120 | And like, they really wanted to be on the team

00:35:13.780 | where this coach was treating them as special.

00:35:15.840 | And now they can look at themselves from the outside, right?

00:35:19.480 | They can look at themselves

00:35:20.680 | like they would look at someone else, right?

00:35:23.420 | You think it's so easy for us to see what's real and true

00:35:27.760 | if it's someone else, right?

00:35:29.080 | If you ask someone,

00:35:29.920 | what do you think of someone who's 10, 11 years old,

00:35:32.880 | who's abused and manipulated and abused by an adult?

00:35:35.840 | We say, oh my goodness,

00:35:36.720 | I feel compassion for that person, right?

00:35:39.120 | But if it's us, right?

00:35:41.100 | Then, oh no, it's guilt and shame

00:35:43.080 | and we have to hide it away.

00:35:44.480 | And when the person starts looking at it,

00:35:46.240 | they can sort of see it from the outside

00:35:48.400 | and it starts to take the energy out of it, right?

00:35:51.140 | Then, well, who should feel guilty about that?

00:35:53.000 | Who's done something wrong?

00:35:54.580 | And like, so now the conceptions come together,

00:35:56.960 | which is often a reflexive, that was my fault.

00:35:59.740 | Oh, I did it.

00:36:00.580 | I went back to it.

00:36:02.040 | I still stayed on the team.

00:36:03.880 | I went back next season, right?

00:36:05.480 | I let it happen again.

00:36:06.920 | But all the guilt and shame inside the person

00:36:09.340 | gets juxtaposed to like, what really happened there?

00:36:11.920 | And then they say, right, I was a terrified child, right?

00:36:15.120 | I didn't understand at all.

00:36:16.640 | And they can come to a place of compassion

00:36:18.920 | and now we are working against the guilt and shame.

00:36:21.600 | And if the person cries about it, that's great, right?

00:36:25.160 | I mean, crying is one of the best coping mechanisms

00:36:27.400 | we have.

00:36:28.240 | It doesn't hurt us and it lets us grieve things.

00:36:31.240 | We can't grieve if there's guilt and shame inside of us.

00:36:34.520 | It just blocks grief, right?

00:36:36.520 | We have to, it has to be a clean slate, in a sense,

00:36:38.960 | in order to feel sadness.

00:36:40.800 | And then you see that it shifts from anxiety,

00:36:44.640 | anger and frustration, usually directed towards the self,

00:36:47.440 | guilt and shame, towards being able to process it

00:36:51.680 | and being able to bring to bear some compassion

00:36:55.020 | and being able to direct the negative emotion,

00:36:57.680 | so to speak, where they're warranted.

00:37:00.120 | And my goodness, the changes that happen.

00:37:03.080 | I mean, it's not like people are miraculously cured, right?

00:37:06.000 | But it's remarkable how just getting it out there

00:37:08.480 | and having like one hour of talking like that,

00:37:11.180 | like what we're talking about now, can leave a person

00:37:14.760 | feeling immensely better.

00:37:16.360 | - It seems to me in hearing this,

00:37:18.700 | that there's this weird wiring that we have.

00:37:23.240 | Because what I'm hearing is when traumas happen to us

00:37:26.160 | or we observe them, what we need to do most

00:37:28.340 | is to confront those and the emotions around that directly.

00:37:32.360 | But instead, our system defaults to guilt and shame

00:37:35.840 | and trying to hide it.

00:37:37.360 | And this repetition compulsion of placing us back

00:37:40.540 | into things similar to those traumas,

00:37:43.600 | or even maybe even worse traumas in an attempt to resolve it.

00:37:47.240 | It's like the most maladaptive wiring diagram

00:37:50.920 | I could possibly think of.

00:37:52.340 | Emotional and presumably physiological wiring diagram.

00:37:56.780 | And this notion of trying to change the past

00:37:59.920 | by doing things now when the exact opposite

00:38:02.900 | is what's going to be beneficial,

00:38:04.880 | also seems like the whole system seems completely backwards.

00:38:08.200 | And I'm chuckling, as I said, it's not because I'm amused,

00:38:11.400 | it's because I'm just baffled once again

00:38:13.240 | at how our wiring can often not serve us well.

00:38:16.260 | But it raises what I think is an important

00:38:21.840 | and interesting question, which is earlier,

00:38:24.080 | you were talking about how people will seek out media

00:38:27.800 | that's really disturbing.

00:38:28.800 | They'll traumatize and re-traumatize themselves

00:38:31.180 | on a daily basis.

00:38:32.780 | So that could be viewed as the repetition compulsion,

00:38:35.460 | where the person will have the same relationship

00:38:37.900 | with seven different, same abusive relationship

00:38:40.520 | with seven different partners in sequence.

00:38:42.660 | Seems terrible.

00:38:44.420 | And yet, as I say this, it also is becoming clear to me

00:38:48.540 | how this almost seems like a poor but desperate attempt

00:38:52.480 | to resolve it in some way.

00:38:55.180 | And so the fork in the road, if I understand correctly,

00:38:59.920 | is to really get to the seed incident,

00:39:03.480 | really get to the thing that started it all,

00:39:05.640 | as opposed to repeating it all. - Yes.

00:39:08.040 | - Does that have to be done in the presence of a therapist?

00:39:12.800 | Is there a benefit to taking a walk

00:39:16.980 | and thinking about these things,

00:39:18.900 | breaking down and crying if that's what's necessary,

00:39:22.120 | or feeling angry if that's what comes up?

00:39:25.720 | The reason I ask it this way is because I worry,

00:39:30.720 | I'll just speak to my own experience,

00:39:34.180 | I worry that in reactivating

00:39:36.240 | or touching into the emotions around something,

00:39:38.740 | that that is itself a form of the repetition compulsion,

00:39:41.600 | because you're feeling it all over again.

00:39:44.060 | You're not seeking out something to evoke that feeling.

00:39:46.580 | So I realize this is a little bit

00:39:47.940 | of a circular argument or question,

00:39:51.700 | but I think it's one that I really struggle with

00:39:53.660 | in trying to parse all the outcome-based therapies

00:39:57.140 | that I hear about and the recommendations

00:40:03.940 | that people make.

00:40:04.780 | I mean, how should we conceptualize this?

00:40:06.680 | Something happens.

00:40:08.020 | Sounds like we need to deal with that thing directly.

00:40:10.400 | Do we need to do that with somebody else?

00:40:12.400 | Can we do that on our own?

00:40:13.480 | If we don't have resources

00:40:16.100 | and we have to do it on our own,

00:40:18.140 | can't hire someone, can't pay someone to work with us,

00:40:20.940 | how do we do that in a way that isn't retraumatizing

00:40:23.940 | ourself in a major way or in a minor way?

00:40:27.140 | How do we know where we are in that landscape?

00:40:30.680 | - Right.

00:40:31.640 | Again, those are, I think, great questions,

00:40:33.620 | and I think it starts with real introspection.

00:40:37.440 | When things are bouncing around in our minds,

00:40:40.060 | often it's very non-productive.

00:40:42.380 | It's the same thing over and over again,

00:40:45.020 | and that's not helpful for us.

00:40:47.140 | So there's an idea which sometimes gets called

00:40:49.380 | an observing ego, the ability to stop

00:40:52.060 | and look at what's going on inside of ourselves.

00:40:54.580 | And so if we're just thinking about it

00:40:57.260 | and we're thinking in the same way we sort of,

00:40:59.120 | in a sense, always think about it,

00:41:00.880 | then all we're doing is reinforcing the trauma.

00:41:03.540 | But if we can distance enough to be like,

00:41:05.900 | huh, I'm interested in what's going on inside of me, right?

00:41:09.500 | Like I think of a certain person who really loves music.

00:41:13.860 | And then at some point in our therapy work,

00:41:16.900 | I learned, like, she was taking long drives,

00:41:20.160 | but the radio wasn't on.

00:41:21.820 | And I was like, well, what's going on, right?

00:41:23.540 | And I asked, and what was going on?

00:41:25.540 | And she was running over and over again in her head,

00:41:27.700 | like, I'm a loser, I'm a loser, right?

00:41:29.740 | And she didn't want the music on

00:41:31.900 | because the music would drown out what she felt

00:41:33.900 | she had to say to herself, right?

00:41:36.120 | And it was that like, wow, that's interesting, right?

00:41:40.780 | And then her ability to observe that and to think,

00:41:44.220 | why am I doing that when it comes into her mind?

00:41:46.660 | Like, what is that trace to?

00:41:48.020 | When did I start doing that?

00:41:49.340 | Like I said, I'm saying it for a point of exaggeration,

00:41:52.380 | like nobody comes out of the womb,

00:41:54.380 | programmed to think I'm a loser, right?

00:41:57.700 | So we don't think that when we're born, right?

00:41:59.500 | So where does that come from?

00:42:01.340 | Then we can think in ways

00:42:03.420 | that allow us to have new thoughts, right?

00:42:06.180 | That we weren't having.

00:42:07.140 | It's not just bouncing around in our minds.

00:42:09.420 | And if we speak or write,

00:42:11.660 | there are even more mechanisms

00:42:13.180 | that come online in our brains, right?

00:42:15.300 | That are then sort of monitoring mechanisms.

00:42:17.220 | We think in a different way if we're using words, right?

00:42:21.140 | And we are better able often

00:42:23.700 | to bring in that observing ego,

00:42:25.300 | like what's going on inside of me.

00:42:26.780 | So it can be very helpful to think,

00:42:29.260 | it can be helpful to talk to someone,

00:42:30.880 | to a trusted other, friend, family, clergy, to write.

00:42:35.620 | I mean, these are things that can be done

00:42:37.500 | without expending any resources, right?

00:42:39.840 | And sometimes it can make really a big difference, right?

00:42:43.180 | There's a way, when did I start thinking that?

00:42:44.800 | And like interestingly in this case,

00:42:46.300 | okay, we did it in therapy,

00:42:47.880 | but it became very clear what that was rooted to, right?

00:42:51.780 | And then in the therapy, which was still relatively young,

00:42:54.780 | but we'd done several sessions

00:42:56.540 | and we weren't talking at all

00:42:58.380 | about what we needed to talk about, right?

00:43:00.180 | But that's what got us to what we needed to talk about.

00:43:03.280 | And when did that start?

00:43:04.480 | And now we're in that same place of exploring that.

00:43:07.740 | And what was the reflex to it?

00:43:09.280 | And the sense of guilt and sense of shame.

00:43:11.500 | And it's where all of that came from

00:43:13.400 | that just got boiled down to I'm a loser, right?

00:43:16.020 | Which this person didn't even have in their mind.

00:43:19.300 | Like I didn't think about myself that way, right?

00:43:22.080 | And it's so interesting, right?

00:43:23.640 | That our memories don't in and of themselves have meaning.

00:43:26.820 | It's like they're flat or colorless, right?

00:43:29.940 | And they're colored in by the emotions

00:43:32.400 | that we attach to them, right?

00:43:34.060 | So the idea that certain memories now before the trauma

00:43:39.060 | were changed, right, by the trauma.

00:43:41.660 | So I tell the story sometimes of a person

00:43:43.900 | who like won an award when they were in high school

00:43:46.040 | that they thought was, oh my gosh, like it shows,

00:43:48.180 | like I can do it, right?

00:43:49.520 | And get out there that after trauma,

00:43:51.900 | they saw the award with a negative emotion attached to it

00:43:54.900 | that was like, oh, it was given to me

00:43:56.340 | and I didn't deserve it.

00:43:57.340 | And almost it was mocking.

00:43:58.820 | Like there's gonna be the greatest achievement of my life

00:44:01.060 | and I was 17 or so.

00:44:02.500 | And to have someone think like that's not how they felt

00:44:06.020 | about that at the time, it's the trauma that changed

00:44:09.900 | the self-talk, the internal state going forward.

00:44:13.980 | And you're talking about miraculous in a negative way,

00:44:17.240 | also change that going backward, right?

00:44:20.260 | And when we can really look at like,

00:44:22.020 | where did that come from?

00:44:23.460 | And we can start unraveling it, it changes.

00:44:26.860 | So in those cases, often it's helpful

00:44:29.580 | to have a good therapist.

00:44:31.500 | It's not always necessary and it certainly,

00:44:34.180 | it's not always possible, right?

00:44:35.840 | So we need other strategies.

00:44:38.080 | And some of those, I write about some of those in the book

00:44:40.620 | of how can we sort of get at trauma

00:44:43.180 | without those formalized mechanisms?

00:44:45.220 | And sometimes if the symptoms are significant enough,

00:44:48.660 | like we really do need to talk to somebody professional

00:44:51.140 | who can help us get to the root of the trauma.

00:44:54.380 | And there's so many times that's the answer

00:44:57.020 | to what's going on with people.

00:44:58.580 | You know, people I've seen have had five residential stays,

00:45:00.900 | I'm not exaggerating this, for mental health reasons,

00:45:03.780 | for substance reasons, and no one's ever taken

00:45:06.180 | a trauma history, right?

00:45:07.540 | And then when you take a trauma history, you say,

00:45:09.100 | well, that's obviously where this is all coming from, right?

00:45:11.980 | Like that's when the drug use started truly thereafter,

00:45:14.280 | the negative self-talk and the negative feelings

00:45:16.260 | that led to the drug use.

00:45:17.600 | Then you go after the trauma and you can change things.

00:45:21.260 | Whereas trying to change things

00:45:22.820 | without looking introspecting, talking about the trauma,

00:45:26.540 | I think of course was futile.

00:45:29.160 | - Do you think that people who can start

00:45:33.460 | to have negative fantasies?

00:45:34.940 | I mean, you mentioned this woman who would take

00:45:36.260 | these long drives to berate herself.

00:45:38.820 | I'm not familiar with that,

00:45:41.320 | but I'll give a little bit of personal disclosure here.

00:45:43.700 | I've felt several times in my life

00:45:46.140 | that I will start to create a narrative

00:45:49.700 | about something that truly hasn't happened,

00:45:52.120 | about something terrible that somebody is going to do

00:45:54.940 | that's going to upset me.

00:45:57.920 | And for the longest time, I would wonder,

00:45:59.740 | why am I doing this?

00:46:00.700 | And I have a couple ideas about why.

00:46:03.420 | One is that I was attempting

00:46:06.940 | to just avoid thinking about other things.

00:46:09.400 | It's just anger is such an attractive emotional force.

00:46:13.260 | In a sense, it's an attractant.

00:46:14.900 | It's not attractive, we don't like it.

00:46:16.180 | And yet oftentimes anger is a great way

00:46:19.020 | to replace feeling something else, feeling sad

00:46:22.400 | or having to come up or to do work or to do something useful.

00:46:26.700 | So it has this kind of like gravitational force to it.

00:46:31.700 | That was one idea.

00:46:33.800 | The other idea was in imagining kind of worst outcomes,

00:46:37.560 | then actually that relationship

00:46:40.120 | could actually seem a lot better in reality.

00:46:42.200 | It's almost like creating this negative contrast.

00:46:45.160 | It's like, oh, well then it's not that bad.

00:46:47.220 | And then the third possibility is I have no idea why,

00:46:50.560 | but it seemed like a reflex

00:46:52.000 | and I spent some time thinking about it.

00:46:53.400 | I can't say I've resolved it completely,

00:46:55.320 | but why would somebody have a narrative

00:46:59.120 | or a default narrative when driving or when walking of,

00:47:02.440 | I'm just going to spend some time

00:47:03.680 | and think about how terrible this thing is going to turn out

00:47:06.080 | or how someone's going to upset me or harm me

00:47:07.860 | or how terrible I am.

00:47:10.780 | It seems again like maladaptive thinking, maladaptive wiring

00:47:15.780 | and yet I have to assume that it serves some purpose.

00:47:18.800 | - Yeah, yeah.

00:47:19.640 | I mean, I think there are three factors there

00:47:22.600 | and they're all bad.

00:47:24.080 | And I think you spoke to at least two of them, right?

00:47:26.720 | They may, I think, speak so powerfully

00:47:29.760 | to how insidious trauma is

00:47:32.480 | and how these are real brain changes inside of us.

00:47:36.320 | So I would say the three factors,

00:47:38.600 | punishment, avoidance and control, right?

00:47:42.200 | So the trauma inside of us that makes a guilt and shame

00:47:47.100 | so often, so often leads to a desire to punish oneself,

00:47:52.100 | right?

00:47:53.980 | And the idea that, oh, that was my fault or I deserve that.

00:47:56.340 | Well, what do we do if something is someone's fault

00:47:58.900 | and someone now deserves punishment, right?

00:48:01.200 | I mean, we punish them, right?

00:48:02.860 | We send them to jail, we give them a fine, right?

00:48:04.900 | We punish them.

00:48:05.760 | And so what we do is punish ourselves, right?

00:48:08.740 | And if we tell ourselves we're a loser

00:48:10.460 | or this awful thing is gonna happen, right?

00:48:12.600 | Then part of what we're doing is saying to ourselves,

00:48:14.580 | see, right, you deserve that.

00:48:16.200 | You're not gonna have anything better, right?

00:48:17.700 | It's a negative, it's a very negative way

00:48:21.060 | that the brain tries to make us, in a sense, do better

00:48:25.340 | by hurting us more for the things that we couldn't

00:48:28.080 | and shouldn't have been able to,

00:48:29.380 | weren't expected to control in the first place, right?

00:48:32.300 | The second is distraction.

00:48:34.100 | As you said, anger, that kind of fantasy

00:48:36.900 | can distract us from affect, feeling, and emotion

00:48:41.740 | that can be much more negative.

00:48:43.140 | You know, anger, it can be more gratifying

00:48:45.500 | than certainly than guilt or shame,

00:48:47.740 | although guilt and shame can serve a punishment purpose.

00:48:50.060 | But if anger is directed also towards ourselves, right,

00:48:53.220 | then it can serve punishment too.

00:48:54.660 | So punishment, avoidance, and the sense of control

00:48:58.300 | that if you think ahead to something awful

00:49:01.540 | that you're imagining is going to happen,

00:49:03.900 | well, maybe that will let you avoid it, right?

00:49:06.060 | I mean, you can see the brain here,

00:49:08.380 | in a sense, really confused.

00:49:10.020 | I mean, part of the brain wants to punish,

00:49:12.200 | part of the brain doesn't want to think about it at all,

00:49:14.300 | and part of the brain wants to make it better.

00:49:16.480 | And then how all of that resolves

00:49:19.020 | if we're not aware that, hey, this is in the context

00:49:21.480 | of our brains being deeply impacted by trauma,

00:49:24.520 | so what's going on here is all maladaptive, right?

00:49:27.620 | 'Cause these negative fantasies of the future,

00:49:30.060 | they may help us feel better

00:49:31.380 | about something in the present,

00:49:33.020 | but they don't help us make anything better, right?

00:49:35.740 | They don't help us make anything better.

00:49:37.860 | So this is the kind of the sequelae.

00:49:40.540 | This is where trauma and all this reflexive stuff

00:49:44.160 | that happens after trauma ultimately lead us.

00:49:47.300 | And you can see how we get lost,

00:49:49.120 | how I've seen over and over again in my own life,

00:49:52.780 | in the lives of other people,

00:49:54.820 | how, man, we get stuck in those situations.

00:49:59.180 | That's why I see people sometimes,

00:50:00.860 | this has been going on for 30 years, 40 years, right?

00:50:04.060 | And it's just been going on over and over and over again

00:50:07.220 | because there's no natural end to any of this, right?

00:50:10.700 | Unless we look at it in a different way

00:50:13.420 | that we've knowledge and information like,

00:50:15.340 | whoa, this isn't the way it has to be.

00:50:17.220 | Let me bring a novel perspective to this.

00:50:19.720 | It doesn't change on its own.

00:50:21.180 | - I'm struck by your statement

00:50:25.180 | that these thoughts or behaviors can make us feel better,

00:50:29.420 | but they don't actually make anything better.

00:50:31.280 | In that way, this mode of imagining terrible outcomes

00:50:36.280 | starts to immediately seem like taking opioids.

00:50:40.500 | You feel better in the moment,

00:50:41.820 | but it doesn't actually make anything better

00:50:43.500 | and it probably makes things worse.

00:50:45.300 | - Yes.

00:50:46.140 | - And just a question of how much worse

00:50:50.260 | and in what direction.

00:50:52.560 | - Yes.

00:50:54.140 | - And so I just want to just pause on that concept

00:50:57.540 | because I think that concept of makes us feel better

00:51:00.700 | but doesn't make anything better.

00:51:01.920 | I think it answers an earlier question

00:51:05.740 | about what seems to be a totally maladaptive wiring diagram.

00:51:10.260 | We need to confront the thing,

00:51:11.400 | but we don't want to go into the repetition compulsion.

00:51:13.520 | So it's a knife edge there to navigate through trauma.

00:51:18.460 | - Yes.

00:51:19.300 | - Working with a very skilled clinician like yourself,

00:51:23.200 | I think is the ideal circumstance for people.

00:51:27.260 | And of course, there are people who can't access support

00:51:31.020 | from somebody for whatever reason.

00:51:33.160 | You've talked about journaling as a useful tool.

00:51:38.160 | Maybe you highlight some of the other things

00:51:41.180 | that people can do on their own.

00:51:42.580 | And then I'd also like to talk about

00:51:44.940 | what makes for a good therapist.

00:51:47.580 | What should people look for

00:51:48.580 | for those that are seeking therapy,

00:51:50.300 | especially nowadays when a lot of therapy

00:51:51.760 | is being done remotely.

00:51:53.020 | But let's just start with the,

00:51:55.660 | let's just call them self-generated

00:51:57.600 | or zero cost sorts of things.

00:52:00.600 | Journaling being the first,

00:52:02.660 | and then what are some of the others?

00:52:03.780 | And what kind of structure would you recommend

00:52:05.780 | someone put around journaling?

00:52:07.700 | Carry a journal around all day

00:52:08.940 | and jot things down as they come up

00:52:10.260 | or sit down and spend an hour

00:52:11.540 | writing in complete sentences, for instance?

00:52:14.280 | - Yeah.

00:52:15.120 | If I could add something to what you had just said

00:52:18.140 | before the question, right?

00:52:19.540 | That we have these short-term coping mechanisms in us, right?

00:52:23.780 | And in a way it makes sense, right?

00:52:25.420 | If we find ourselves in just terrible situations,

00:52:29.500 | then a short-term coping mechanism

00:52:31.380 | can get us through them, right?

00:52:33.040 | So our brains are built that way

00:52:34.680 | and that's part of survival too, right?

00:52:36.980 | And whether now in the modern world,

00:52:39.020 | whether it's food, it's drugs, it's sex, it's alcohol, right?

00:52:43.700 | Or it's negative thoughts, right?

00:52:46.020 | This is short-term soothing.

00:52:48.800 | Even the negative thoughts and anger is short-term soothing

00:52:51.600 | at the expense of long-term change, right?

00:52:55.480 | And that's where addictive pathways can come into play

00:52:59.240 | and that's where again,

00:53:01.720 | how we're built evolutionarily for survival

00:53:04.800 | doesn't help us in the way humans have evolved.

00:53:08.200 | Like we haven't lived this way

00:53:09.480 | throughout 99.9 something percent of human history, right?

00:53:13.880 | So we're not adapted to this.

00:53:16.260 | So I want to just make a point of saying that

00:53:17.800 | about the short-term soothing

00:53:19.160 | at the expense of long-term change, you know?

00:53:22.680 | And then the question you had asked about say journaling

00:53:25.520 | or what can we do that's outside of a professional,

00:53:28.980 | I think the hallmark of it

00:53:31.060 | has to be bringing new eyes to it, right?

00:53:33.800 | Like thinking about self with a curiosity

00:53:36.680 | instead of just a simple automaticity or repetition, right?

00:53:40.440 | Like why am I thinking about this?

00:53:42.640 | When did this start?

00:53:44.180 | Why is this in me?

00:53:46.760 | It's that whether it's words or whether we're writing

00:53:50.520 | that's so important.

00:53:51.660 | So I think for journaling, it depends on the person.

00:53:55.160 | I mean, we don't want somebody carrying around

00:53:56.560 | a journal all day if then there's a compulsion

00:53:58.980 | to I need to write about everything

00:54:00.080 | that's going on in my mind, right?

00:54:01.260 | Like that might be good to,

00:54:02.480 | okay, write a little bit at night, right?

00:54:04.340 | Or someone who might think,

00:54:06.080 | sometimes this really comes into my mind in a strong way

00:54:08.720 | and it could be unpredictable, right?

00:54:09.920 | I want to have the journal with me.

00:54:11.860 | So, ah, that thing is back in my mind now.

00:54:14.940 | Let me write about it, right?

00:54:16.520 | Because then putting words to it

00:54:18.240 | and then being able to read those words, right?

00:54:20.560 | And when people read, even do a little bit of journaling

00:54:23.000 | and they read like, oh, I thought again

00:54:26.600 | about how I'm a terrible person who can't have a good life

00:54:29.840 | because I was in such a bad car accident

00:54:33.000 | or because that person attacked me

00:54:34.640 | or because when I was in school, I was bullied

00:54:37.240 | because I looked different than everyone else, right?

00:54:39.760 | Or I acted different for everyone else.

00:54:41.520 | Wow, you know, to actually see that written out,

00:54:44.880 | it's, you know, it's a little bit of that,

00:54:47.360 | it's a little bit of that,

00:54:49.760 | like when you're saying it to someone

00:54:51.280 | as if it were someone else, right?

00:54:52.900 | Because now there's enough distance from it.

00:54:54.840 | Like I'm looking at the words I wrote, right?

00:54:56.860 | That we get some distance and we can start to integrate

00:54:59.800 | some of the, not just the compassion,

00:55:02.880 | but integrating compassion and logic, right?

00:55:05.460 | Of like, okay, I feel a sense of compassion.

00:55:07.320 | Oh wait, what does this mean?

00:55:08.560 | What really happened here, right?

00:55:10.560 | And gosh, I did start thinking differently after that.

00:55:13.440 | I started, that's where this came from, right?

00:55:15.480 | That's why I'm saying this.

00:55:17.080 | It's those kinds of revelations that we can have

00:55:19.960 | through, again, the written or spoken word.

00:55:22.600 | And I think, again, that involves a trusted other

00:55:25.760 | or writing, right?

00:55:27.320 | And I think that those are ways we can do this

00:55:30.400 | where we bring some de novo perspective

00:55:33.660 | to something that often has been bouncing around

00:55:36.200 | inside of us.

00:55:37.040 | And it's amazing to me that I can see such intelligent

00:55:41.400 | and pathically attuned people who've had the same thing

00:55:45.560 | running over and over again in their mind for years.

00:55:49.320 | And it just points out that our brains

00:55:51.220 | don't automatically say, hey, wait a second.

00:55:54.320 | I've been spinning wheels here for a long, long time.

00:55:56.480 | Like, was there another way to look at this?

00:55:58.440 | We need something from the outside,

00:56:00.320 | which can just be knowledge, right?

00:56:02.080 | Which is why I think what we're doing here

00:56:03.940 | or the reason I wrote the book that I wrote

00:56:06.800 | was apprehending this amazing surprise to me, right?

00:56:11.800 | Which is like, wow, like some huge percentage

00:56:14.600 | of everything I'm treating is rooted in trauma

00:56:19.040 | and the opacity of trauma, right?

00:56:21.280 | Which is why we don't see that, oh, the depression,

00:56:24.280 | the panic attacks, the life change, the addiction,

00:56:26.680 | the maladaptive choices, like, oh, this is all coming

00:56:30.320 | from trauma because it hides itself in that opacity.

00:56:34.320 | So we need a de novo perspective if we're doing it

00:56:37.520 | on our own and we need that if we're doing it in therapy,

00:56:40.480 | which might link to like finding the right therapist, right?

00:56:42.920 | Which is also part of your question.

00:56:45.120 | - Yeah, I definitely want to know about how to assess

00:56:48.120 | and find the right therapist.

00:56:49.300 | Before we cover that, however, something came up

00:56:54.300 | in the course of your answer.

00:56:57.100 | I can immediately relate to this idea

00:57:00.040 | that certain behaviors are really maladaptive

00:57:03.040 | and are stuffing things down or avoiding the topic

00:57:07.920 | is problematic and bringing a curiosity

00:57:10.160 | and an introspection and almost a third personing

00:57:12.800 | of the experience that we've had in order to try

00:57:16.840 | and address it truly from a new perspective.

00:57:20.160 | It occurred to me as we were discussing this, however,

00:57:24.640 | that some people, and yes, maybe I'm talking a little bit

00:57:27.600 | about my own experience, we have a sense of our own identity

00:57:32.000 | and how people view us and our ability

00:57:34.480 | to be functional in the world in ways that we like.

00:57:37.160 | Effective at work or a good brother or a good mother

00:57:40.320 | or father or human being in the world.

00:57:43.320 | We have relationships.

00:57:44.680 | And I think that one thing that I have heard

00:57:47.840 | and maybe I've experienced is that sometimes

00:57:51.720 | those maladaptive thoughts or behaviors,

00:57:54.680 | the things that generate a kind of a repetition of anger

00:57:58.400 | or of arousal or activation or sadness,

00:58:01.340 | that we have some internal process where we funnel that

00:58:04.880 | into a functionality in the world.

00:58:06.720 | So I'll give a more concrete example.

00:58:09.480 | So in thinking about things that have upset me in the past

00:58:13.760 | and in imagining bad outcomes in the future,

00:58:16.900 | there's a certain internal state of arousal

00:58:18.960 | that comes about.

00:58:20.240 | And for many years, I was able to use that,

00:58:23.560 | not to feel angry, but rather to work an extra three hours

00:58:27.040 | a day or to pack my schedule

00:58:30.400 | with work and social engagement so I could show up

00:58:33.820 | in a way that I hopefully was a very good brother

00:58:36.180 | to my sister, for instance.

00:58:37.780 | So in a way it was a transformation of something negative

00:58:41.940 | inside of me into a functionality in the world

00:58:44.900 | that was actually very rewarding and beneficial.

00:58:47.960 | And yet in describing it, I can immediately see

00:58:51.100 | how it would be wonderful if I could source

00:58:53.120 | from something else.

00:58:54.540 | And yet you can imagine and I can imagine

00:58:58.000 | how one would be reluctant, maybe even terrified

00:59:01.040 | of giving up that source, it's a fuel.

00:59:04.020 | And I think in knowing some of the traumas of other people

00:59:08.560 | and their reluctance to work through those,

00:59:11.040 | obviously I'm not a therapist,

00:59:12.480 | I sense this over and over again

00:59:14.980 | that one's positive identity can often be linked

00:59:18.780 | to something difficult in their past.

00:59:20.840 | And so people are reluctant to give up this fuel

00:59:23.960 | because in that sense, it's functional.

00:59:27.320 | The only thing that allowed me to kind of start

00:59:31.480 | to address this and why I'm still so curious about this,

00:59:34.180 | 'cause I don't think I've worked through this process

00:59:36.520 | completely, again, a little more self-disclosure there,

00:59:39.600 | is that I was told that these words,

00:59:44.600 | just imagine how much better it would be

00:59:47.160 | if you could source from a different fuel,

00:59:50.980 | a fuel that felt better.

00:59:52.360 | Maybe, it was on this sentence,

00:59:55.180 | it was maybe you could actually be much more effective.

01:00:00.180 | Maybe you could be 10 times the better brother.

01:00:03.360 | Maybe you could have 10 times more

01:00:06.460 | insider work capacity, et cetera.

01:00:08.320 | So it's on that hint of a promise

01:00:10.820 | that at least I was inspired to start looking

01:00:13.900 | into these things and reading about trauma in your book

01:00:16.520 | and elsewhere and start to think about this.

01:00:18.240 | So again, I realize this is a long-winded question

01:00:21.300 | and a somewhat complex idea, but I think,

01:00:23.320 | or I hope that people will be able to resonate

01:00:25.120 | with this idea that sometimes we want to stay attached

01:00:27.280 | to this short-term soothing,

01:00:30.160 | that the punishment, distraction, or control,

01:00:31.920 | because it evokes this arousal

01:00:33.960 | and then we can apply that arousal.

01:00:35.880 | - Yes, yes.

01:00:37.280 | I think what you're describing maps, I think, clinically

01:00:40.040 | to what gets called sublimation.

01:00:41.800 | So there's something negative inside of us,

01:00:44.640 | but we sort of transfer that energy,

01:00:46.560 | we transfer that into something that is adaptive

01:00:49.500 | or that is positive, right?

01:00:50.800 | So the idea of anger, right?

01:00:52.120 | When I think of that thing and it makes anger in me,

01:00:54.400 | I channel that into harder work, right?

01:00:56.480 | Or I channel that into like,

01:00:57.640 | I'm gonna go be nicer to my brother, something like that.

01:01:01.000 | And there's validity to that, right?

01:01:03.720 | And, but it can become like self-justifying.

01:01:06.680 | If a person thinks, well, like,

01:01:08.320 | look at what this is doing for me, right?

01:01:10.080 | I wouldn't work as hard without it, right?

01:01:12.160 | Now we start to become attached to the trauma,

01:01:15.360 | whereas I think what you had said is absolutely true,

01:01:19.120 | that just because we can sublimate

01:01:22.280 | some of the negative affect feeling emotion

01:01:25.160 | that comes from trauma into something productive,

01:01:27.960 | doesn't mean that that's best, right?

01:01:30.840 | I mean, you know, we can get to our destination

01:01:33.000 | by taking a very circuitous route, right?

01:01:35.160 | We might waste an hour getting there, but we get there.

01:01:37.720 | That doesn't mean that that's best.

01:01:40.280 | And it also doesn't look at all the negative, right?

01:01:42.400 | In this example, the wasted fuel, the wasted time, right?

01:01:45.220 | We get somewhere, but we are not optimizing.

01:01:48.840 | And I have yet to see one person who has addressed the trauma

01:01:53.840 | and become less functional, right?

01:01:56.140 | It's always either they're just as functional,

01:01:59.080 | but they're happier, right?

01:02:00.720 | Or more functional, because as you said,

01:02:03.080 | like just because we may be able to sublimate,

01:02:05.880 | well, maybe what's going on will be 10 times better, right?

01:02:08.960 | If we weren't sublimating,

01:02:11.180 | because the sublimation limits us, right?

01:02:13.000 | It limits our perspective to only what we can see and do

01:02:16.480 | through the lens of the trauma.

01:02:18.360 | And that is never better than the alternative.

01:02:22.500 | - Thank you for that.

01:02:24.180 | - Yeah, you're welcome, yeah.

01:02:25.400 | - Let's discuss how one could or should go

01:02:30.120 | about finding a really good therapist.

01:02:32.720 | Typically, in my experience, this is done by word of mouth.

01:02:39.120 | You know, there's this person,

01:02:39.960 | you might want to work with them, they're really great.

01:02:41.800 | But what are some of the characteristics

01:02:43.200 | that one should look for?

01:02:44.800 | And should we take into account whether or not

01:02:48.400 | we are a person who, you know, for instance,

01:02:51.800 | I've heard this from listeners,

01:02:54.040 | although I'm definitely not talking about myself here

01:02:57.080 | in cloaking something.

01:02:59.520 | Some people will say, you know,

01:03:00.740 | I want to work with a somatic therapist

01:03:02.520 | because I've actually heard someone say,

01:03:04.560 | I think in feels, you know, I feel stuff in my body,

01:03:07.680 | so I want to work with someone

01:03:08.760 | who can really acknowledge that.

01:03:10.220 | Or someone else will say, you know,

01:03:11.960 | I want to work with somebody who has this orientation

01:03:14.720 | or that orientation, or is open to my particular lifestyle,

01:03:19.400 | or isn't going to tell me

01:03:20.440 | that I have to leave my relationship.

01:03:22.080 | You know, I feel like people already show up

01:03:23.920 | to the question of who to work with,

01:03:25.760 | with all these, you know, things internally,

01:03:27.960 | some of which are voiced and some of which aren't.

01:03:30.520 | So I'd love for you to talk about maybe

01:03:32.000 | some of the core features of a really good therapist,

01:03:36.160 | and then how to look for a therapist,

01:03:38.480 | and also how to think about oneself

01:03:40.320 | in looking for a therapist

01:03:41.620 | because of these kind of predispositions.

01:03:43.760 | - Right, right.

01:03:44.960 | Well, there's a lot of data about this over the years

01:03:49.300 | that if you look at what are the top 10 important factors

01:03:53.120 | to find in a therapist, just repeat rapport 10 times, right?

01:03:58.120 | I mean, that's the key.

01:03:59.520 | And if you think about that, it's pretty amazing, right?

01:04:02.100 | Because therapeutic modalities can be so different, right?

01:04:05.480 | And I think what that's telling us is,

01:04:09.000 | in a way, something very obvious, right?

01:04:10.560 | Like, what does rapport mean?

01:04:11.880 | Like, you know, somebody's paying attention, right?

01:04:13.840 | It's trust, it's a back and forth.

01:04:15.680 | It's like, yeah, even I'm doing something difficult,

01:04:18.900 | I'm doing it with someone who's really helping me,

01:04:20.520 | someone who's in it with me, right?

01:04:22.040 | Someone who's really paying attention,

01:04:23.480 | wants me to be better, that's indispensable.

01:04:26.520 | I mean, it's just indispensable.

01:04:27.960 | And I write in the book,

01:04:28.900 | is someone, a therapist is not making eye contact,

01:04:31.120 | or this is the way they do it, right?

01:04:32.620 | And you know, you gotta fit into the box

01:04:34.320 | of the way they do it.

01:04:35.540 | That is not going to be helpful.

01:04:37.780 | And then what I think about that is,

01:04:41.660 | the different modalities,

01:04:42.880 | it doesn't actually tell us that,

01:04:44.500 | oh, the modality is irrelevant.

01:04:45.980 | I think that's not true.

01:04:47.800 | I think that good therapists are not pigeonholed

01:04:51.480 | by a certain modality.

01:04:52.800 | They may come at the world largely through a psychodynamic,

01:04:56.920 | or a CBT, or a DBT lens.

01:04:59.060 | There's lots of different ways to do therapy.

01:05:02.360 | But when you really talk to those people,

01:05:04.160 | really good, experienced therapists,

01:05:06.400 | it's all coming through the vehicle of the rapport,

01:05:09.560 | but they're practically shifting to what the person needs.

01:05:13.220 | You know, I don't understand the idea that like,

01:05:15.420 | oh, I just do this, right?

01:05:17.580 | I don't do that.

01:05:18.420 | And when people are pigeonholed that way,

01:05:20.340 | I don't think they help their patients very well, right?

01:05:22.980 | We have to be diverse enough to say,

01:05:25.280 | hey, I want all the arrows in the quiver, right?

01:05:27.700 | And even though there might be one that I favor,

01:05:29.940 | and that's the lens I see things through,

01:05:32.000 | no, I can be versatile, I can shift,

01:05:34.140 | I can adapt to what this person needs.

01:05:36.660 | And I think if you have that, you've got a,

01:05:39.840 | if you have that, you've got a winning combination.

01:05:42.240 | - Great, so people should perhaps try a few therapists

01:05:44.820 | and maybe have a session or two or three

01:05:46.880 | to see if the rapport feels like it's taking root.

01:05:49.880 | Is that, do you have that right?

01:05:51.240 | - Yeah, and I think that's why word of mouth is important,

01:05:53.200 | right, if someone you trust tells you,

01:05:54.720 | hey, this is a good person, that says a lot, right?

01:05:57.480 | It already makes the pretest probability is quite high.

01:06:01.160 | But yes, it's interesting to see when people have a therapist

01:06:06.080 | or they called their insurance

01:06:07.260 | and they're assigned a therapist, this thought that like,

01:06:09.340 | oh, that's the person I have to have now.

01:06:11.260 | And it's like, no, you should look at that like anyone,

01:06:13.980 | you would be interviewing, right, for a job, right?

01:06:17.380 | But you gotta bring, again, the right set of thoughts

01:06:20.940 | to that to be helped, right?

01:06:22.980 | Which is like, I want someone who has rapport with me.

01:06:25.520 | I don't want someone who's gonna make it easy, right?

01:06:27.940 | Who's like, well, it's, gosh, it's kind of pleasant

01:06:29.700 | because then that means they're not talking

01:06:31.100 | about the difficult things, right?

01:06:32.520 | So if one brings like, I know this isn't gonna be easy,

01:06:34.900 | I gotta talk about difficult things, right?

01:06:36.920 | Even if one doesn't recognize,

01:06:38.440 | oh, I gotta talk about the trauma in me, right?

01:06:40.420 | But to go to therapy thinking, no, it's,

01:06:43.320 | I mean, sometimes it's enjoyable,

01:06:44.740 | but a lot of times, right, it's not, right?

01:06:46.860 | It's hard work, it can be excruciating, we can cry doing it.

01:06:49.940 | But to say, right, that that's how I'm gonna be helped

01:06:52.180 | and I want someone who's gonna do that with me,

01:06:55.180 | you know, who's really looking at

01:06:56.900 | what's going on inside of me, how do we help me?

01:06:59.360 | And I can feel sort of the robustness of that.

01:07:02.440 | If one brings that approach and then looks at the therapist

01:07:05.580 | through that lens, you're very likely to then move on

01:07:08.880 | from someone who's not a good choice, right?

01:07:11.060 | And really stick with someone who is,

01:07:12.940 | even though that doesn't mean

01:07:14.400 | it's always like pleasant and enjoyable.

01:07:16.560 | I mean, it has to not be that sometimes.

01:07:19.600 | - Right.

01:07:21.060 | Maybe we could drill a little deeper

01:07:22.340 | into the mechanics of therapy.

01:07:24.540 | I put out a few questions to audience

01:07:27.120 | asking what they want to know about therapy

01:07:28.720 | and it was amazing.

01:07:30.100 | I got hundreds, if not thousands of responses saying,

01:07:33.600 | how should I show up to therapy?

01:07:35.060 | So for instance, should people take

01:07:36.500 | a five minute meditative drop-in before

01:07:39.260 | or should they just show up cold and let it emerge?

01:07:42.460 | During therapy, is it a good idea to take notes

01:07:46.700 | or to not take notes?

01:07:48.180 | And then post-therapy, how should clients, patients,

01:07:52.540 | as they're sometimes called one or the other,

01:07:54.880 | I never know which, how should they process that information?

01:07:58.320 | Should they take some designated time afterwards

01:08:00.840 | and in an ideal world, take a 30 minute walk afterwards

01:08:04.380 | and think about the material

01:08:05.820 | or should they set it aside and come back to it?

01:08:07.620 | Of course there are constraints, work and family, et cetera.

01:08:11.120 | But there's a lot of knowledge out there

01:08:13.980 | about how to best show up to a workout,

01:08:16.340 | warm up for five, 10 minutes, then do this, et cetera.

01:08:18.700 | And then the cool down.

01:08:19.620 | I mean, here we're talking about hard psychological work

01:08:22.880 | aimed at bettering oneself.

01:08:24.340 | So to my knowledge, I've not ever seen this information

01:08:29.040 | anywhere, it'd be very useful to hear your thoughts on this.

01:08:31.840 | - Yeah, well, I'm not trying to duck the question,

01:08:34.300 | but I think it varies so much by person.

01:08:37.800 | So if you think about the first part of your question,

01:08:39.520 | I think was how to show up to therapy, right?

01:08:42.020 | And I think the answer would be,

01:08:43.180 | whatever lets you be fully present when you're in therapy.

01:08:46.820 | Now, for some people, there's gonna be, I show up early,

01:08:50.020 | I sit, I calm myself, I meditate a little bit.

01:08:52.520 | I mean, that's how then they're present, right?

01:08:54.440 | For other people, they just show up, walk into the room,

01:08:57.440 | they can stop another present, right?

01:08:59.280 | 'Cause whatever works for that person

01:09:01.480 | so that they're really there, their thoughts,

01:09:03.660 | their energy is really in what's going on.

01:09:06.320 | And the same thing applies on the other end.

01:09:08.540 | Now, there are people who are really well-served

01:09:12.040 | by going for a walk if they can

01:09:14.000 | or sitting quietly after therapy,

01:09:15.660 | kind of putting that in order, right?

01:09:17.200 | Otherwise they lose some of it, right?

01:09:18.840 | Or like some of the ahas, right?

01:09:21.040 | Or the, oh, that's an interesting thought

01:09:22.920 | that they really need to put it in order.

01:09:24.300 | Maybe that involves taking some notes during therapy, right?

01:09:27.520 | For other people, they need to do the exact opposite.

01:09:29.880 | They need to like leave, not think about that at all,

01:09:32.900 | and then they can reflect on it later and learn from it.

01:09:35.560 | So, you know, we're so different.

01:09:37.360 | Human beings, there's such a diversity in us

01:09:39.820 | that I think there's no hard answer to that.

01:09:43.160 | It was like being present when it's happening,

01:09:46.040 | then being able to sort of consolidate

01:09:48.780 | and retain what's been gained is most important.

01:09:53.160 | And I think we have to figure that out person by person.

01:09:55.880 | I mean, I try and do that in the work of like,

01:09:57.580 | what's serving this person best?

01:09:59.500 | And sometimes we, you know, sometimes it evolves

01:10:01.580 | and sometimes we talk about it, but it varies so much.

01:10:05.220 | - If someone were thinking about embarking on therapy

01:10:07.960 | or more therapy to address trauma

01:10:10.120 | or just general issues of life,

01:10:12.460 | what is the frequency that you recommend?

01:10:14.380 | I could imagine two extreme models.

01:10:16.340 | One is, okay, I'm going to finally tackle this trauma.

01:10:19.420 | I'm going to do therapy three times a week,

01:10:22.140 | but for a shorter period of time, you know,

01:10:24.260 | six months, you know, over and out,

01:10:26.900 | versus this open-ended model of once a week,

01:10:30.440 | typically for as long as it takes.

01:10:34.400 | - Right, right.

01:10:35.820 | I think that also varies.

01:10:38.580 | And I work with people in varied ways

01:10:40.820 | from someone who's doing well,

01:10:43.000 | and like we meet for a half hour every six months, right,

01:10:45.700 | to doing week-long hourly sessions,

01:10:48.800 | to spending three intense days with someone in a row, right?

01:10:53.140 | So I think as far as like kind of guiding principles,

01:10:58.140 | what I have found in my own life,

01:11:01.100 | 'cause I value my own therapy tremendously,

01:11:05.760 | so I found in my own life and in my own clinical work,

01:11:08.900 | that if it's less than once a week,

01:11:11.400 | then it's hard for us to retain, really.

01:11:14.560 | You know, we spend a lot of time kind of catching up,

01:11:17.620 | okay, what's happened?

01:11:18.460 | Let's get back to the place we were at before, right?

01:11:20.960 | Which is why I think if we're really going to get somewhere,

01:11:23.260 | we're not just trying to maintain something, right?

01:11:25.400 | Then I think once a week for an hour

01:11:27.560 | is really kind of the minimum, right?

01:11:30.280 | But more intensive work, it's like the more intense it is,

01:11:34.440 | it's not linear, right?

01:11:36.200 | It's an exponential gain.

01:11:37.480 | Like we do a lot of intensive work, right?

01:11:40.520 | Where someone will come and do 30 clinical hours with us

01:11:45.040 | over the course of a week.

01:11:46.500 | So five or six different clinicians, 30 clinical hours.

01:11:50.040 | And we've found that the benefits of doing that are immense.

01:11:55.040 | It's like I say, a year's worth of therapy consolidated.

01:11:58.380 | And you take both 30 hours,

01:11:59.640 | let's say we go almost every week,

01:12:01.920 | maybe that's 45 or 50 hours,

01:12:03.980 | but 30 hours with that kind of intensity

01:12:07.560 | is worth probably 60 hours done in a different way.

01:12:11.840 | Because then it's in us in an active way, right?

01:12:15.080 | It's in the therapist in an active way.

01:12:16.840 | It becomes very, very dynamic.

01:12:18.840 | So I think turning up the intensity,

01:12:20.960 | if there's something that we really need to process,

01:12:23.720 | absolutely makes sense.

01:12:24.840 | And I do that in my own life is something now it's like,

01:12:26.760 | whoa, something is really distressing me.

01:12:29.480 | And it's linking into prior trauma.

01:12:31.640 | And I can see what's going on in me.

01:12:33.260 | Now I start to have ruminative thoughts with negativity.

01:12:36.160 | Like I got to go more, right?

01:12:38.200 | Because I got to do that processing

01:12:40.240 | so I can get to the place that I am,

01:12:42.040 | which is not that,

01:12:42.880 | it's not that the trauma has no impact on me, right?

01:12:45.320 | It's that the impact is much less

01:12:47.200 | than it was before the therapy.

01:12:48.940 | And that I most often, more often than not,

01:12:52.840 | have an ability to see

01:12:54.680 | when it's now intruding into my thoughts.

01:12:57.440 | And it's taking me away

01:12:59.040 | from like what I really think and believe,

01:13:00.640 | or being able to draw logic and emotion together

01:13:03.000 | and make good decisions.

01:13:04.400 | Turning up the intensity then absolutely makes sense.

01:13:08.320 | - This very deep, intensive work of 30 hours in a week,

01:13:13.280 | what brings somebody to the type of work of that sort?

01:13:18.160 | Is it a suicide risk or a severe addiction situation?

01:13:22.300 | I mean, how does one gauge how much therapy

01:13:24.280 | they ought to be doing?

01:13:27.320 | And should it always be on the therapist

01:13:30.320 | to decide that frequency?

01:13:33.760 | What would bring someone to a situation

01:13:36.440 | of five therapists in 30 hours a week in one week?

01:13:40.080 | - Right, right.

01:13:41.600 | Yeah, it's usually a person

01:13:43.840 | who is really distressed by something,

01:13:46.800 | whether that's, it's so negatively impacting their life.

01:13:51.320 | Or sometimes a person comes to a realization,

01:13:53.360 | I just can't take this anymore, right?

01:13:54.680 | Or I'm sick of this cyclical depression

01:13:56.480 | and I got to stop having panic attacks.

01:13:57.960 | Like I need help, right?

01:13:59.880 | But it's usually some crisis point

01:14:02.680 | with the idea of crisis and the meaning of,

01:14:05.640 | okay, something comes to a head

01:14:07.060 | and after it things are gonna be different, right?

01:14:09.120 | Not a crisis and things are gonna be negative afterwards,

01:14:11.760 | but a point where then that cognitive flexibility

01:14:15.240 | comes to the fore of like,

01:14:16.300 | wait, I need to do something different, right?

01:14:18.360 | So that's often what brings us.

01:14:20.480 | You know, sometimes it's other people pointing it out

01:14:23.120 | or somebody's had an intervention somewhere,

01:14:25.480 | or yes, that person has been hospitalized

01:14:27.800 | after a suicide attempt,

01:14:29.120 | or they've gone back to rehab again for the third

01:14:32.780 | or fourth time and their life is really in danger.

01:14:35.080 | Sometimes it's that, and sometimes it's a person realizing,

01:14:38.280 | yeah, I just wanna, I wanna look at myself,

01:14:40.200 | I wanna understand myself better.

01:14:42.040 | You know, I know that what's going on in me

01:14:44.060 | isn't as good as it can be, right?

01:14:46.100 | So I think people can come to it

01:14:47.940 | for all sorts of different ways.

01:14:50.560 | And I think, yes, I think a lot of times

01:14:52.320 | it would be the therapist to say it looks more work,

01:14:54.960 | you know, more intensive work or can make a difference.

01:14:58.320 | But I think the person also needs to, you know,

01:15:01.000 | take ownership, right, of their own therapy

01:15:02.980 | and say, if I don't feel hoped enough,

01:15:04.960 | well, I have to think about that, right?

01:15:06.540 | And talk to the therapist about that

01:15:08.240 | 'cause maybe that therapist isn't a match, right?

01:15:10.960 | Or maybe you talk to the therapist

01:15:12.480 | and the therapist can change his or her approach, right?

01:15:15.640 | Or maybe you talk to the therapist

01:15:17.320 | and increase the frequency, right?

01:15:19.280 | But the idea is to be aware of it, right?

01:15:22.380 | And if one's needs aren't being met, to acknowledge that,

01:15:25.760 | right, 'cause people can get into a rhythm of therapy

01:15:28.480 | where it's really not helping them, right?

01:15:30.840 | But they either feel sort of nihilistic about it,

01:15:33.240 | like, oh, I'm no better and I'm going to therapy, right?

01:15:35.640 | Or sometimes there's a sense that while I'm in therapy,

01:15:38.760 | so I'm kind of checking that box

01:15:40.160 | of doing something for myself,

01:15:41.560 | but it's not really getting me anywhere.

01:15:43.400 | And then the part of the brain that's controlled

01:15:45.200 | by the guilt and shame and avoidance

01:15:47.240 | thinks that's a great idea, right?

01:15:49.080 | So again, this ability to observe ourselves

01:15:51.320 | and like, what's going on?

01:15:52.520 | Am I being helped in the way, do I feel helped, right?

01:15:55.680 | Am I in some ways even like happy that I'm not feeling helped

01:15:59.560 | 'cause I don't have to face this thing

01:16:00.720 | I don't want to face, right?

01:16:02.160 | Or am I too afraid to say I need more help, right?

01:16:04.840 | Do we really need to look at ourselves?

01:16:06.760 | And this is where the insurance systems

01:16:08.440 | often are very difficult

01:16:09.560 | 'cause it's hard sometimes for a person to say,

01:16:11.520 | oh, I need more therapy 'cause that may not be possible,

01:16:13.780 | right?

01:16:14.620 | So there are sort of negative factors

01:16:17.640 | in the world around us,

01:16:18.700 | but ultimately I think the answer to the question

01:16:20.560 | comes down to observing ourselves

01:16:23.120 | and taking ownership of like what's going on in us

01:16:25.560 | and how we're feeling

01:16:26.800 | and then feeling that commitment to self

01:16:31.120 | or to self-care to say, I need to go change this.

01:16:33.740 | - And for those that maybe don't have the means

01:16:35.960 | or insurance or access to do even one day a week therapy

01:16:40.880 | in the journaling model,

01:16:42.360 | could one perhaps take an entire day,

01:16:46.240 | as awful as it might seem,

01:16:48.520 | to do a lot of journaling and thinking and walking,

01:16:51.240 | you know, do a self-generated intensive,

01:16:54.400 | do you think there's utility to that?

01:16:57.240 | - I mean, there could be, but again, it depends by person

01:16:59.760 | 'cause there could also be something negative about that.

01:17:02.120 | If it's, you know, someone who's not at the point,

01:17:04.920 | not ready for that, right?

01:17:05.940 | I mean, we don't come at,

01:17:07.920 | you know, we don't come directly at the trauma immediately,

01:17:10.500 | at least most of the time we don't do that, right?

01:17:13.300 | And we often don't explore it in depth.

01:17:16.600 | Like this idea that, oh, that person now has to go through

01:17:18.840 | every second of the trauma is actually not true.

01:17:21.360 | I mean, sometimes it is,

01:17:23.040 | but that's not the common situation, right?

01:17:26.440 | It's more often that person has to acknowledge,

01:17:28.840 | like the example of like, I was sexually abused.

01:17:31.480 | And if they acknowledge that and say, okay, like, gosh,

01:17:35.160 | what has that done to me?

01:17:36.440 | That doesn't mean, well, let's parse out every moment

01:17:38.640 | of like how that was and the terror of that, right?

01:17:41.640 | So that can lead people to a worse place, right?

01:17:44.220 | So I think the idea of biting off small pieces, so to speak,

01:17:50.100 | where a person is writing, right, or is talking.

01:17:53.100 | But I think if one is writing,

01:17:54.440 | it is good to communicate with another, right?

01:17:57.360 | Another trusted person.

01:17:59.220 | And if there's not someone in one's personal life,

01:18:01.780 | you know, they're clergy members.

01:18:02.720 | Even if one isn't affiliated with an organized religion,

01:18:06.020 | you could probably go places and get a clergy

01:18:08.240 | to want to help you, right?

01:18:09.680 | I mean, there are people out there

01:18:10.760 | who want to help other people.

01:18:12.040 | So we say, what if someone has no one?

01:18:14.380 | I mean, almost never do we have no one here, right?

01:18:17.180 | 'Cause we could probably go find someone.

01:18:18.900 | But we need to take that in pieces.

01:18:22.040 | So there's some risk to trying to do the intensive thing,

01:18:25.480 | you know, on one's own.

01:18:27.120 | And that's where I would put in,

01:18:28.600 | if a person's having suicidal thoughts

01:18:31.040 | or even thoughts of death, of not wanting to be alive,

01:18:33.680 | I don't deserve to be alive.

01:18:34.840 | I mean, these are warning signs for really getting help.

01:18:37.460 | So there are some signs that say,

01:18:38.760 | hey, don't try and do that on your own, right?

01:18:40.840 | Go try and find a resource.

01:18:42.440 | And it's, you know, things that get to that level

01:18:44.320 | of severity of, and often a person knows that.

01:18:47.520 | I mean, am I in a place where I know I'm not healthy

01:18:50.380 | and I'm having kind of scary thoughts?

01:18:53.040 | Then we need, that's a person

01:18:54.960 | who really shouldn't be doing that on their own.

01:18:57.120 | - Great, thank you for that.

01:18:58.240 | - Yeah, you're welcome.

01:18:59.400 | - So we've been talking a lot about talking.

01:19:02.140 | And now I'd like to talk a little bit about chemistry.

01:19:05.720 | - Yes.

01:19:06.560 | - Drugs.

01:19:07.380 | - Yes.

01:19:08.260 | - So maybe first we could talk prescription drugs.

01:19:11.240 | I mean, you're a psychiatrist, so you're approved to

01:19:13.840 | and presumably do prescribed medication

01:19:16.320 | where appropriate.

01:19:18.360 | And this is a vast landscape, of course.

01:19:20.360 | We've got ADHD.

01:19:22.720 | And I should just tell you, I get more questions

01:19:24.320 | about ADHD and the drugs related to ADHD and dopamine

01:19:27.840 | than any other topic, any other topic.

01:19:31.320 | So there's ADHD, there's OCD, there's depression,

01:19:35.520 | there's antidepressants and so forth.

01:19:37.480 | Is there some way that we can wrap our arms around

01:19:41.720 | all of that as a way of wading into this drug question

01:19:46.720 | and just address, how does one decide

01:19:49.680 | when medication is useful?

01:19:51.280 | Because in the end, the dissection tool

01:19:53.920 | that the psychiatrist or therapist has is language.

01:19:56.840 | And at some point, one has to make an assessment

01:19:58.840 | about dopamine or serotonin

01:20:00.760 | or whether or not a given drug would help.

01:20:02.760 | And most therapies, I believe don't involve

01:20:07.760 | putting someone in a brain scanner.

01:20:09.240 | And to my knowledge, there still is not

01:20:10.840 | a very good blood test to assess,

01:20:12.680 | oh, is this person's dopamine low or high?

01:20:14.680 | Correct me if I'm wrong.

01:20:15.960 | And ultimately that, and I know there are companies

01:20:18.760 | out there, so I'm not trying to undermine those companies.

01:20:20.680 | But if I happen to do that in this statement,

01:20:22.120 | if you take a blood test and find that your serotonin

01:20:24.840 | metabolites are low, my understanding is it's possible

01:20:28.160 | that you are too low in serotonin in the brain,

01:20:30.600 | but that's a very indirect window

01:20:32.160 | into what's really going on.

01:20:33.680 | So how do you think about prescription drugs

01:20:38.960 | in the context of treating trauma and other conditions?

01:20:43.560 | And then maybe we'll drill into some

01:20:44.800 | of the more specific conditions.

01:20:46.520 | - Sure, I mean, I would first comment that, right,

01:20:48.640 | there aren't tests for these things.

01:20:50.880 | And I think the tests for metabolites,

01:20:52.640 | I mean, things are so different, you know,

01:20:54.520 | by the time what we're talking about has been metabolized,

01:20:58.000 | you know, often to some very significant extent,

01:21:00.160 | left the brain, now it's in the peripheral blood

01:21:02.280 | that we really don't learn from that.

01:21:04.400 | And I think that we tend to overutilize medicines

01:21:08.960 | in this country because we have a healthcare system

01:21:12.320 | that often, that's so based on throughput

01:21:15.520 | that we wanna polish the hood

01:21:16.880 | when there's a problem in the engine, right?

01:21:18.360 | So we overutilize medicines often as an endpoint, right?

01:21:22.040 | Oh, we're gonna make that person's depression better

01:21:23.720 | with an antidepressant.

01:21:25.440 | Well, I mean, maybe, right?

01:21:27.240 | But most of the time, for that person's depression

01:21:30.800 | to really get better and stay better,

01:21:32.400 | they need to unravel what's driving the depression, right?

01:21:35.800 | So the first step is,

01:21:38.120 | I think there are two steps to it, right?

01:21:39.840 | The first assessment step is,

01:21:42.000 | is there a diagnosis that the vast majority of the time,

01:21:47.000 | if not sometimes all the time, really warrants a medicine?

01:21:50.640 | So the bipolar disorder, OCD, ADD, right?

01:21:55.080 | These are diagnoses that we understand more about them

01:21:59.080 | and what's going on in the brain

01:22:00.600 | and how medicines can treat or stabilize them,

01:22:03.880 | which doesn't mean the medicine is necessarily,

01:22:05.680 | it's not a substitute for therapy, right?

01:22:08.000 | But sometimes the medicine and therapy can go hand in hand.

01:22:11.240 | So for OCD, for example, warrants therapy,

01:22:14.160 | but it almost, not always,

01:22:16.360 | but it almost always warrants medicine too

01:22:18.920 | so that you can ease the systems

01:22:20.760 | that are making the rigidity and the repetition in the brain.

01:22:23.880 | So the first kind of branch point can be,

01:22:27.000 | what is the diagnosis?

01:22:28.120 | What is the level of severity, right?

01:22:30.120 | And I think that's very, very important.

01:22:32.960 | Where I think it's a little more, maybe even interesting,

01:22:36.120 | is using medicines to help the person engage in the therapy

01:22:41.120 | as productively as possible.

01:22:44.520 | And here's where I think we're so limited

01:22:47.520 | by how we categorize medicines

01:22:50.400 | and this sort of pharmaceutical, insurance-driven,

01:22:56.240 | medical system we have that I think throws us off

01:23:00.600 | in tremendous ways.

01:23:01.840 | So you think about how medicines are categorized,

01:23:04.000 | so antidepressants.

01:23:05.760 | And the vast majority of people

01:23:07.440 | who are helped by antidepressants,

01:23:09.240 | they don't have clinically severe depression, right?

01:23:12.480 | Those medicines create more distress tolerance in us, right?

01:23:16.600 | And if you think about how helpful that can be,

01:23:18.960 | if you're gonna go,

01:23:19.800 | now you're gonna do something difficult,

01:23:20.960 | where you're gonna bring that trauma

01:23:22.760 | or the stressors to the surface and you're gonna process

01:23:25.160 | and you're gonna try and make life change.

01:23:27.120 | If we can make more distress tolerance in us,

01:23:30.080 | that can be so, so much better, right?

01:23:32.720 | And think about the category of medicines

01:23:34.520 | that are called antipsychotics,

01:23:35.960 | which really puts people off, right?

01:23:38.600 | But most of the prescriptions for antipsychotics

01:23:41.680 | are not for psychosis, right?

01:23:43.600 | And there are ways in which low dosing

01:23:46.520 | of some of those medicines can help intervene

01:23:49.680 | in negative pathways, right?

01:23:51.920 | In pathways that are about distress

01:23:54.200 | and sending out those tendrils of neurons

01:23:57.160 | that are about hypervigilance and avoidance in our brain.

01:24:01.480 | And we can often get at that.

01:24:03.520 | And if you can improve someone's distress tolerance

01:24:05.800 | and you can use medicines that take away

01:24:08.400 | what clinically is rumination, right?

01:24:10.480 | Not the standard meaning of that word,

01:24:13.360 | but the clinical meaning of it,

01:24:14.880 | where there are distress centers in our brain

01:24:17.240 | that are overactive.

01:24:19.040 | And then we get stuck

01:24:20.240 | in these maladaptive negative pathways,

01:24:22.320 | where we think about something over and over and over again

01:24:25.280 | with no real chance of solving it,

01:24:27.240 | because that's not what's going on inside of us.

01:24:29.640 | So medicines can help that,

01:24:32.080 | but we have to have some flexibility

01:24:33.760 | around their conception.

01:24:35.200 | And the modern medical system of a 15 minute visits,

01:24:39.320 | you know, to a psychiatrist that are weeks apart,

01:24:42.400 | I mean, I don't understand how that goes well, right?

01:24:46.160 | In the vast majority of times,

01:24:47.280 | I think it doesn't go well

01:24:48.440 | because it's not enough time to do the therapy,

01:24:51.200 | even generate the understanding.

01:24:53.040 | So then medicines get thrown at the person.

01:24:55.240 | This is how, you know, we use,

01:24:57.040 | I think approximately five times as much medicine,

01:24:59.800 | I think across the board as say the Dutch population, right?

01:25:03.200 | They think, well, why is five times more

01:25:05.080 | is a lot more medicine, right?

01:25:07.600 | And you know, they have a healthcare system

01:25:09.760 | and a cultural system that to the best of my understanding

01:25:12.960 | is more rooted in taking responsibility for oneself, right?

01:25:16.560 | So if a person comes in and cholesterol is high, right?

01:25:19.600 | The first order of business is,

01:25:21.560 | hey, you can take better care of yourself, right?

01:25:23.200 | Like this person really needs to lose some weight,

01:25:25.120 | exercise more, right?

01:25:26.480 | They're not just jumping to like,

01:25:28.080 | let me give you a medicine

01:25:29.080 | and, you know, and shift you through the healthcare system

01:25:32.040 | and out the other side of the door, right?

01:25:33.920 | And the same thing is true in mental health, you know,

01:25:37.280 | and I'm not trying to be critical

01:25:39.400 | to the psychiatrist or the nurse practitioners

01:25:42.400 | or people who are practicing in that way,

01:25:44.600 | because oftentimes there is no choice, right?

01:25:47.080 | If they're working in a healthcare system

01:25:49.280 | that the standard is highly spaced

01:25:53.760 | or spaced apart 15 minute visits,

01:25:56.480 | what alternative is there, right?

01:25:58.320 | But to look at, okay, I'm gonna use medicines

01:26:00.560 | because I don't have another tool to bring to bear.

01:26:03.600 | So I think the healthcare system

01:26:05.200 | and its focus on throughput and its short-term,

01:26:07.720 | talk about, you know,

01:26:08.560 | we talk about short-term response, right?

01:26:10.600 | There are short-term soothing

01:26:11.760 | at the expense of long-term health.

01:26:13.800 | And I think that is the metaphor

01:26:16.480 | that applies to our healthcare system, right?

01:26:18.800 | Where if we are gonna try

01:26:21.520 | and treat a symptom in a short-term,

01:26:23.480 | we're gonna do it in a 15 minute visit,

01:26:25.080 | that we're gonna do it in a way

01:26:26.800 | that maybe it soothes the symptom, maybe it doesn't,

01:26:29.120 | but it does not get at the problem.

01:26:31.920 | We need to invest more resources to get at the problem.

01:26:35.080 | And I think that's where a sort of protest, you know,

01:26:37.760 | if people, as a society,

01:26:39.600 | we say, look, we don't like the way our healthcare is going,

01:26:42.640 | like we need more focus on what the actual problems are,

01:26:45.840 | that yes, we would spend more money,

01:26:48.080 | you know, treating people and taking care of people

01:26:50.480 | 'cause it's more human time,

01:26:52.160 | but ultimately less suffering, less death, right?

01:26:56.280 | And ultimately more productivity.

01:26:57.920 | I think as an economy, we would save so much money

01:27:01.520 | if we spend money on the human aspects of mental healthcare

01:27:05.380 | because people would be more functional.

01:27:07.000 | They're spending less time in the hospital, right?

01:27:08.960 | They're more productive when they're working.

01:27:11.960 | There's less entry into the criminal justice system.

01:27:15.080 | So I think medicines get overused

01:27:19.000 | in part for systemic reasons,

01:27:21.200 | in large part for systemic reasons,

01:27:23.440 | and also for some of these categorization reasons.

01:27:26.200 | Oh, that person meets some technical criteria

01:27:28.640 | for depression, we've got to give them this medicine

01:27:30.340 | instead of really thinking, wait,

01:27:31.600 | what's going on in this person?

01:27:33.640 | And I see this over and over again.

01:27:35.000 | I see someone who's on seven medicines

01:27:37.040 | and they're on seven medicines

01:27:38.200 | to treat seven different symptoms.

01:27:40.120 | And now they have side effects

01:27:41.280 | from all those seven medicines.

01:27:42.380 | Maybe two of them are to treat the side effects

01:27:44.180 | from the other five, right?

01:27:45.900 | And that's bad, right?

01:27:48.480 | And if you really get at what's going on in them,

01:27:51.160 | now they're doing much better

01:27:52.720 | and maybe they're on two medicines, right?

01:27:55.100 | So I don't know if that's a helpful answer to that.

01:27:58.280 | - It is, it's a very helpful answer.

01:28:00.080 | I mean, I think at least in the spheres

01:28:02.600 | that I run these days,

01:28:04.040 | I hear a lot of negative statements about antidepressants.

01:28:06.520 | I think, you know, I'm old enough to remember

01:28:08.720 | the book "Listening to Prozac"

01:28:10.360 | and I remember when Prozac and things like it

01:28:14.940 | first started showing up and the excitement.

01:28:16.840 | And then nowadays I hear more about the problems

01:28:19.980 | with all these drugs, you know?

01:28:21.380 | And maybe that's just 'cause I have arms

01:28:23.220 | in both the scientific,

01:28:24.500 | but also in the kind of wellness community

01:28:26.040 | where people think a lot about behavioral change.

01:28:28.140 | Fortunately, I think that they do that.

01:28:30.580 | But of course these drugs, as you mentioned,

01:28:33.080 | can have enormous utility as well.

01:28:35.460 | I'd like to just pick up on one theme

01:28:38.140 | that I haven't heard a lot about anywhere else,

01:28:40.140 | which is the short-term versus the long-term use

01:28:42.200 | of these drugs.

01:28:43.040 | 'Cause I could imagine, you know,

01:28:45.040 | someone feeling like they're finally gonna tackle something

01:28:47.760 | that's been inside them for a long time,

01:28:49.900 | either because they're really struggling

01:28:51.720 | or because they're just done with not working it through.

01:28:55.540 | And they decide to start a medication

01:29:00.540 | that would give them higher levels of distress tolerance

01:29:04.100 | for a short while.

01:29:05.700 | I mean, is there anything to say

01:29:06.740 | that someone couldn't take a properly prescribed medication

01:29:11.740 | for a week or for the first three months of the work

01:29:15.940 | and then know that they can come off it?

01:29:17.500 | Because I think that the black and white model

01:29:19.980 | of, okay, you're either gonna start this drug

01:29:21.340 | and stay on it forever, or be taking some drugs forever,

01:29:25.140 | or you're not gonna take anything.

01:29:27.040 | I mean, that just seems to,

01:29:27.940 | life doesn't, does life have to work that way?

01:29:31.100 | Is there short-term use that can be effective?

01:29:33.700 | - Yeah, absolutely, yes.

01:29:35.100 | Yes, in American medicine,

01:29:36.860 | we are so much better at starting medicines

01:29:39.420 | than we are at taking them away, right?

01:29:41.760 | And part of that, I think, is driven

01:29:43.800 | by such a strong presence of the pharmaceutical industry.

01:29:47.780 | And the pharmaceutical industry

01:29:50.440 | does a lot of very good things, right?

01:29:52.860 | But, you know, there's such thing

01:29:55.220 | as too much of a good thing, right?

01:29:57.300 | And then as a society, when something seems positive,

01:30:00.460 | this, I think, also is human nature.

01:30:02.020 | We can over-invest in it, right?

01:30:03.840 | So you think about when Prozac

01:30:05.240 | and those kinds of medicines came out,

01:30:07.560 | they were safer medicines,

01:30:09.160 | they're billed as antidepressants,

01:30:10.780 | and the thought was, well, they're gonna fix depression,

01:30:12.780 | right, and it's not how that works, right?

01:30:15.980 | So if we look at them as tools, right,

01:30:19.220 | then we can deploy them sometimes for the longer term,

01:30:22.500 | 'cause sometimes that's necessary,

01:30:24.280 | but absolutely for the shorter term, I mean, absolutely.

01:30:28.040 | If we thought of Prozac and those kind of medicines,

01:30:31.100 | not as, oh, they're antidepressants,

01:30:33.100 | we thought, look, what they do

01:30:34.540 | is they seem to make there be more serotonin

01:30:38.740 | in certain circuits that are important for mood regulation,

01:30:42.980 | anxiety regulation, distress tolerance,

01:30:45.700 | so those medicines can really help somebody

01:30:47.960 | if they're very severely depressed

01:30:49.540 | and we wanna sort of get them feeling better.

01:30:51.940 | They can also help someone

01:30:53.380 | if they could use more distress tolerance

01:30:56.120 | in a discrete period of time, right?

01:30:58.560 | When we think about them that way,

01:31:00.460 | we think about them as tools that we could apply

01:31:03.660 | for short-term or long-term.

01:31:05.020 | We don't see them as fixes, right,

01:31:07.560 | and we don't see them as then substitutes

01:31:10.500 | for the human-to-human work that needs to be done.

01:31:13.380 | I mean, I've been in my training at times

01:31:16.240 | in healthcare systems,

01:31:17.900 | and I've seen in many other circumstances

01:31:20.060 | that look at medicines as answers,

01:31:22.060 | and this idea that, oh, that person is a,

01:31:25.260 | and a lot of times there'll be a number, right?

01:31:27.940 | The number is the diagnosis,

01:31:29.860 | and that number gets this medicine,

01:31:32.380 | and I'm not sure we could be more misguided than that,

01:31:36.140 | and that's what leads to adding medicines,

01:31:37.700 | adding medicines, it's not working,

01:31:39.020 | of course it's not working,

01:31:40.580 | because no one's really paying attention to what's going on,

01:31:42.540 | so add more medicines and then medicines for the medicines,

01:31:45.020 | and I mean, we know this is true.

01:31:46.860 | We know this is true,

01:31:48.900 | but we haven't had the wherewithal as a society

01:31:52.020 | to say, like with a lot of things in society,

01:31:54.340 | to say, hey, this isn't okay, right?

01:31:56.340 | I mean, we need more.

01:31:57.660 | Give these people who are trying to help us,

01:31:59.380 | they need more latitude to help us,

01:32:00.940 | so we need more human-to-human contact

01:32:03.500 | to get at what's really going on,

01:32:05.380 | and yes, that's an investment of time and energy

01:32:08.380 | and money in the short term,

01:32:10.100 | and sometimes that's money from the systems, right?

01:32:12.540 | But if we do that, my goodness,

01:32:14.820 | look at the payoff of that.

01:32:17.540 | - What is your thought about anxiety and ADHD

01:32:22.700 | as a separate phenomenon in terms of medication?

01:32:27.260 | - Again, ADHD is the thing

01:32:30.020 | that seems to come up most in questions.

01:32:31.900 | I can't tell you the number of, especially students,

01:32:34.820 | but also young working professionals

01:32:37.100 | and even people who are outside those categories

01:32:41.740 | who are interested in or are taking

01:32:45.020 | Ritalin, Adderall, Modafinil, R-Modafinil, or Vyvanse

01:32:50.860 | because they seem to struggle focusing without it,

01:32:53.620 | or, and I don't know 'cause I'm not one of those individuals,

01:32:57.460 | or because they seem to just like how well they can focus

01:33:01.580 | when they do take those compounds.

01:33:03.540 | And so my understanding is these compounds

01:33:06.340 | mainly increase dopaminergic transmission in the brain,

01:33:09.340 | also adrenaline, epinephrine in the brain,

01:33:12.420 | so they're more or less stimulants.

01:33:13.660 | They look a lot like, at least chemically,

01:33:15.260 | they look a lot like cocaine and amphetamine,

01:33:17.100 | although they're not quite cocaine and amphetamine.

01:33:20.020 | So should we be concerned about this?

01:33:22.340 | Is this a different sort of epidemic?

01:33:24.620 | Can these drugs be used to train the brain to focus

01:33:28.460 | and then people can withdraw from these drugs?

01:33:30.860 | I mean, I think this is a huge topic

01:33:33.020 | and one that maybe warrants its own episode entirely,

01:33:35.700 | but as long as we're on the topic,

01:33:37.540 | what are your thoughts about medication for ADHD?

01:33:40.100 | - Sure, I think medication for ADHD

01:33:43.340 | can be extremely effective.

01:33:44.900 | And the studies show us that, right?

01:33:47.700 | They show us that if there is ADD,

01:33:50.660 | then medication for ADD is very, very helpful.

01:33:54.460 | And that's true in youths.

01:33:56.220 | It seems to be true if adults have adult ADHD or ADD,

01:34:00.460 | like we kind of know that's true,

01:34:02.380 | but all attention deficit

01:34:05.140 | is not attention deficit disorder, right?

01:34:07.940 | And there we go to the reflexive 15 minute visits,

01:34:11.940 | throw medicines at things, right?

01:34:13.860 | Attention deficit can come from many, many places.

01:34:17.620 | And one of them is anxiety, right?

01:34:20.460 | There's so many other reasons, depression affects attention,

01:34:23.940 | poor sleep affects attention, poor diet can affect attention,

01:34:27.340 | stress in life can affect attention.

01:34:29.780 | So, and certainly trauma and the thing,

01:34:32.180 | the problems that trauma spins off can affect attention.

01:34:35.180 | So, you know, this is really the truth

01:34:38.260 | that while teaching once about medicines and pharmacology,

01:34:42.900 | I was frustrated about how the answer to everything

01:34:46.780 | was like, what medicine do we use?

01:34:47.940 | What medicine do we use?

01:34:48.860 | As opposed to like, this is just one piece of the puzzle.

01:34:51.620 | And I told an anecdote,

01:34:53.660 | which I think it was a clinical anecdote.

01:34:56.460 | Like, what do you think is going on?

01:34:57.540 | And I think that if I told that to,

01:35:00.500 | I don't know, middle school students or something,

01:35:02.740 | they would probably say,

01:35:04.020 | you just told the story of a person

01:35:05.820 | with a rock in their shoe,

01:35:07.460 | which is the story that I was actually telling, right?

01:35:10.780 | But several people I was talking to,

01:35:13.220 | they're physicians, right?

01:35:15.220 | ADD, right?

01:35:16.660 | It's like, no, every time the person steps down,

01:35:18.340 | the rock hurts and they're not able

01:35:19.980 | to maintain attention, right?

01:35:21.620 | Like, that's what's going on.

01:35:22.980 | But we're so programmed to think about medicines

01:35:27.140 | and inappropriate use of ADD medicines.

01:35:29.940 | As you said, there's dopaminergic impact.

01:35:32.180 | There's epinephrine, norepinephrine impact.

01:35:34.580 | We're affecting what are called prefrontal alpha-2 receptors

01:35:37.460 | that like really need to be helped if there's real ADD.

01:35:41.380 | But if there isn't, that is not a good thing to do,

01:35:44.620 | which is why it is quite fascinating

01:35:46.680 | that when people have ADD,

01:35:48.980 | they tolerate generally stimulants very well

01:35:52.200 | without the other problems that can come of stimulants.

01:35:55.200 | And again, I don't claim to know why that is,

01:35:57.700 | but we see that phenomenon.

01:35:59.780 | But when people are being treated for ADD

01:36:02.840 | and they don't have ADD,

01:36:04.120 | which sometimes they know they don't have ADD,

01:36:05.900 | but the stimulants make them function better,

01:36:07.540 | so they go to somebody and get the stimulants,

01:36:09.620 | that's not a good thing to do, right?

01:36:12.340 | 'Cause stimulants, when they're not needed over time,

01:36:15.080 | they do affect our physical function.

01:36:17.000 | They affect our judgment, right?

01:36:18.540 | There are a lot of negative things that come from that.

01:36:20.820 | They can affect the vigilance inside of us.

01:36:22.900 | So yes, it's a valid diagnosis,

01:36:26.680 | but it gets made when it's not present very often,

01:36:30.540 | which we see with a lot of diagnoses

01:36:32.500 | that you can throw medicine at.

01:36:33.660 | We see the same thing with bipolar disorder.

01:36:35.840 | True bipolar disorder is extremely important

01:36:38.500 | to utilize medicines effectively.

01:36:40.600 | But how many people are diagnosed with bipolar disorder

01:36:43.180 | if they absolutely don't have bipolar disorder?

01:36:46.820 | But it can be a catch-all diagnosis

01:36:49.840 | because there's, in a sense,

01:36:51.340 | something to do for it, in quotes, right?

01:36:53.860 | And you can throw medicine at it, right?

01:36:55.580 | So, I mean, what do we expect, right?

01:36:57.680 | If we have a healthcare system

01:36:59.320 | where you have 15-minute visits with your psychiatrist,

01:37:01.540 | of course we're gonna throw medicines at everything.

01:37:03.500 | And then the training paradigms

01:37:05.120 | are gonna look at it through that lens.

01:37:07.380 | And then very often, again, I gave the example

01:37:09.780 | of seeing somebody on seven medicines.

01:37:11.980 | I mean, the first thought I have is,

01:37:14.060 | how many of those medicines are actually counterproductive?

01:37:17.100 | And a lot of the time, it's not like,

01:37:19.040 | oh, every now and then one is counterproductive.

01:37:21.060 | No, that's the case.

01:37:22.580 | That's the case a lot of the time.

01:37:24.380 | And again, I come back to,

01:37:26.180 | if we're not putting thought into it,

01:37:28.740 | what other result would we expect?

01:37:30.700 | - Thank you for that answer.

01:37:34.060 | I'm very curious what constitutes

01:37:36.500 | negative effects of stimulants.

01:37:37.980 | So if somebody's taking Adderall or Ritalin

01:37:40.660 | in order to work longer hours or focus

01:37:43.180 | because they have attention deficit,

01:37:44.780 | but not necessarily ADHD.

01:37:46.860 | And again, I'm not recommending anyone do this.

01:37:48.580 | I've just heard the numbers that have come back,

01:37:50.980 | at least from surveys and discussions

01:37:52.880 | with colleagues at Stanford and elsewhere,

01:37:55.060 | other college campuses,

01:37:56.260 | that upwards of 75% of college students

01:37:59.340 | use semi-regularly these drugs off,

01:38:02.140 | not by prescription, just to study and to learn.

01:38:05.140 | - Yes.

01:38:06.180 | - I can imagine sleep issues because these are stimulants.

01:38:09.820 | What sorts of other issues can they create

01:38:12.500 | for people, problems they can create?

01:38:14.820 | - I think a touchstone maybe for,

01:38:16.840 | that's running through our conversation, right?

01:38:18.620 | Is prioritizing the short-term benefit

01:38:21.620 | over solving a long-term problem, right?

01:38:24.540 | Which we might say is a human tendency.

01:38:27.060 | And we see it across the topics that we're discussing.

01:38:29.940 | So short-term use of stimulants,

01:38:32.940 | sure, people are more alert.

01:38:34.060 | They can stay awake more.

01:38:35.660 | They can study more intensely and longer.

01:38:38.360 | Okay, there's some short-term benefit of that.

01:38:40.580 | Over there, even there, there can be problems, right?

01:38:43.420 | But we can say, let's just say for sake of argument

01:38:46.240 | that in the short term,

01:38:47.080 | there's something to be gained by doing that, right?

01:38:49.400 | But, oh my goodness, there's so much that is,

01:38:53.460 | there's so much risk to that, right?

01:38:55.200 | And how many times have I seen someone

01:38:57.100 | who they're doing that

01:38:57.960 | and they're just doing that to study, right?

01:39:00.180 | And now they're addicted to the amphetamines

01:39:02.860 | and their behavior changes and they don't know it.

01:39:06.320 | Talk about shifting our brain towards a more defensive,

01:39:10.420 | sort of suspicious outward look, view of the world,

01:39:14.380 | that we see a lot of that.

01:39:16.140 | So we see judgment impairment.

01:39:18.700 | We see heightened levels of anxiety.

01:39:20.900 | We see more impulsivity in decision-making.

01:39:23.900 | And sometimes we can get to the point

01:39:26.880 | of seeing frank psychosis.

01:39:28.260 | Now that's not common,

01:39:29.700 | but have I seen young people

01:39:32.040 | who've done exactly what you're describing, right?

01:39:34.100 | They're using Adderall or they're using Ritalin to study.

01:39:37.420 | And then I see them when they're coming into the hospital,

01:39:40.000 | they're screaming about how someone's trying to hurt them.

01:39:43.080 | Boy, then it's the worst case scenario,

01:39:45.660 | but it shows like that's where that can go.

01:39:48.000 | And how much is there between the,

01:39:49.940 | oh, I'm just using it to study

01:39:51.200 | and that severe outcome

01:39:54.060 | that is actually quite negative for a person.

01:39:56.720 | It might change how they think about that friendship

01:39:58.800 | or that relationship, right?

01:40:00.320 | A lot negative happens when we change our brains

01:40:03.680 | without an ability to see like,

01:40:05.340 | what is it actually doing to us?

01:40:07.140 | Which is part of my whole theme about trauma, right?

01:40:09.580 | It changes our brains and we don't know it, right?

01:40:12.460 | Well, the same is often true

01:40:15.460 | of amphetamines used inappropriately.

01:40:17.960 | It shifts our brain and we don't realize

01:40:20.940 | that we're a little bit more impulsive

01:40:22.300 | in our decision-making, a little bit less trusting.

01:40:24.820 | These are significant negative things

01:40:26.820 | that if we don't know it,

01:40:28.240 | person will just say,

01:40:29.580 | oh, I'm just using it to study.

01:40:30.700 | I'm using it to work more.

01:40:32.460 | That's not without its high level of risk.

01:40:36.720 | - What are your thoughts on cannabis?

01:40:39.640 | I've said it many times on this podcast before.

01:40:41.800 | I'll say again,

01:40:42.640 | I feel fortunate that I've never really been attracted

01:40:45.020 | to alcohol or drugs of any kind,

01:40:47.540 | so much so that if all the alcohol and all the marijuana

01:40:52.380 | and all the cocaine and amphetamine disappeared,

01:40:55.060 | I wouldn't notice any change in my life, right?

01:40:59.180 | And I feel lucky in that way

01:41:00.220 | 'cause I know a lot of people feel an attraction

01:41:03.680 | to these things as almost a gravitational force

01:41:06.320 | from their first drink, they just feel,

01:41:08.380 | I once heard it described in this,

01:41:09.940 | I think it was in an Augustan Burroughs book, "Dry,"

01:41:12.180 | where he was an alcoholic.

01:41:13.380 | He said that the first drink he had,

01:41:15.420 | it felt like this magic elixir

01:41:17.260 | that meshed with the physiology of his blood

01:41:20.380 | in the most seamless way.

01:41:21.700 | And as I was reading this, I thought, oh my goodness,

01:41:24.520 | first of all, that's the most foreign experience for me

01:41:27.540 | in terms of alcohol.

01:41:29.060 | And second, gosh, that must be terrible,

01:41:32.200 | and you can, but at the same time,

01:41:33.660 | you could really understand

01:41:34.500 | why someone would be drawn to that.

01:41:35.900 | So cannabis nowadays is legal or decriminalized

01:41:40.380 | in many areas of the US.

01:41:42.380 | A lot of people seem to use the argument,

01:41:46.020 | it's better than drinking,

01:41:48.020 | or they only do it for sleep or anxiety management.

01:41:53.100 | I'm not looking to demonize or support the cannabis.

01:41:57.660 | So what are your thoughts about cannabis

01:41:59.260 | for anxiety management, depression,

01:42:01.300 | and maybe even for ADHD for that matter?

01:42:03.820 | - Sure, if I could make an alcohol comment, right?

01:42:07.940 | The number of times I've seen alcohol,

01:42:10.060 | like having been a good idea for coping with something,

01:42:13.100 | it approaches zero, right?

01:42:15.260 | The alcohol for coping is just never good.

01:42:18.980 | And there's an additional risk factor

01:42:20.780 | that there are certain genetic profiles

01:42:23.580 | where people respond strongly to alcohol,

01:42:26.460 | like as you're saying, it's not just,

01:42:28.180 | oh, there's a little bit of short-term relief of distress,

01:42:31.460 | but there's a sort of euphoric response.

01:42:33.460 | And those genetics, we don't understand them completely.

01:42:36.380 | They seem to be in Northern European populations,

01:42:39.600 | more prevalent as you had West in Northern Europe.

01:42:42.260 | So we understand that where risk factors are demographically,

01:42:45.700 | but we can't pinpoint that for any one person.

01:42:47.940 | And there's a tremendous risk of that

01:42:50.060 | when a person responds so strongly to alcohol

01:42:52.660 | or habituates coping to alcohol.

01:42:55.540 | Cannabis is a little bit of a different story.

01:42:57.520 | I mean, how I have seen that play out,

01:43:00.700 | and again, this isn't coming from any expertise

01:43:02.860 | around the neuropharmacology of it,

01:43:06.300 | like how is this really working in the brain?

01:43:08.260 | It comes from an observation that what it seems to do

01:43:11.660 | is to narrow our attentional perspective, right?

01:43:15.220 | So it's why people will say,

01:43:16.500 | well, they wanna use cannabis before watching a movie

01:43:19.420 | with friends or something, right?

01:43:20.700 | And I think, okay, I think why people are doing that

01:43:24.220 | is because a cognitive spectrum narrows,

01:43:27.340 | and then instead of worrying about that thing at work

01:43:29.500 | or that relationship issue, one can just be present, right?

01:43:32.340 | For it gates out other attentional intrusions, right?

01:43:36.460 | So in some ways, I mean,

01:43:38.340 | I've absolutely seen it be helpful to people.

01:43:40.700 | I mean, it's been legalized in Oregon,

01:43:43.340 | which is where I spent a lot of my time,

01:43:45.460 | and it's not where all of my practice is.

01:43:47.540 | But what I have seen is it is at times helpful,

01:43:50.340 | say, around sleep, right?

01:43:51.580 | Because a person can gate out other intrusive thoughts

01:43:54.300 | and they can just relax and go to sleep.

01:43:56.420 | But there can be another side of that too

01:43:58.900 | that at higher levels of distress,

01:44:01.140 | at higher levels of tension,

01:44:03.140 | what it can do is narrow the focus of cognition

01:44:06.500 | to the thing that is negative, right?

01:44:08.740 | So the idea that, oh, this is a treatment

01:44:12.340 | for depression, anxiety, trauma is not true, right?

01:44:17.060 | Can it be helpful under certain circumstances?

01:44:19.900 | Like, I think the answer to that is yeah.

01:44:21.540 | I mean, I know the answer to that is yes

01:44:22.780 | 'cause I've seen it play out clinically that way,

01:44:24.940 | but it can also be harmful too.

01:44:27.380 | So there again, like anything that has any power,

01:44:30.300 | power to influence our brains,

01:44:32.180 | we wanna be thoughtful and careful about it.

01:44:34.300 | I mean, do I think that it's safer than alcohol?

01:44:36.780 | Yes, I mean, I think we so clearly see that.

01:44:40.060 | Does that mean it was just uniformly safe?

01:44:42.380 | No, right?

01:44:43.460 | So we wanna be respectful of anything

01:44:45.780 | that can change how our brain is working.

01:44:48.140 | And I think that certainly includes alcohol

01:44:50.340 | and I think it certainly includes cannabis too.

01:44:52.700 | - I'd love to talk about psychedelics for two reasons.

01:44:58.180 | One, there seems to be a tremendous amount of interest

01:45:01.460 | in psychedelics as a therapeutic clinical tool.

01:45:04.620 | I know there's also recreational use

01:45:06.220 | and I'll just preface all this by saying that my stance is

01:45:10.620 | we absolutely know for sure

01:45:13.020 | that these are controlled substances.

01:45:14.660 | They're illegal to possess, sell or use

01:45:16.780 | in most of the country.

01:45:18.780 | There are a few areas where they are decriminalized

01:45:21.700 | and psychedelics is a broad category, of course,

01:45:25.700 | and we can touch on some of the different ones.

01:45:28.420 | But whereas five years or so,

01:45:32.260 | five years ago or so, I was truly afraid

01:45:34.620 | to say the word psychedelics in any kind of public venue.

01:45:37.460 | There are laboratories at Stanford working on ketamine,

01:45:41.420 | psilocybin, MDMA, mostly in animal models.

01:45:45.540 | There's terrific work going on

01:45:48.380 | at Johns Hopkins School of Medicine

01:45:49.940 | and Matthew Johnson's lab and others

01:45:52.300 | looking at the clinical applications

01:45:53.780 | mainly of high dose psilocybin and LSD.

01:45:56.380 | There's the MAPS trials with MDMA.

01:45:58.300 | So nowadays it's safe for an academic like me

01:46:01.780 | to say the word psychedelics.

01:46:02.980 | And I'd love to approach this question of psychedelics

01:46:05.700 | from a place of true exploration and curiosity,

01:46:08.780 | but with the preface that we're talking about this

01:46:11.940 | in a legal clinical setting.

01:46:15.180 | And the legality is something that's now in process.

01:46:19.220 | I don't think it's completed, but that's my understanding.

01:46:22.300 | But there are trials.

01:46:24.180 | You can go to clinicaltrials.gov and put in MDMA

01:46:29.180 | and you'll see a bunch of clinical trials

01:46:30.780 | that are happening in the recruiting subjects.

01:46:33.660 | So I think it's safe to have the conversation now.

01:46:36.540 | And I'd love your thoughts about psychedelics.

01:46:38.940 | Maybe we could start with psilocybin and LSD

01:46:43.220 | as a broad category of drugs that at least my understanding

01:46:46.140 | is they touch on mainly the serotonin system,

01:46:49.380 | some specific receptor activation and modulation

01:46:52.620 | tend to change notions of space and time,

01:46:55.980 | adjust internal state.

01:46:57.540 | Maybe we would start there

01:46:58.820 | and then maybe venture into some of the other ones.

01:47:00.780 | So what are your thoughts on these drugs

01:47:02.340 | for therapeutic potential,

01:47:03.940 | also potential hazards, et cetera?

01:47:07.860 | - Yeah, I think if we look at the true psychedelic,

01:47:10.340 | so psilocybin and LSD, like ketamine and MDMA,

01:47:13.980 | they're different categories of medicine.

01:47:15.620 | They're these sort of novel tools to bring to bear.

01:47:19.060 | But if we start with psilocybin, LSD, true psychedelics,

01:47:22.980 | I think why they have gained so much momentum

01:47:27.980 | over the last several years is because the data

01:47:31.140 | coming from the labs and the academic centers

01:47:35.660 | is so powerfully positive.

01:47:38.060 | And as someone who's, I'm interested in anything

01:47:40.740 | that's potentially helpful, right?

01:47:42.900 | And I wanna learn and understand that

01:47:44.540 | because a lot of things that are potentially helpful,

01:47:47.180 | you go and look at the data and you see

01:47:48.820 | that that's not helpful or that's harmful.

01:47:51.220 | I think what we have seen with psychedelics

01:47:53.980 | is that they're so helpful, right?

01:47:56.860 | And the trials are bearing that out.

01:47:58.660 | And of course, these are used in professional hands

01:48:01.140 | and with the right kind of guidance

01:48:02.740 | are extremely powerful tools, but used in the right way

01:48:06.180 | by someone who knows how to utilize them

01:48:08.300 | in the right set and setting

01:48:10.140 | can have an immense positive impact.

01:48:13.140 | And that's why I think that the thought is there

01:48:16.740 | across people and more and more people feel comfortable

01:48:19.500 | saying it and talking about it.

01:48:21.380 | I mean, we're in the state of Oregon now

01:48:23.100 | where the thought is we're moving towards legalization

01:48:26.500 | of psilocybin early in 2023.

01:48:29.780 | And it's part of the new data, right?

01:48:32.300 | And how it meshes with the older data, right?

01:48:34.660 | How it meshes with data from the '60s and '70s

01:48:37.500 | that showed such a strong, powerful impact

01:48:40.140 | of these medicines.

01:48:41.300 | And I have a whole set of thoughts

01:48:42.660 | about what's happening there

01:48:44.620 | and they're just, they're conjectures, right?

01:48:46.700 | But my read of, you know,

01:48:49.180 | as best I can try and understand the neuroscience

01:48:51.820 | and the clinical applicability and the changes is,

01:48:56.540 | you know, what happens is we see less communication,

01:48:59.620 | less chatter in the outer parts of the brain, right?

01:49:03.180 | In the outer parts of the cortex.

01:49:04.740 | And I think that as human beings,

01:49:07.660 | we sort of glorify the parts of the brain

01:49:10.780 | that only we have.

01:49:12.500 | I mean, certainly in my growing up, right?

01:49:14.860 | I mean, what did I learn?

01:49:16.100 | Even if you think about like learning about the brain

01:49:17.780 | in high school, right?

01:49:18.860 | I learned that like, wow, we're great as humans

01:49:21.420 | 'cause we have language and other animals don't

01:49:24.020 | and we can use tools and like, aren't we so great

01:49:26.660 | because we have this part of the brain

01:49:28.380 | that other animals don't and it lets us function, right?

01:49:32.620 | Okay, there's some truth to that, right?

01:49:34.660 | That we can do things others can't do

01:49:37.540 | but we get lost often in the outer parts of the cortex

01:49:42.540 | which I think are about survival, right?

01:49:46.340 | So we come back to the things you and I talked about

01:49:48.300 | early on of like, why are these trauma mechanisms in us?

01:49:51.420 | Right, so much of what's going on in our brains

01:49:53.700 | is about survival.

01:49:55.100 | And I think living, so to speak, in the cortex, right?

01:49:58.540 | In the outer part of the brain is consistent

01:50:01.780 | with a focus on survival.

01:50:03.540 | So if you think that's where language is,

01:50:05.100 | that's where vision is, that's where executive function is,

01:50:08.020 | so planning and task execution.

01:50:10.980 | So, so much of that is about making our way

01:50:14.420 | in the world around us.

01:50:16.420 | So we tend to glorify that and think,

01:50:18.340 | well, that's in a sense where our existence is, right?

01:50:21.380 | And I believe that is not true, right?

01:50:24.140 | And again, can I say that for sure?

01:50:25.700 | Of course not, right?

01:50:26.900 | But my read of 20 years of doing clinical work

01:50:29.420 | and thinking about all sorts of medicines

01:50:31.380 | and thinking about the psychedelics in a lot of depth,

01:50:35.740 | I think that what they do

01:50:36.820 | is they take us out of the cortex, right?

01:50:39.220 | 'Cause that's where we run into these problems.

01:50:41.340 | That's where we bounce things over and over again,

01:50:43.700 | that the distress centers deep in our brain,

01:50:45.820 | in the brainstem, kind of ally

01:50:48.540 | with the outer parts of the cortex.

01:50:50.900 | And they say, right, we're in distress,

01:50:52.700 | we wanna stay alive.

01:50:54.220 | Often a lot of us have had trauma

01:50:56.420 | that makes these changes in the brain.

01:50:58.340 | And then we're thinking all the time,

01:50:59.780 | like what would I do if there were war?

01:51:02.620 | What would I do if there's civil war, if someone bombs us?

01:51:05.340 | What will I do if the economy collapses, right?

01:51:07.740 | What will I do if somebody gets sick?

01:51:09.380 | We're thinking all this future projection

01:51:12.180 | that is all coming from a place of fear, right?

01:51:15.660 | It's all coming from a desire to think about things

01:51:18.340 | and control the future with this part of the brain

01:51:20.700 | that is so uniquely human, right?

01:51:23.660 | And I think when we take the neurotransmission

01:51:26.220 | out of those places, right,

01:51:28.100 | and we set it in a part of the brain

01:51:30.180 | and say the insular cortex, right?

01:51:32.220 | The parts of the brain that are sort of in the middle,

01:51:34.820 | right, which I think,

01:51:36.540 | I believe is where our humanness really is.

01:51:39.460 | So the psychedelics make there be less chatter,

01:51:42.220 | communication in these other parts of the brain,

01:51:44.660 | and then we become seated in the part of the brain

01:51:48.020 | that I believe is most about our experience

01:51:51.140 | of true humanness.

01:51:52.620 | Which is why when you read about people

01:51:55.380 | who have experiences, and I've heard about them,

01:51:57.220 | people talk to me about this, right?

01:51:58.700 | They've utilized it, they talk with me.

01:52:01.340 | So whether it's someone telling me their story

01:52:03.340 | or it's coming from research data,

01:52:05.420 | you know, it's why people can sort of see with clarity

01:52:07.980 | that, oh, that trauma,

01:52:10.860 | like that thing is not my fault.

01:52:13.060 | Or like we feel a sense of compassion for ourselves.

01:52:15.260 | We relieve ourselves, release ourselves from guilt.

01:52:18.060 | And it's like, why is this so helpful to people?

01:52:21.420 | And I think it's because it can do

01:52:24.260 | what we are trying to get at in good therapy.

01:52:27.160 | But it can really catalyze that

01:52:29.340 | by just putting a person in that part of the brain

01:52:32.480 | that can see it for what it is

01:52:34.660 | without all that chatter in the cortex

01:52:37.020 | about how you gotta think it's your fault

01:52:38.240 | or you won't avoid it again.

01:52:39.220 | And that makes the repetition compulsion.

01:52:41.020 | How do I think ahead to the next thing that might happen?

01:52:42.780 | And what else bad might happen?

01:52:44.440 | I mean, we don't get anywhere doing that.

01:52:46.460 | And I think where we get somewhere

01:52:48.540 | is when we seat ourselves deeper in the brain,

01:52:51.100 | which I think we do if we're like doing really good therapy

01:52:53.840 | and we're, you know, we're in the deep parts of the brain.

01:52:56.820 | But these psychedelics, the medicinal value, I believe,

01:53:01.260 | is putting us in that part of the brain

01:53:03.640 | where a person can really find truth.

01:53:05.620 | And that's why I think that it's come so far

01:53:08.780 | in these few years,

01:53:10.380 | because I think that is very clinically evident.

01:53:14.380 | And I think we're gonna see more and more

01:53:16.160 | the value of that and how what the psychedelics do

01:53:20.580 | can become, I believe, a heuristic for understanding like,

01:53:23.740 | wait, how are our brains really functioning?

01:53:26.440 | And what are the parts that really matter

01:53:28.720 | to our experience of being human?

01:53:31.600 | It's those parts of the brain, right?

01:53:33.000 | The deep parts of the brain, the insular cortex,

01:53:35.700 | and the areas around it that say light up

01:53:38.520 | when a person has an experience of spiritual ecstasy

01:53:42.760 | or an experience of connection with another person, right?

01:53:45.800 | So we kind of have these telltale markers

01:53:48.120 | that something is going on there

01:53:49.900 | that's very important and very special.

01:53:52.360 | And I think we're more attracted

01:53:53.860 | to the outer parts of the brain

01:53:55.060 | because they're easier to study, right?

01:53:56.900 | I mean, as you know better than I do,

01:53:58.700 | we started studying the brain through lesion studies, right?

01:54:01.220 | 'Cause it was easier to see if a person got hurt

01:54:03.340 | in this part of the brain

01:54:04.180 | or had a stroke in that part of the brain, what changes.

01:54:06.820 | So we look at the cortex 'cause one, it's easier to study

01:54:09.720 | and we tend to glorify it.

01:54:11.580 | And I think that has been misguided.

01:54:14.740 | And I think that we're learning

01:54:18.140 | about how that's been misguided

01:54:20.100 | through the study of these novel modalities

01:54:23.580 | from Western perspectives, but of course,

01:54:25.100 | they've been used for a long, long time in other cultures,

01:54:28.460 | but novel from our perspective.

01:54:30.660 | - Yeah, I'm fascinated by this idea

01:54:32.140 | that in these middle brain structures

01:54:34.260 | is where our humanity lies.

01:54:36.680 | And as you said, I also wonder whether or not

01:54:39.280 | other animals experience life more from that orientation

01:54:44.160 | with less chatter.

01:54:45.200 | We can only guess, but the dog lover

01:54:49.860 | and being in the presence of animals

01:54:53.020 | that seem to just be present in what's happening

01:54:55.460 | in their immediate environment,

01:54:56.540 | not too much anticipation. - Right, I mean,

01:54:59.540 | what you're talking about is sentience as important.

01:55:02.140 | And sentience is extremely important, right?

01:55:04.500 | And if we're going to overvalue, say, language,

01:55:06.920 | then I think we undervalue sentience, right?

01:55:09.500 | Which is why I think we tend to undervalue animals, right?

01:55:13.040 | And they're suffering because, well,

01:55:14.500 | they're not saying anything about it, right?

01:55:16.140 | And, you know, they're not writing about it.

01:55:17.980 | So, okay, it's easy to ignore.

01:55:19.900 | And we think about, again, the hubris of that, right?

01:55:22.340 | The, oh, because we can think and talk and write,

01:55:24.280 | like we must be feeling more than species

01:55:27.500 | that don't do that.

01:55:28.340 | I mean, I think that that is so true

01:55:31.060 | and that we're going to understand more about sentience

01:55:33.660 | in other species and how, you know,

01:55:35.560 | that's at the core of existence.

01:55:38.700 | And my hope would be that we value more humans and animals,

01:55:43.500 | right, through the evolution of that understanding.

01:55:47.380 | - The hallucinations that accompany psychedelics like LSD

01:55:52.380 | and psilocybin have such an attractive force to them

01:55:56.660 | as a concept and as an experience.

01:56:00.080 | And so I think most often when people hear hallucinogens,

01:56:04.500 | they think, and psychedelics, they think about hallucinating.

01:56:07.700 | - Right.

01:56:08.540 | - It makes sense why they would.

01:56:09.360 | But what's so interesting to me is nothing in your answer

01:56:12.460 | about psychedelics, psilocybin and LSD focused

01:56:16.020 | on hallucinations per se.

01:56:17.860 | It was more about feeling states, accessing a feeling state

01:56:20.820 | or a relation to an event or to a person or to oneself.

01:56:24.420 | Maybe even I caught hints of maybe even empathy

01:56:27.280 | for oneself for the first time.

01:56:29.680 | None of that had to do with seeing sounds

01:56:34.060 | or hearing colors and, you know,

01:56:36.140 | these kind of cliche statements about hallucinations.

01:56:39.020 | So I am aware of laboratories,

01:56:41.500 | one at University of California Davis in particular,

01:56:44.060 | but a few others that are trying to generate

01:56:46.620 | chemical variants of psychedelics

01:56:49.300 | that lack the hallucinogenic properties,

01:56:52.940 | but maintain these other properties as therapeutic tools.

01:56:56.740 | And as I say that, I realize that people

01:56:59.260 | in the psychedelic community are probably thinking,

01:57:02.260 | oh, that's horrible.

01:57:03.100 | That's the dismantling of the core thing.

01:57:05.980 | But the simple question is,

01:57:07.600 | do you think the hallucinations are valuable for anything?

01:57:10.740 | - And I think we're really getting

01:57:12.260 | into the philosophical, right?

01:57:14.700 | The ontological, right?

01:57:15.900 | There's this sort of trying to understand being, right?

01:57:18.980 | And I don't claim to know the answer to that.

01:57:22.420 | I think that at times it seems like the hallucinations

01:57:26.660 | have a metaphorical or a symbolic way of being helpful,

01:57:31.660 | right, because people will come to understand things

01:57:36.020 | that they hold dear and true after the experience, right?

01:57:41.860 | That often, not always,

01:57:43.980 | come through the lens of the hallucination.

01:57:46.900 | So are the hallucinations necessary?

01:57:50.260 | Are those hallucinations sometimes important, sometimes not?

01:57:53.660 | I mean, I think we don't understand that,

01:57:55.860 | and I think we want to be respectful

01:57:57.900 | of the sort of mystery of that.

01:57:59.900 | But what I think is fascinating is,

01:58:02.500 | you think about substance abuse and what that means is,

01:58:05.680 | well, one aspect of that is that a person has experiences,

01:58:08.580 | thoughts, conceptions of self in the world

01:58:10.700 | with the substance that,

01:58:12.060 | without the substance, they know are wrong, right?

01:58:14.260 | People talk about liquid courage, right?

01:58:16.460 | And, "Okay, I feel better about myself

01:58:17.660 | and I feel courageous 'cause I've had a couple of drinks.

01:58:19.420 | Now, after that, I feel normal about myself

01:58:23.340 | and that was false," right?

01:58:25.260 | And we see that.

01:58:26.340 | That's part of what substance intoxication means, right?

01:58:29.700 | But what we see with the psychedelic medicines

01:58:33.500 | is something that's incredibly different, right?

01:58:35.860 | That people are having experiences that are so de-linked

01:58:39.300 | from our normal experience of reality.

01:58:42.160 | And then when they come, in a sense, back online,

01:58:45.100 | in a normal cognitive way, they realize like,

01:58:47.680 | "Wow, now I'm applying all those mechanisms

01:58:49.780 | of trying to understand truth to that

01:58:52.440 | and what I see is that it's true and wow, it's true."

01:58:55.980 | Like, I mean, we hear that all the time, which tells me,

01:58:58.480 | "Hey, something different is going on there."

01:59:01.100 | And of course, these are powerful tools, so misused,

01:59:03.620 | like very bad things can happen.

01:59:05.340 | But you think about the clinical utility

01:59:07.260 | and what does it mean that so many people

01:59:10.740 | change for the healthier or even change their lives

01:59:14.380 | after an experience because it so resonates.

01:59:17.060 | It's like, "Oh, now I understand something that's true."

01:59:19.220 | And it's not something bizarre.

01:59:20.740 | It's like, "I wasn't responsible for being raped that time."

01:59:23.560 | Or, "I'm not less than, even though my sexuality

01:59:27.900 | or my gender identity is different

01:59:29.260 | from some silly binary concept," right?

01:59:31.580 | Like people kind of often get it

01:59:33.140 | and they feel differently about themselves

01:59:34.800 | and guilt and shame are impacted.

01:59:36.700 | So I think we're likely to see

01:59:38.580 | that they are powerful anti-trauma mechanisms,

01:59:42.480 | again, used clinically in the right hands.

01:59:44.780 | And I think that we're also gonna see

01:59:46.760 | that they're heuristic for understanding our brain

01:59:49.380 | that goes against what I see as some of the reflexive hubris

01:59:52.940 | of, "Well, the outer parts must be the best

01:59:54.820 | because that's what makes us human

01:59:56.920 | and other animals don't have it

01:59:58.060 | and we're better because we're human."

01:59:59.320 | It means it makes no sense, you know?

02:00:01.180 | - I'd like to talk about MDMA.

02:00:03.860 | And I'll preface this by saying I was a participant,

02:00:06.580 | actually, technically I'm still a participant

02:00:08.540 | in a clinical trial.

02:00:09.660 | So I have experience of doing it twice.

02:00:12.960 | The trial involves three separate dosings of this.

02:00:16.880 | I was reluctant to do it outside of a clinical trial,

02:00:21.400 | mostly because I was aware

02:00:23.700 | there can be some cardiac effects.

02:00:25.340 | And I liked the idea there'd be a clinician on hand.

02:00:27.440 | And I'll just say that I found the experiences

02:00:31.220 | to be profound, beneficial,

02:00:34.900 | and very different from one session to the next.

02:00:38.940 | The first one felt a whole collection of ideas

02:00:43.940 | and relational things came up

02:00:47.800 | that felt very powerful and transformative.

02:00:49.780 | And I do think that I learned there.

02:00:51.900 | I exported a number of things.

02:00:53.860 | My particular experience isn't relevant here,

02:00:56.100 | but the second time I expected it to be the same way.

02:00:59.020 | And it was very mellow and relaxing

02:01:03.120 | and was deeply tied to kind of notions of acceptance.

02:01:07.560 | So there weren't all these revelations and wow, new insights.

02:01:11.240 | It was very much about sort of grounding

02:01:13.860 | into a kind of a calmer state.

02:01:16.520 | So I have the personal experience of benefiting from these

02:01:20.260 | in ways that I think still benefit me

02:01:22.060 | and was very struck by the power of MDMA.

02:01:25.460 | And my very crude understanding of the pharmacology

02:01:28.820 | and the state that is being under MDMA

02:01:31.260 | is that it encourages or increases dopaminergic transmission

02:01:35.280 | but also serotonergic transmission,

02:01:37.480 | which is, to my knowledge,

02:01:38.600 | a kind of a rare state for the brain to be in.

02:01:41.320 | That typically it's more of a seesaw

02:01:42.940 | of dopaminergic drive towards external goals

02:01:46.180 | or more serotonergic drive towards more placidity

02:01:50.120 | or comfort with what one already has.

02:01:52.460 | And so with both those systems amplified,

02:01:55.020 | the only way I can describe it subjectively

02:01:56.820 | is that everything sort of funneled back in

02:01:58.620 | and it was almost like a pursuit of inner landscape.

02:02:03.180 | And I can only imagine what it would be like

02:02:06.540 | in the context of doing this with somebody else

02:02:10.500 | also taking MDMA.

02:02:11.620 | I have no idea what that's like.

02:02:13.640 | That's my report of the experience.

02:02:16.240 | I know that the experience can vary.

02:02:18.060 | What are your thoughts about the chemistry

02:02:20.780 | and what sorts of states do you think MDMA is creating

02:02:26.160 | that can explain why it's a useful therapeutic tool

02:02:29.460 | in some cases and what sorts of cases those might be?

02:02:32.980 | - Sure, sure.

02:02:34.080 | To clarify, I think part of what we're starting with

02:02:37.900 | is like this is very different than the psychedelics, right?

02:02:40.860 | Which are seeding our consciousness

02:02:42.380 | in these deep centers of the brain, right?

02:02:44.540 | Whereas what MDMA is doing is sort of flooding

02:02:48.100 | with positive neurotransmitters, right?

02:02:50.480 | In certain parts of the brain.

02:02:51.780 | And I think what that creates is a greater permissiveness

02:02:55.460 | inside to entertain or approach different things, right?

02:03:00.460 | So I think where we see it's tremendous,

02:03:03.760 | my read of the data is around potentially,

02:03:06.240 | and we're seeing in some of the trials, right?

02:03:07.960 | Tremendous benefit for trauma, right?

02:03:10.360 | And you think about what we were talking about earlier,

02:03:12.480 | how this reflexive guilt, shame,

02:03:14.860 | hypervigilance, avoidance, right?

02:03:17.320 | And when these systems are flooded

02:03:19.960 | with these neurotransmitters,

02:03:21.520 | it's more permissive to sort of think about that, right?

02:03:23.900 | And to think about that without, again,

02:03:25.580 | all the chatter of that's your fault,

02:03:27.840 | or you're never gonna get anywhere because of that,

02:03:29.820 | or you know what that means, right?

02:03:31.500 | They can kind of go away and then we can think about it

02:03:33.620 | in a way that isn't through the lens of fear, right?

02:03:36.800 | And I think that's the power there

02:03:39.080 | is that it's permissive of approaching something,

02:03:42.360 | contemplating something, you know, a different, a novelty.

02:03:46.600 | We talk about a de novo approach.

02:03:48.620 | And I think that's also why the experience can vary

02:03:51.700 | because you could also see how

02:03:54.080 | if you're not thinking about something, right?

02:03:56.680 | So there's not a clinical guidance to it.

02:03:59.260 | You could be in a state where like,

02:04:01.380 | I just feel good, right?

02:04:02.720 | And I'm thinking about good things

02:04:04.480 | and like that can feel good, right?

02:04:06.440 | But that's not necessarily problem solving, right?

02:04:09.520 | So the clinical guidance says,

02:04:11.240 | hey, let's take that state and do something with it, right?

02:04:15.240 | Now that you're in this state,

02:04:16.800 | hey, let's make cable, the sun is shining, right?

02:04:19.140 | You're in a state where we can look at things

02:04:21.500 | that are traumatic, right?

02:04:22.880 | We can approach them from a de novo perspective.

02:04:25.800 | And I think it's part,

02:04:26.800 | I think that explains why you had these different experiences

02:04:29.240 | from one to the other,

02:04:30.500 | because your brain is just in a state

02:04:32.060 | that's conducive to something, right?

02:04:34.160 | But if there's not the mechanism to have that thing happen,

02:04:37.700 | like conducive to something therapeutic,

02:04:39.740 | then you might go there on your own,

02:04:41.420 | or you might just be in a state

02:04:43.260 | where you have a sense of wellbeing and you sit with that.

02:04:46.640 | - Which sort of seems like a waste to me.

02:04:48.340 | I mean, this is what I tell people when they ask about MDMA.

02:04:51.980 | I said, at least from my experience,

02:04:53.520 | that the potential hazard there

02:04:55.800 | is that in that very high dopaminergic,

02:04:57.960 | serotonergic state,

02:04:59.200 | there were moments where I felt like I could get excited

02:05:02.440 | about any one specific concept

02:05:05.020 | that I might even just think about, for instance,

02:05:08.100 | water and how nourishing it is,

02:05:09.800 | and really just go down the path of water and the world

02:05:13.020 | and all the water.

02:05:13.860 | And you can, you're in a state that is very prone

02:05:18.380 | to suggestion, internal suggestion.

02:05:20.900 | And so the guidance turned out,

02:05:22.300 | the guidance from the clinician turned out

02:05:23.740 | to be immensely valuable in allowing me

02:05:26.420 | to go into my own head for bits of time,

02:05:29.220 | but then also to resurface and share and exchange

02:05:32.100 | in a way that to,

02:05:33.580 | I'm trying to really get something out of it

02:05:35.580 | that was useful and that I could export,

02:05:37.140 | because of course water is wonderful,

02:05:38.420 | but I'm not really interested

02:05:39.380 | in growing my relationship to water.

02:05:42.580 | And I really felt like I could understand for the,

02:05:44.620 | I never went to raves or anything growing up,

02:05:46.660 | I never did MDMA recreationally,

02:05:48.740 | but I understood for the first time

02:05:50.440 | how people could get really attached to an environment

02:05:52.980 | and feel connected to things,

02:05:54.180 | because I think with all that serotonin,

02:05:56.040 | you just feel connected to everything around you.

02:05:58.500 | So I think it's a slippery slope there.

02:06:01.060 | And I don't know what the future

02:06:03.020 | of the clinical use of MDMA looks like,

02:06:05.620 | but I would hope that whoever's thinking about

02:06:08.180 | guiding these sessions is really thinking carefully

02:06:11.140 | also about evolving the practice

02:06:12.700 | to help people really move through in a sequential way

02:06:16.300 | so they can leave with something valuable.

02:06:18.900 | - Yes, 100%, 100%.

02:06:21.340 | These are such powerful tools.

02:06:23.700 | And again, if they're powerful tools

02:06:25.180 | and we're using them without respect for them, right?

02:06:29.760 | Without clinical guidance, we incur risk, right?

02:06:32.340 | I mean, you know, getting obsessed with water,

02:06:34.700 | well, and it probably isn't going to hurt you, right?

02:06:36.940 | But if someone is out using it,

02:06:39.340 | there's around other people,

02:06:40.740 | what one can feel positively about

02:06:43.060 | or become sort of obsessed in the short term about

02:06:44.920 | can be very counterproductive, right?

02:06:46.300 | There can be a lot of risk to that.

02:06:47.580 | So I think it anchors back to these are very powerful tools.

02:06:52.380 | We're coming to understand them much, much more,

02:06:54.860 | and we're coming to understand

02:06:56.260 | that they have immense potential to be helpful to us.

02:06:59.220 | But I think and hope that that only also increases

02:07:03.220 | our respect for those modalities

02:07:06.540 | and what can come, what negative can happen

02:07:09.660 | if we're not respectful.

02:07:11.860 | - It's going to be very interesting

02:07:13.040 | to see where all of this goes in the next few years,

02:07:15.300 | not just in Oregon, but elsewhere.

02:07:16.940 | It's one way or another, it's happening.

02:07:19.040 | It seems to have a momentum that is not going to stop.

02:07:22.180 | So very exciting area to be sure.

02:07:25.700 | - I agree.

02:07:27.180 | - I have a question about language.

02:07:29.660 | In your book, you talk about how we need to be careful

02:07:32.820 | about the use of language around trauma

02:07:35.140 | and maybe problem solving and problem describing in general.

02:07:39.140 | You know, at one extreme you hear that your brain

02:07:43.260 | and your body hear every word you say,

02:07:45.460 | and we have to be so careful with language.

02:07:48.960 | And that actually frightened me for a number of years

02:07:51.820 | 'cause I would hear that and I thought, gosh,

02:07:53.080 | if I just think that something is bad,

02:07:54.740 | now it's going to hurt me worse,

02:07:56.200 | which itself is part of that whole packing down of an issue.

02:08:00.900 | Very hard to avoid thoughts without distraction.

02:08:05.080 | So that's one extreme.

02:08:08.300 | On the other hand, you know, I can say,

02:08:12.020 | I can tell somebody I love them with a tone of hatred.

02:08:15.860 | I can tell somebody I hate them with a tone of love.

02:08:19.220 | So how should we think about language in parsing trauma?

02:08:23.420 | And in your book, you talk about,

02:08:25.300 | you give some cautionary notes about talking

02:08:28.180 | about depression, trauma, and PTSD

02:08:30.580 | in terms that might diminish their real severity

02:08:35.580 | in some cases.

02:08:37.020 | And I was really struck by that.

02:08:39.380 | So maybe just touch on, you know,

02:08:40.760 | how should we talk about these things in a way

02:08:43.160 | that doesn't diminish them for ourselves

02:08:45.740 | or for other people?

02:08:47.140 | And at the same time honors the fact

02:08:49.380 | that there's a lot of trauma out there

02:08:51.700 | and there's a lot of depression out there

02:08:53.820 | and we need to talk about it.

02:08:55.740 | - Yeah, I think this is a very complicated

02:08:58.760 | and in many ways convoluted topic.

02:09:00.580 | Like I think it's wonderful that we have language,

02:09:03.060 | but boy, language leads us astray often too.

02:09:06.700 | And you think about how people define words.

02:09:09.500 | Like someone says a word, what is it?

02:09:11.100 | Does a person know what that word means?

02:09:13.500 | What nuance are they taking from it?

02:09:15.220 | That we just have to be very careful

02:09:17.740 | what we're saying and what we're communicating.

02:09:20.380 | And I think this doesn't mean,

02:09:21.760 | because, you know, there's a sort of phenomenon now

02:09:24.900 | where people are trying to control language,

02:09:27.180 | I think too much.

02:09:28.020 | Like you can't say anything

02:09:28.940 | that someone else might find hurtful.

02:09:30.580 | You have to refer to people

02:09:32.260 | in ways they choose to be referred to,

02:09:34.140 | even if those are ways that others don't understand

02:09:37.260 | or ways they themselves have decided

02:09:39.220 | or ways that might be psychologically

02:09:42.180 | or clinically unhelpful.

02:09:43.780 | So I think the over control of language is not good,

02:09:47.780 | but I think the specificity of language

02:09:49.940 | of what are we trying to say?

02:09:51.320 | How are we defining it?

02:09:52.700 | Even the word trauma, right?

02:09:53.860 | We're talking about trauma,

02:09:54.780 | so we want to define what that means, right?

02:09:56.700 | It doesn't just mean like, oh, anything kind of negative,

02:09:59.400 | right, because then that dilutes it down

02:10:01.180 | to meaning nothing, right?

02:10:02.660 | It also doesn't just mean, you know, injury in combat, right?

02:10:07.660 | Like we have to talk about what that is.

02:10:09.500 | So I think anchoring it to something

02:10:11.260 | that rises to the magnitude of overwhelming

02:10:13.160 | our coping skills and changing us,

02:10:15.060 | like then at least I define it that way

02:10:17.100 | and I can communicate that to you

02:10:18.860 | and we can understand what we're talking about, right?

02:10:21.680 | I think that another aspect of language,

02:10:24.120 | while again, we need this middle ground

02:10:26.220 | and I don't think that it is okay

02:10:28.660 | for the over control of language to shut down expression,

02:10:32.520 | but we also have to acknowledge, you know,

02:10:35.260 | how we're so much less distanced from each other

02:10:38.060 | through social media and I think social media

02:10:40.460 | can do very, very good things

02:10:41.860 | as hopefully we're doing now, right?

02:10:44.000 | But it can also be used to harm people from a distance,

02:10:47.960 | right, and how much hatefulness is there out there

02:10:52.020 | that I think comes from anger and frustration in people,

02:10:54.380 | again, back to trauma, right,

02:10:56.020 | where people just want to be angry

02:10:57.600 | and it's not really issues that they're talking about,

02:11:00.140 | but then there's a target of that anger

02:11:02.560 | and, you know, people feel beleaguered by that

02:11:06.200 | and the words that people use sometimes are so awful

02:11:10.640 | that someone reading that,

02:11:11.800 | like if you're in the demographic

02:11:13.260 | that's being targeted, right, and you're reading that,

02:11:15.840 | I mean, how does a person not feel,

02:11:18.280 | not feel beset upon, vulnerable, right?

02:11:22.320 | And then I think that also fuels, you know,

02:11:24.920 | things like we just had this terrible shooting in Buffalo,

02:11:27.440 | right, like just hate motivated, right?

02:11:29.780 | And I think that because that kind of language

02:11:32.280 | becomes very real to people who may take it in,

02:11:34.520 | it fuels their hate and then they do something to enact it,

02:11:37.680 | which of course creates greater fear and vulnerability.

02:11:41.380 | And I think there was some civility and decorum

02:11:44.760 | that was in our world not that long ago, right?

02:11:47.800 | I mean, you know, I'm in my early fifties,

02:11:49.440 | I'm not that old, right?

02:11:50.840 | But I remember a time when in political discourse,

02:11:54.320 | people were civil to one another, right?

02:11:56.960 | Now, so much, I mean, it's not all of it, right?

02:12:00.080 | But there's an acceptance of things

02:12:01.540 | that are just bombastic, right?

02:12:03.380 | There's like, it's a circus sideshow sometimes

02:12:05.900 | of people being just angry and aggressive

02:12:10.060 | and it's not really linked to anything,

02:12:11.820 | although it's allegedly linked to something,

02:12:13.420 | but then other people's anger can attach to it

02:12:15.900 | and it's not about what it's about,

02:12:17.260 | but it's about aligning with the anger.

02:12:19.340 | And I think that there is so much damage

02:12:24.340 | that comes from that.

02:12:25.380 | And I think, you know, should we have,

02:12:28.240 | should it be okay that people sometimes are talking,

02:12:31.960 | communicating, using language in ways

02:12:34.100 | that would like get us suspended from middle school, right?

02:12:37.340 | Ways I don't want my eight-year-old to see.

02:12:39.680 | I mean, is that really okay?

02:12:41.760 | Or do we need to take a stand

02:12:43.640 | for like rational use of language?

02:12:45.140 | I don't want my use of language to be over-controlled

02:12:47.860 | by someone who thinks they sort of understand better

02:12:50.400 | than the rest of us how to communicate with those, okay?

02:12:52.580 | I don't want that.

02:12:53.420 | It's stereotypically a sort of idea of the left, say, right?

02:12:57.580 | At least in our society.

02:12:59.060 | But I also don't want language that can be so angry

02:13:03.700 | and so aggressive that it is perpetuating

02:13:07.580 | or spreading vulnerability and that it facilitates trauma.

02:13:12.060 | And I think we could set standards as a society

02:13:15.320 | where we say, look, I don't want anybody in power

02:13:17.660 | who's gonna behave that way, right?

02:13:19.620 | I don't care if their whole agenda is like,

02:13:21.420 | make Paul Conte's life better.

02:13:23.020 | I'm still not gonna vote for you, right?

02:13:25.120 | If you're behaving towards others

02:13:26.820 | in a way that's denigrating,

02:13:28.120 | you're behaving in a way that I feel essentially ashamed of,

02:13:31.580 | right?

02:13:32.420 | And I feel that a lot, right?

02:13:33.260 | I see the politics, you know, I see things play out.

02:13:36.220 | It's not always political.

02:13:37.580 | Of course, not always political, but I see things play out.

02:13:39.780 | And I think, oh my gosh, I feel embarrassed.

02:13:41.820 | Like we're somehow okay with this.

02:13:43.900 | Well, it doesn't matter which side

02:13:44.860 | of the political spectrum it's coming to.

02:13:47.460 | And I think that's an indicator

02:13:48.980 | that what we're doing is really hurtful to us.

02:13:53.980 | People become more angry.

02:13:55.500 | They attach to the anger.

02:13:57.660 | People feel more beleaguered.

02:13:59.100 | There's more divisions between us.

02:14:00.600 | And it seems more and more like,

02:14:01.860 | well, we can only really identify with people

02:14:04.320 | who are just like us.

02:14:05.340 | And like, what does that really mean?

02:14:06.380 | I mean, the divisions that it creates between us.

02:14:09.380 | And that, you know, that promotes so many negative things.

02:14:13.420 | Right?

02:14:14.260 | I mean, think about ways in which it promotes

02:14:15.380 | white supremacy, right?

02:14:16.340 | It's just one example, right?

02:14:17.780 | And we've seen that play out,

02:14:19.180 | that this is really bad for us.

02:14:21.780 | And we've got to look at that.

02:14:23.880 | I mean, if we don't look at that,

02:14:26.260 | I don't think it's always something is going to happen.

02:14:28.180 | Like something is happening, right?

02:14:29.740 | It's happening now.

02:14:31.080 | - Yeah, and it really, to my mind,

02:14:33.860 | it really seeps down into the soil

02:14:35.860 | of everything that we're talking about on all sides.

02:14:39.220 | - Yes.

02:14:40.060 | - People are activated.

02:14:41.340 | People are upset about one thing or the other.

02:14:45.420 | - Right.

02:14:46.260 | - And no one is immune from upset,

02:14:47.860 | regardless of political affiliation.

02:14:50.000 | And everybody seems to be upset nowadays.

02:14:53.040 | And as I was hearing you talk about this,

02:14:55.220 | I feel a lot of resonance with what you said,

02:14:58.780 | and I also am hoping you run for office.

02:15:01.260 | (laughing)

02:15:03.100 | - So I don't think I have the gumshoe for that,

02:15:05.260 | but thank you for that.

02:15:06.740 | - Oh, that would be wonderful.

02:15:08.060 | - Thank you.

02:15:09.180 | - I'd like to talk about a concept

02:15:11.500 | of taking care of oneself.

02:15:14.020 | This comes up in the book.

02:15:15.700 | - Yes.

02:15:16.540 | - This is something we talk a lot about on this podcast.

02:15:18.240 | I mean, I think people have heard me blab endlessly

02:15:20.340 | and I'll probably go into the grave

02:15:22.800 | telling people to get sunlight in their eyes when they can

02:15:25.120 | and to try and get proper sleep

02:15:26.540 | and to have a few tools for reducing their anxiety

02:15:31.500 | in real time and on and on and on.

02:15:33.680 | You know, we hear about this concept

02:15:36.340 | of taking care of oneself.

02:15:37.700 | And I think at a surface level,

02:15:41.300 | it can sound a little bit light.

02:15:43.180 | You know, oh, take care, take good care.

02:15:46.140 | But to me, it's a deep and powerful concept.

02:15:50.060 | And I was very happy to see it in your book

02:15:53.020 | and also to learn a lot of ideas

02:15:56.460 | about what that really looks like.

02:15:58.860 | Because whether or not somebody is in the early stages

02:16:02.100 | of considering whether or not they have trauma

02:16:04.300 | or is in the deep stages of working that through

02:16:06.380 | or has made it through the tunnel some distance,

02:16:09.460 | taking care of oneself is an ongoing process.

02:16:12.980 | I'd love for you to just describe

02:16:17.020 | what taking care of oneself means to you as a clinician.

02:16:21.020 | And of course, the practices and things

02:16:23.720 | that you encourage people to do.

02:16:25.300 | But how should we think about taking care of oneself?

02:16:28.940 | Because on one extreme, you could imagine massages

02:16:31.980 | or treats, vacations and chefs for hire

02:16:36.640 | that take care of everything for ourselves.

02:16:39.420 | And on the other extreme, you could say,

02:16:41.700 | you know, leaning into life in a way

02:16:44.660 | that you're paying attention to small things

02:16:46.380 | while working very, very hard.

02:16:48.100 | So it's such a big concept.

02:16:51.040 | But how do you think about taking care of oneself?

02:16:53.480 | How should I take care of myself?

02:16:55.420 | How should people take care of themselves?

02:16:56.980 | - Sure.

02:16:57.900 | I see here what I think is a very fascinating dichotomy,

02:17:01.740 | right, that in some ways,

02:17:03.180 | like think about how complex our brains are, right?

02:17:05.680 | How complex our psyches, our unconscious minds are.

02:17:08.380 | There's so much complexity there.

02:17:10.640 | But on the other hand, psychological concepts

02:17:14.340 | that are consistent with health are often very simple, right?

02:17:18.460 | By which I don't mean light, right?

02:17:21.020 | But simple, straightforward, right?

02:17:23.980 | And I think self-care is absolutely one of them.

02:17:26.580 | I mean, how much is talked about

02:17:28.020 | how to take care of oneself

02:17:29.500 | that just skips over the basics that are necessary

02:17:32.280 | as a building block for all else.

02:17:33.740 | So it doesn't matter how many chefs or vacations

02:17:36.380 | or whatever a person has,

02:17:38.100 | if the basics of self-care aren't squared away.

02:17:41.100 | And it's not a light concept to say like,

02:17:43.820 | look, are you sleeping enough, right?

02:17:46.340 | Are you eating well?

02:17:47.500 | Are you getting natural light?

02:17:49.540 | Are you interacting with people

02:17:51.080 | who are good to interact with, right?

02:17:53.000 | Are you accepting negative interactions in your life?

02:17:56.440 | Are you living in circumstances

02:17:57.900 | that make you feel okay or not?

02:18:00.420 | They're very, very basic premises,

02:18:03.940 | but so often we're not looking at them at all, right?

02:18:07.740 | We're not looking at them at all

02:18:09.620 | because we tend to skip over them.

02:18:12.020 | And we tend to skip over them either

02:18:14.220 | because again, in some automatic way

02:18:16.360 | that sometimes is trauma-driven

02:18:18.140 | or we're not gonna look at that, right?

02:18:20.180 | And often not taking care of ourselves

02:18:21.940 | can have the punishment, distraction, right?

02:18:24.480 | There's so much that can come into that

02:18:27.020 | or our sense of power is tied

02:18:30.100 | to not taking care of ourselves.

02:18:31.420 | I mean, I'll give you an example is

02:18:33.300 | I tend to, for whatever reason, do reasonably well

02:18:37.220 | with very poor self-care, right?

02:18:39.260 | And like that was very adaptive

02:18:41.300 | when I was in some medical training, right?

02:18:43.140 | And I'm like, okay, I can eat a lot today.

02:18:45.620 | I can not eat, right?

02:18:46.580 | I can sleep two hours.

02:18:47.780 | I can sleep eight, right?

02:18:49.840 | I mean, overall, that's not good.

02:18:51.740 | And it hasn't been good for me as I've aged,

02:18:54.340 | but then I realized, look,

02:18:55.980 | I'm doing all these things that make myself healthier,

02:18:58.060 | but like what, I ignore that, right?

02:19:00.260 | And why am I ignoring it?

02:19:01.300 | That was a key question.

02:19:02.120 | Why am I ignoring it?

02:19:03.140 | Because somewhere inside of me as it was,

02:19:05.220 | and still to some extent is,

02:19:07.300 | this idea that my ability to be really functional, right?

02:19:10.460 | To generate success in the world around me

02:19:13.060 | is tied to my ability to do that, right?

02:19:15.660 | That, oh, but if I stop doing that

02:19:17.540 | and now I'm like, I'm eating and sleeping regularly,

02:19:19.700 | then I'm gonna lose some edge.

02:19:21.060 | And so, and even I think about this all the time,

02:19:23.740 | but I realize, hey, I'm also, I'm not doing it inside.

02:19:27.580 | And I think it's really grounding to the basics

02:19:32.140 | that really help us of like,

02:19:33.520 | what are the basics of what I'm doing

02:19:35.260 | and not doing in my life?

02:19:36.460 | Diet, exercise, sleep, people, circumstances,

02:19:39.980 | leisure activities, I mean, sunlight.

02:19:42.360 | I mean, I think immensely important

02:19:44.600 | and dramatically undervalued.

02:19:47.180 | - Well, I wanna thank you for that.

02:19:48.500 | And I wanna thank you for today's discussion.

02:19:51.580 | I found it to be incredibly informative

02:19:54.320 | and I know our listeners will also.

02:19:56.660 | I also wanna thank you for the work you do.

02:19:58.700 | I mean, you obviously run an incredibly robust

02:20:02.000 | clinical practice that I'm aware

02:20:03.860 | that you're constantly trying to improve,

02:20:05.700 | even though it's operating at the highest levels already.

02:20:08.940 | And I really, the reason why you're here today

02:20:12.740 | is because I've done a wide and deep search

02:20:15.540 | for people in these areas.

02:20:18.460 | And there are so few who have the background

02:20:22.340 | in medical training and physiology

02:20:24.940 | in the psychoanalytic and psychiatric realm,

02:20:28.220 | and also have a grounding toward the future of what's coming

02:20:33.220 | and who can encapsulate so many different orientations

02:20:36.900 | and bring them together into a coherent piece.

02:20:39.560 | So I really thank you. - I so appreciate that.

02:20:42.640 | - Yeah, and for your book, which is incredible,

02:20:45.600 | I will go on record saying,

02:20:48.260 | I think this is the definitive book on trauma.

02:20:51.420 | And I really encourage people to read it

02:20:53.800 | and will continue to encourage people to read it.

02:20:55.780 | So many valuable takeaways and insights and tools there.

02:20:59.820 | So on behalf of the listeners and myself,

02:21:03.340 | thank you so much for joining us today.

02:21:05.980 | - You're very welcome.

02:21:06.860 | And again, I take that to heart

02:21:08.540 | and I'm very appreciative of being here.

02:21:10.440 | So you're very welcome and thank you as well.

02:21:12.900 | - Thank you.

02:21:13.780 | Thank you for joining me for my discussion

02:21:15.420 | with Dr. Paul Conte.

02:21:16.940 | I also highly recommend that you explore his new book,

02:21:20.480 | which is "Trauma, The Invisible Epidemic,

02:21:22.900 | How Trauma Works and How We Can Heal From It."

02:21:25.480 | It's an exceptional resource,

02:21:26.840 | both for those that have trauma

02:21:28.280 | and those that don't have trauma

02:21:30.460 | or those that suspect they might have trauma.

02:21:33.340 | Again, it's a deep dive into what trauma is

02:21:36.100 | and offers many simple tools that anyone can apply

02:21:39.320 | with a therapist or not in order to heal from trauma.

02:21:43.100 | And if you'd like to learn more about Dr. Conte

02:21:45.000 | and the work he does directly with patients,

02:21:47.480 | please check out his website, pacificpremiergroup.com.

02:21:50.540 | We've also provided a link to both the book

02:21:52.900 | and pacificpremiergroup.com in the show note captions.

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02:22:29.660 | Not so much in today's episode,

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02:24:16.480 | So thank you once again for joining me

02:24:18.100 | for my discussion with Dr. Paul Conte.

02:24:20.260 | And last, but certainly not least,

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02:24:24.500 | [upbeat music]

02:24:27.080 | (upbeat music)

Dr. Paul Conti: Therapy, Treating Trauma & Other Life Challenges | Huberman Lab Podcast #75

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