The Peter Attia Drive - #190 - Paul Conti, M.D.： How to heal from trauma and break the cycle of shame

00:00:00.000 Hey, everyone. Welcome to the drive podcast. I'm your host, Peter Atiyah. This podcast,

00:00:15.500 my website, and my weekly newsletter all focus on the goal of translating the science of longevity

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00:00:41.740 head over to peteratiyahmd.com forward slash subscribe. Now, without further delay,

00:00:47.780 here's today's episode. I guess this week is Dr. Paul Conte. This is a name that may sound

00:00:54.820 familiar to some of you as Paul was one of our initial guests back in September, 2018. I believe

00:01:00.400 it was episode number 15. Paul is a practicing psychiatrist and recent author of Trauma,

00:01:06.580 the Invisible Epidemic, How Trauma Works and How We Can Heal From It. A book that brings his valuable

00:01:11.700 insights about how we can collectively heal from trauma's effects to a larger audience.

00:01:16.940 Paul's a graduate of Stanford University Med School, which is where we met. He completed his

00:01:20.580 psychiatry training at Stanford and Harvard, where he was appointed chief resident. He then

00:01:24.540 served on the medical faculty before moving to Portland and founding a clinic. This episode

00:01:28.960 and my conversation with Paul is focused primarily around trauma. And in that, we discuss a number of

00:01:34.560 things. We talk about Paul's upbringing and his experience and how that got him interested in

00:01:38.060 studying medicine and ultimately psychiatry and trauma specifically. We look at the impact of trauma

00:01:43.500 on the brain, patterns around trauma, and how often people don't recognize the implications of trauma

00:01:48.340 in their life. We talk about the lack of biomarkers in psychiatry and psychology, the misguidance

00:01:53.300 around trauma in the mental health system, how we kind of treat trauma as a symptom as opposed to

00:01:57.660 going after the problem, and the importance of lowering the barrier around trauma so that people

00:02:02.240 can begin to receive help. From there, we look at the shame that comes with trauma, how shame is

00:02:08.020 often the thing that prevents people from getting help, and how we can start to change the stigma

00:02:12.360 around that shame that comes with past trauma. We end the discussion with a conversation

00:02:16.500 around psilocybin and MDMA and their potential in this space. So without further delay,

00:02:21.420 please enjoy my conversation with my good friend, Paul Conte.

00:02:29.840 Paul, amazing to be back here in person with you.

00:02:32.780 Thank you.

00:02:33.360 It's been way too long. And the only thing I miss, well, not the only thing, but one of the things I

00:02:40.340 miss the most about going to New York frequently was that we got to see each other constantly. And now

00:02:45.720 that we don't really travel that much. It's mostly phone calls, but...

00:02:49.240 We got to spend so much time together, and I do miss that too. And it's just really wonderful to

00:02:53.780 see you. And I so appreciate you having me here and spending time with you and family. It's wonderful.

00:02:59.440 I'm excited to talk about your book, of course. But I think even though a lot of people have heard

00:03:05.400 you on the podcast before, because we sat down probably three years ago, I'd probably take the

00:03:11.160 assumption here that a lot of people are also hearing about you here for the first time.

00:03:14.100 So let's tell people a little bit about who you are. What's your day job? What is it you do?

00:03:20.040 Sure. I'm trained as a psychiatrist, and a big part of my day job is being a clinical psychiatrist.

00:03:26.420 I also do some consulting work along the lines of understanding brain function and how brain

00:03:33.000 function can impact us in personal or professional settings. But by and large, my work is really

00:03:38.280 grounded in the clinical. And I do have a clinic, about 15 really great people I work side-by-side

00:03:44.620 with and trying to meet the needs of people who bring us whatever mental health question there

00:03:49.480 may be, which sometimes is clinical care and sometimes it's just trying to understand themselves

00:03:53.900 and the world around them better.

00:03:56.220 When is it in your journey of medical school and prior that you sort of had this inkling that

00:04:03.220 you were interested in mental health?

00:04:04.340 I think around the time in the clinical rotation part of medical school, probably into the last

00:04:10.100 year when I realized that you could really be a doctor and understand medical things and

00:04:16.480 how they impact people and really kind of be grounded in that aspect of practicing medicine,

00:04:21.840 but also trying to understand people's experiences of life. What do people think and feel as they're

00:04:28.500 going through their day and that you could combine these two things and then be grounded to all the

00:04:33.920 things one learns about life, just going through it and really help people in that way. And that just

00:04:39.480 had such tremendous appeal as a sort of widely encompassing way of approaching trying to be of help.

00:04:46.860 You, of course, didn't come to medical school in the typical way. You were not a pre-med. You had been

00:04:52.180 out and working for four years or so before medical school, if not more. So what were you doing,

00:04:58.040 first of all, before you made this decision to go to medical school?

00:05:00.840 I worked for a consulting firm in New York and really enjoyed a lot of aspects of the work,

00:05:07.260 the business and the financial aspects of it. But there was just something I kind of wanted more,

00:05:12.500 you know, I wanted to know more and learn more and be more directly involved with people.

00:05:17.780 And it was kind of a nebulous sort of theoretical set of thoughts, but, you know, it led to medical

00:05:23.640 school to try and learn more and explore like what might that be able to bring.

00:05:27.980 We've spoken about this, obviously, before you write about it in the book. There are a handful

00:05:32.240 of events that occurred during your upbringing, your adolescence, that I think ultimately shaped

00:05:38.580 how you now think about this thing called trauma. You want to talk about some of those things?

00:05:43.920 Sure. I had a really interesting course of life in the sense that in kind of the first half of my life,

00:05:50.600 there weren't major traumas. So I was fortunate to have a stable family system around me and to

00:05:57.200 develop a pretty stable sense of self, which is much easier to do if there aren't big traumas.

00:06:03.700 And then in the second half of my life, there started to be some very major traumas. And to

00:06:10.320 experience the traumas after having developed an orientation to myself and to the world that had

00:06:17.060 been free of them was very, very striking. I think it put me in a place to see, even though I didn't

00:06:24.600 completely understand them, but like what was going on in me and what was changing in me and what were

00:06:29.000 the impacts of the trauma on me in a way that was distressing and surprising. And I think that's

00:06:35.300 also part of what led me towards mental health, where seeing like, wow, these things are happening in

00:06:40.140 me. And then there's a set of thoughts that come from that of like, well, what happens if you

00:06:44.780 experience these traumas and you don't have the good fortune, have a stable family system around

00:06:49.260 you and have developed a strong sense of self? Because my sense of self was really thrown off

00:06:54.000 by the traumas that happened, even though I'd kind of gotten through those formative stages without that.

00:07:00.140 How old were you when your brother committed suicide?

00:07:03.120 So I would have been 24, 24 at the time that he committed suicide.

00:07:06.860 And at the risk of asking an obvious or maybe not so obvious question, how shocked were you

00:07:15.540 at that time? Because you hear these tragedies of someone commits suicide and everybody around says,

00:07:22.200 well, it was just a matter of time. This almost seemed inevitable. And then you hear these other

00:07:26.580 stories where everybody around is in such disbelief. So they're really coping with not just the loss,

00:07:32.940 but the feeling blindsided and guilty and how did we not see this? And so where on that spectrum

00:07:39.660 were you and I guess by extension, your family?

00:07:43.080 In the shock and disbelief side of the spectrum, which I think like a lot of families that go

00:07:48.100 through this, if one stood from the outside and looked at the development of events and what was

00:07:53.600 really going on and what was changing in my brother is he had had a huge trauma a few years before where

00:08:00.220 he had a very significant medical issue that had come out of the blue and was life-threatening and

00:08:05.300 really shook his sense of self. And he was very different after that in ways that I could see in

00:08:11.980 some sense, but not fully understand. So I think from the outside, one probably could have seen that

00:08:17.460 there were these changes in him that would have meant it was not necessarily that shocking.

00:08:22.500 But from the inside, we often don't see that or we have our mechanisms of denial or of rationalization

00:08:30.560 that tell us like, no, things are pretty okay when really they weren't. And then the shock of it

00:08:36.860 happening and then of realizing, oh, like what could I have seen? Would I have seen? You know, I think

00:08:41.740 it contributes to a lot of the guilt and the shame that people feel. It's a bad combination,

00:08:47.340 right? An immense amount of shock. And then immediately thereafter, a sense of guilt and

00:08:54.000 responsibility and also a sense that if there haven't been big traumas that, oh, like they don't

00:08:59.300 happen. That's not something that happens to me or happens to us. And I think we can get into that

00:09:04.620 mindset because it sort of psychologically protects us a little bit, but it can make the shock of a trauma

00:09:10.940 like that in a sense, all the more difficult because we start to feel cursed or unworthy or

00:09:17.760 like, you know, there's some mark of stigma that I think is just very, very frightening.

00:09:24.060 How did your other brother, your parents cope with this and how did you talk about it with them or

00:09:30.020 what was discussed and how did you all move on in the immediate aftermath of that?

00:09:34.000 I think my other brother and I were sort of built in somewhat the same way of like kind of continuing

00:09:41.500 to persevere and trying to find something new that can make life feel better, which often means

00:09:48.380 working toward achievements, applying ourselves, which can be quite a good defense against trauma.

00:09:54.180 I think in my parents, it was a little different. My father's a more sort of outgoing,

00:09:58.340 gregarious person and was able to fall into a social network that was really supportive of him.

00:10:05.260 Whereas my mother, who has since passed away, was more of a private person, less socially

00:10:10.500 connected and I think ultimately suffered from a lot of depression without her or us really

00:10:17.200 understanding it. And I think that's part of what pushes so strongly towards my interest in trauma

00:10:23.120 is the realization of like all the things we didn't understand or understood enough to know

00:10:30.460 weren't good, but didn't have the words or the understanding to really talk about it and to

00:10:37.340 talk about like what had happened and what it meant and the changes to all of us that we don't have a

00:10:43.640 ready lexicon or a ready environment to be able to talk about things. And then people at times sort of

00:10:50.020 retreat into themselves and then the trauma stays very, very immediate, even though that immediacy

00:10:56.980 can play out over years and years. So I think we were very ill-equipped. Like I think most people,

00:11:02.920 you know, we were just, we were ill-equipped to handle a massive trauma and its impact upon all of

00:11:08.100 us individually, let alone the greater complexity of all of us as a family.

00:11:13.100 Is it more common that in a situation like that where a child commits suicide and the parents and

00:11:18.960 siblings are left picking up the pieces that very little is spoken explicitly? I mean, I think about

00:11:27.020 the stories in my life of people I grew up with who, for whom suicide was a, was an issue. So I mean,

00:11:33.760 had a girlfriend in college whose mom committed suicide, had a very close friend in high school

00:11:38.100 whose dad committed suicide, had another girlfriend in high school whose dad committed suicide. And

00:11:44.140 one of these had a very tragic outcome. The one, there was a friend whose dad committed suicide,

00:11:49.500 he later committed suicide. And that was an example of where I thought to myself, and it's something I

00:11:54.360 felt very guilty about because I was in college and my mom called me to tell me he wasn't doing well.

00:12:02.100 And it was in April and it was during finals. And she said, you know, and his dad had committed

00:12:08.320 suicide two years earlier. And she said, look, he's really, he just doesn't seem like he's doing well.

00:12:12.380 I said, well, you know, like I, and I did to this day, I just feel so ashamed over this. You know,

00:12:17.140 I said, I'm going to be home in like three weeks. I'll connect with him then. But you know, at that

00:12:22.900 moment in my life, nothing seemed more important than graduating first in my class. And anything that

00:12:28.460 was going to stand in the way of that was, I couldn't go home for a weekend at my mom's request.

00:12:34.060 And of course, by the time I got home, it was too late. He was dead. And I just wondered,

00:12:37.940 like, it's so obvious. And yet I did nothing. What was talked about? What else was being done?

00:12:45.920 So not to dwell on this too much, but I'm just curious how much you remember in the months after

00:12:50.840 your brother's death, was there a time where you sat around the kitchen table and said, boy,

00:12:56.100 it would really be great if we had a therapist here that could help us process what's going on? Or

00:13:01.000 after the funeral, was it sort of like, nope, we're all kind of going to do our own mechanism of coping?

00:13:06.600 I mean, there was some discussion about it. And I think partly because maybe the generation I'm in,

00:13:13.920 I mean, I hadn't been to medical school yet. So I had no knowledge of anything, but I may be a little

00:13:18.180 more inclined to want to talk about things. Like I could tell, like, we all seem not to be doing

00:13:23.480 well, but I didn't know the words to put to it. I mean, we don't, in a sense, give ourselves

00:13:29.140 permission to have like words of immensity, right? Of impact of, oh, my whole existence feels

00:13:35.120 different. Like we don't quite know or feel a sense of permission to say those things. And then

00:13:40.880 often the reflexive nature of shame causes us to go inside. And I think that's a primary point that I

00:13:48.660 wish to make about trauma is that there is a reflexive shame that comes of being traumatized.

00:13:56.020 The same shame we see if someone is assaulted and then presents talking about the assault

00:14:00.460 through the lens of their shame that had happened. These powerful stories that reinforce the reflexive

00:14:07.740 nature of a sense of shame that drives us inward. So we don't have the words for it. And we feel very,

00:14:14.060 very bad about it. Even the trauma that you felt as a result of not going home. Like you say,

00:14:19.860 well, it's so obvious, but it's obvious only in retrospect. At the time, it was not obvious

00:14:25.660 because those words of desperation and of immensity were not being used. And we sit within a social

00:14:32.980 context around us that in a sense normalizes not really talking about it in those big words or the

00:14:41.020 words of like, everything has changed and I don't know what to do about that or what that means.

00:14:45.460 And then we kind of move forward as best we can, but we're sort of limping forward without really

00:14:51.900 talking about the things that matter, which really starts with how differently we feel about

00:14:56.640 ourselves. I think we all felt a sense of shame and a sense of responsibility of what should I have

00:15:02.240 seen? What should I have done? And he was living at home at the time. So for my parents, their thought

00:15:08.160 of how they could have, would have, should have seen something, known something, that sense of shame

00:15:13.480 drives everyone inside. And now we're trying to communicate and we don't have the words anyway,

00:15:19.260 but we're like muffle. There's trying to communicate while being sort of grogd or all of it. And we

00:15:24.280 don't know, like, I don't know the words to say, and I'm driven inside too. And then I think the

00:15:29.460 things that we do often fail to give us what we need. And then you do see that cascade of trauma

00:15:36.220 where one suicide follows upon the initial suicide or the people around the person feel so guilty and

00:15:43.420 ashamed that their lives head in different directions. You know, I think my mother became

00:15:48.100 depressed and more isolative. And it really changed the course of her subsequent life in a way that I

00:15:54.160 think was very negative without any of us really knowing how do we understand this and what do we

00:15:58.800 do about it? And I think that's among the biggest aspects I'm fighting against of saying, like, look,

00:16:04.700 we need to be able to talk about these things. Like, what's more important and what's more worth the

00:16:08.500 time and effort to put the right words of understanding to than what happens inside of us after trauma?

00:16:14.380 You were living in New York, obviously, at the time. I'm guessing this was probably a very

00:16:19.480 significant factor in your decision to take an orthogonal turn in your career towards medicine.

00:16:26.080 But it's interesting that it turned you to medicine, but not necessarily to psychiatry immediately.

00:16:30.880 It would take a few years within medical school to realize that psychiatry became the vehicle through

00:16:36.080 which you wanted to help someone. I mean, everybody goes to medicine for the same reason.

00:16:39.280 And generally speaking, everybody has some desire to help in one way or another. And then, of course,

00:16:44.540 the purpose of medical school is to figure out the avenue in which you want to do that.

00:16:48.860 What other thoughts did you have as you went to medicine as it pertained to

00:16:51.760 your brother or were there other factors that shaped that as well?

00:16:55.820 I see in retrospect in myself what I often have seen in my clinical work over these past 20 years,

00:17:01.860 which is there's a sort of bifurcation often after big trauma. And, you know, I had wanted to sort of

00:17:08.780 other things in my life before my brother's death. I wasn't completely happy with my career. And I

00:17:13.280 thought, well, maybe I want more education. And I had a lot of thoughts about that. And the idea of

00:17:18.740 doing those things was really based on some sense of faith and confidence in myself. They're like,

00:17:22.960 hey, I could go do that. I could apply myself. I could learn new things. I could take a different path

00:17:27.180 and figure it out. But after Jonathan's death, there was a bifurcation where I start to feel

00:17:35.660 very differently about myself, to feel incompetent, to feel incapable. I mean, how could I even hope to

00:17:42.040 take care of myself if I couldn't be a brother to my own brother? And my thoughts about myself changed

00:17:49.700 in this way that I now write about in the book and I think about and talk about a lot, which was

00:17:55.960 sort of forgetting that I had a sense of confidence in myself. And, you know, I was going in a negative

00:18:02.420 direction of becoming less healthy and drinking too much and just wallowing in my own unhappiness

00:18:08.320 through a sense of guilt and shame over what had happened. And it really came to a point of realizing

00:18:14.480 this is not going well. And I'm sort of forgetting who I've always thought I was.

00:18:20.840 And I got a little bit of therapy, which was a very kind of wild thing to do. Like, you know,

00:18:25.860 no one went to therapy. And there was a sense of stigma even around needing mental health help

00:18:30.120 after my brother's suicide. But even in that little bit of therapy, it helped me ground again

00:18:35.940 to like, no, I don't actually feel differently about myself. And if anything, then I felt more of

00:18:42.880 a drive. Like, I want to go do this good thing. And yes, it was a drive to help people, but it was

00:18:48.340 really based in a drive of self that am I going to take care of myself in a way that says, if you're

00:18:53.600 not happy and you want more of your life, right, in the way that you see it, are you going to go do

00:18:58.640 that? And that's where I think helping ourselves and helping others comes together. I mean, if I had

00:19:03.060 no confidence in myself that I could guide my own life or be worth having in anyone else's life,

00:19:09.320 how would I go off and do something to help other people? And I think that's often what we see after

00:19:15.020 tragedy is in a very seductive and evil way, the consequences of trauma beckon us to limit our

00:19:23.500 horizons, to see ourselves in a different and very negative way, which leads to bad things, right?

00:19:28.880 It leads to depression, it leads to panic attacks, it leads to substance abuse. It just, it leads to

00:19:33.920 not being who we want to be. And often juxtaposed to that is seeing the trauma through a lens that

00:19:41.280 makes us redoubled in wanting to be who we can be. And our understanding of trauma, whether it gets the

00:19:48.120 best of us and the guilt and shame wins the day, and the changes to our memories of who we think we

00:19:53.040 are, is it going to be that? Or are we going to be lodged into life in a way that lets us move forward?

00:20:00.140 And I was very fortunate to have gone the good path, right? Instead of where it could have led

00:20:06.680 me. And going to medical school was, although yes, I wanted to help people, you know, it was about me

00:20:12.180 and my sense of confidence in myself that ultimately wasn't taken away by my brother's suicide, but man

00:20:19.420 really could have been. When you think back to your residency, you stayed at Stanford after med school

00:20:26.380 for the first part of your residency before going to Harvard. You think back to those first couple of

00:20:31.300 years, what stands out in terms of what you learned and how one teaches psychiatry? Because in some ways

00:20:39.040 it strikes me as a more difficult discipline to teach than say surgery. In many ways, if I think back to my

00:20:46.980 residency, there's a knowledge base you have to glean, and then there's a technical set of things you have

00:20:52.980 to be able to do. And they're relatively easy to mirror, but at least from my vantage point,

00:20:58.040 teaching somebody how to make a psychiatric diagnosis might be less challenging than teaching

00:21:04.160 somebody how to talk to someone and elicit information that would allow you to make that

00:21:10.100 diagnosis, or more importantly, communicate with a person in a way to help them. In other words,

00:21:15.340 using words seems harder than using a needle and suture. So what is the process of education in a

00:21:24.440 psychiatric residency program? There's lots of learning of facts, right? Of course, around

00:21:29.280 neurobiology and around medicines and around different modalities of therapy. So I think in that way,

00:21:34.400 it's probably similar to other fields of endeavor. But then there are the less tangible aspects

00:21:41.020 that are the most important, right? Like how do you establish rapport, right? How do you really be

00:21:46.920 present with someone? And I think that's where the training in the field, I think across the board,

00:21:52.760 often fails us. And I think part of that is sort of the world, the society we live in,

00:21:58.800 in the world of modern medicine. I was very, very struck, and I can continue to be over these past 20

00:22:05.020 years of how so much of what I learned, say, as a second year psychiatry resident, I think we should

00:22:13.260 be teaching people in elementary school, right? And I really do mean that about like, just how we

00:22:19.540 respond to the world around us, right? Even the idea that bullying comes from a sense of shame in the

00:22:26.240 person doing the bullying, and then creates a sense of shame and inadequacy in the person on the receiving

00:22:30.600 end. And how does this all work in our brains? And how do logic and emotion clash in our brains?

00:22:36.800 And emotion wins over logic, yet we're taught that we're logical creatures. Things like that,

00:22:43.320 I was in some sense actually quite incensed at a whole education process that doesn't prepare us to

00:22:50.480 live life by telling us the basics of what goes on in our brains, right? So I was very struck by that,

00:22:57.460 and also struck that as I was learning it, it wasn't necessarily being directly applied in the

00:23:03.640 field. As mental health has tried to kind of fit itself in with the rest of medicine,

00:23:09.160 it wants to have very clear diagnostic paradigms. So this trend away from describing someone in a

00:23:16.040 narrative, you say, well, how would you diagnose that person? Years ago, it would be in a narrative,

00:23:20.740 you know, you would talk about who that person was in at least a couple of paragraphs.

00:23:24.000 And that's by and large gotten reduced to a number. And in trying to regiment itself in a way that I

00:23:31.900 think is overly rigid and serves the field's interest and desire to integrate with the rest

00:23:37.460 of medicine, we start losing the truth of really sitting with people and being present with people.

00:23:43.380 And a lot of what I learned about how to be a psychiatrist was about boundaries with other

00:23:47.660 people, which do in many cases make sense. But the boundaries were put forth in a way that was

00:23:55.580 often about eliminating the realness of presence with someone. And I think that's the part that

00:24:01.700 maybe is the intangible or the harder aspect of the field that I think doesn't really have to be

00:24:06.700 that way. If we realize that we're going to help people through understanding, through really being

00:24:10.980 with someone and trying to understand their experience. And of course, having it be about the

00:24:15.000 other person, but being a real person with them that I did find in my training process, but I didn't

00:24:21.920 find in the field, which is largely moving towards these brief appointments and just giving people

00:24:26.700 medicines instead of trying to understand what's going on with them. A lot of what I often describe

00:24:31.140 as polishing the hood when it's very clear there's something going on in the engine.

00:24:35.700 And while I learned a great deal and I learned from some wonderful people who role modeled for me how to

00:24:41.380 be with people you were trying to help, there was also a great deal of disappointment with a field

00:24:47.860 that often in its training and its interaction with patients ignored the crucial point of realness

00:24:54.460 of the experience of the other person. I want to think about the differences between these two

00:24:59.580 programs you trained in, right? Because you did half of your training at Stanford and half at Harvard,

00:25:04.080 which are generally regarded as two of the finest psychiatry training programs in the country,

00:25:09.320 but they have a very different method of training. So what did you find as you moved across the

00:25:16.480 country for the second half of your training and how did that impact the way you practice today?

00:25:22.080 Because in some ways you have a luxury of having seen two very different approaches to psychiatry,

00:25:29.400 a more sort of biologic and a more clinical, more of a sort of Freudian view versus a more,

00:25:35.340 I don't know how the way you would describe the one at Stanford, but it seems to me

00:25:38.540 more of a neurobiology view, both of which strike me as having huge benefits if they can be

00:25:44.720 integrated. Was it received that way by you? I think I didn't understand, certainly not at the

00:25:51.700 beginning because Stanford is so neurobiology based. So the medical and neurobiological approach

00:25:59.040 to psychiatry is just among the finest points of that program. And I was lucky to learn a lot of

00:26:05.440 neurobiology, neurochemistry, function of medicines, aspects of the different parts of our brain and

00:26:11.780 how they communicate amongst one another to generate our perception of reality and at times

00:26:16.880 the problems that can afflict us. I learned a lot about that, but I think I didn't realize

00:26:22.660 how little I was learning of the psychology of being a psychiatrist, of the unconscious motivations

00:26:30.120 in us of this rich history of understanding human beings that is so tremendously important to being

00:26:38.280 able to help people. And it was only when I got to Harvard and Dr. Marianne Bataraco, to whom I'm

00:26:44.980 eternally grateful, I think recognized in me, she was very impressed with the amount of biology knowledge

00:26:51.820 I have. And I think that she was kind of horrified with the lack of psychology knowledge and then really

00:26:56.280 helped me to get that knowledge once I was there from the people who could really teach it to me.

00:27:01.760 And I ended up on the other side of that feeling like I had learned a lot of what I really needed

00:27:07.920 to know. And then the way, like, how do you put the rubber to the road of that is by being a real

00:27:14.580 person with the person that you're trying to help, which I think is the way I approach the field and

00:27:19.740 the people that I work with, we approach the field the same way. But we're really the instrument

00:27:24.660 through which all of that comes and hopefully helps somebody. So that maybe is in one's personality

00:27:30.700 or you just kind of realize that, that like, oh, when I'm being sort of more rigid in a certain way,

00:27:36.360 like I'm less helpful. And if I'm less that way in a more existential therapy approach to realness

00:27:42.700 with a person, then I can use all of what I've learned, the neurobiological and the psychological,

00:27:48.820 to really make a difference to someone. And I think that I figured out through practice,

00:27:55.200 right? And through learning what really helps someone, just like I found my way to trauma. I

00:27:59.560 didn't decide, I'm going to be a trauma person. I'm going to write a trauma book. I saw it was

00:28:05.180 undergirding a very, very high percentage of everything that I was trying to treat. So the things

00:28:11.860 like that, I think we learn by trying to apply what we know. And I ended up being very fortunate

00:28:16.920 to have had the brain biology knowledge and the psychological knowledge, although it was a little

00:28:22.060 bit distressing to realize when I got to Harvard, how little I knew. And I probably wouldn't have

00:28:28.220 known how little I knew unless I had had that experience that really exposed that.

00:28:33.660 When was the first edition of the Diagnostic and Statistical Manual published? I don't know where

00:28:39.560 this fits in the evolution and history of psychiatry.

00:28:41.760 1948, somewhere in the late 1940s, I think 1948, but in that range.

00:28:49.080 And as you alluded to earlier, the DSM as it's abbreviated is really, at least in part,

00:28:54.900 a way to catalog and create crisp diagnoses around psychiatric illness, correct?

00:29:01.340 That's what it has evolved to. In the initial versions of the DSM, it was describing in a sense,

00:29:07.880 the phenomenology of what is this particular diagnosis like? What are the aspects of it?

00:29:14.260 What's felt or experienced by the person and what's seen from the outside? And then there were

00:29:20.580 sort of clusters of symptoms that would then lead one to think that that diagnosis fits,

00:29:28.720 which acknowledges, in a sense, the unique aspects of human beings, that if we get too rigid about that,

00:29:34.120 we start serving, in a sense, the manual, right, instead of the person. And in many ways,

00:29:40.900 the DSM evolved as a way of allowing for research criteria to say, okay, we want to be calling a

00:29:46.680 diagnosis sort of the same thing if we're going to communicate among clinicians and do research.

00:29:51.940 But in my very strong opinion, that has come to a place that now is so overly rigid that you have

00:29:58.620 this very, very thick book that could give everyone multiple diagnoses, right? Because it's kind of

00:30:02.740 designed to do that, and then come up with a number that justifies the 15-minute appointment

00:30:07.320 in which the person has no hope of actually being understood in any way, because you can't do that

00:30:13.220 in 15 minutes. And we're at the DSM-5 right now, correct? We're in the fifth generation of this

00:30:18.380 manual, which seems to get updated about every 15 or 20 years. Yes, it's the fifth generation.

00:30:23.580 There are technical revisions in between. But yeah, it's really evolved to something that I

00:30:28.060 think is so rigid that it, in many ways, works against the clinical care that we're trying to

00:30:37.580 achieve. And again, I'm all for criteria and being able to have descriptive language and research

00:30:42.320 criteria. But we've gotten to the point where it often gets called like a Bible, which I think is

00:30:47.400 is like a very unfortunate word to use in many ways. It implies that there's something in that

00:30:54.060 book that actually tells you what mental health problems are and what they are not. And some of

00:31:00.120 the criteria really make no sense. So for example, someone who has vicarious trauma that they're

00:31:06.600 experiencing, but not in an occupational framework, doesn't meet criteria for a PTSD diagnosis, which has

00:31:13.800 come to mean like everything trauma. So if you have trauma, that's real or legitimate, you have PTSD.

00:31:20.180 And if not, you don't, right? Like this is clearly makes no sense. But the field often views it that

00:31:25.500 way and then applies criteria that are not the be all and end all of the human experience, and then

00:31:32.200 becomes very, very rigid in a way that I think trivializes often what's going on with someone and

00:31:40.080 trend towards that symbolism of capturing everything in a number as opposed to in a human experience.

00:31:46.080 And I think we've gone so far away from the realness of human experience and how to sit with

00:31:52.400 a person and be helpful that the field has in many, many ways led itself very, very far astray. And I

00:31:59.420 think that the evolution of the DSM is both a driving cause of that and also a resultant symptom of that

00:32:06.280 too. Outside of post-traumatic stress disorder, PTSD, how often does the word trauma appear in the

00:32:14.600 DSM-5? Well, it appears in other places, but it doesn't appear in a foundational way, right? Because

00:32:23.140 if the book is descriptive, then the book is looking to take an inventory of signs and symptoms. It's not

00:32:30.580 looking at causality. And that is a problem because so much of the depression that I see,

00:32:37.820 so much of the anxiety spectrum disorders, obsessive compulsive disorder, for example,

00:32:42.460 abuse of substances and addiction or alcoholism is undergirded by trauma. And trauma changes that

00:32:49.160 person's experience of life to a place of fear and vulnerability. And then that drives the subsequent

00:32:56.000 problems. But if we're not looking at what's at the root of the things that we're describing,

00:33:02.900 then we're just taking a descriptive inventory. And that's how we end up polishing the hood,

00:33:08.720 right? I can't tell you how many people I've seen with very severe substance disorders that haven't

00:33:14.300 been helped by three, four, five, six courses of treatment. And they're then often labeled as

00:33:20.160 failing the treatment. And very often the treatment has never taken the trauma inventory.

00:33:26.680 And it is trauma that is driving the substance use. It's trauma that's changed that person's

00:33:32.380 internal dialogue towards something that's extremely negative, that tells them that

00:33:36.160 they're not worthwhile and they'll never get anywhere in life. And why try for a new job or a

00:33:40.560 new relationship? Because nothing ever works out for you. And this wasn't that person's belief in

00:33:46.320 themselves before trauma. It's undergirding everything. And then it's spinning off these

00:33:52.140 symptoms. And then we take inventory of the symptoms as if they are the be all and end all.

00:33:57.440 And then somehow we're surprised when the treatments don't work. So the fact that we're not looking to

00:34:03.760 etiology, and I think that's a huge problem. And it fits with not actually paying attention to people

00:34:10.100 that, you know, I would get handoffs that would describe a person in a number like, oh, who's the

00:34:14.000 patient I'm taking over? That's a 296.44 with a 309.81. And they're like, oh my goodness, right?

00:34:20.460 We're talking about human beings here. But we've somehow reduced that to numbers that indicate a

00:34:25.580 set of symptoms. And it's hard for me to see how one could argue the field hasn't been led astray

00:34:32.460 if that's become the standard. Let's define trauma as broadly as we can, because

00:34:39.960 there's probably somebody listening to this right now who's thinking, okay, trauma could be an injury.

00:34:47.420 And if they can extrapolate from that and say, well, psychological trauma, we talked about PTSD.

00:34:52.480 I can see how a soldier coming back from Fallujah, having watched people getting blown up,

00:35:00.020 both civilians and soldiers. I can see how that would be traumatic. Obviously the story with your

00:35:06.800 brother. Yep. I can see how that's traumatic, but trauma includes much more than that. So how do you

00:35:13.120 define for somebody who's really hearing about this for the first time, what trauma means?

00:35:19.740 Trauma is anything that pushes our coping skills to and beyond their limits, and then results in a set

00:35:28.800 of feelings inside that could be acute terror, or it could be, for example, a chronic sense of

00:35:34.920 denigration. But it creates these feelings inside that then change the functioning of our brain,

00:35:42.340 the communication within our brain among the various parts in a way that shifts the lens through

00:35:50.000 which we see ourselves and the world around us. So it pushes our coping skills beyond the limits,

00:35:55.100 and then it changes the ways that our brains function. And that's identifiable in modern science.

00:36:02.220 So when we can see the changes in space-aged neuroimaging that shows how the connectivity

00:36:08.740 in the brain shifts, or even the fact that trauma changes the expression of genetically determined

00:36:15.700 characteristics in us, because genes are either on or not on, and that changes as a result of trauma,

00:36:21.860 and can be passed down to children even years after the trauma occurs. So someone can have the trauma

00:36:29.300 occur, change the brain, and then have a child years later, and the child is impacted by the

00:36:35.220 trauma that occurred years before. So these are real changes inside of us, identifiable by modern

00:36:41.280 science, that happen when our coping skills are pushed beyond the limits. And our view of trauma

00:36:47.400 comes through this history of seeing trauma through the lens of combat. This is sort of the most

00:36:53.240 obvious way to see it. Like that person went off to war, and they experienced terrible things in war,

00:36:59.580 and they came back, and it's so clear that they are different, right? So that's how we look to acute

00:37:05.400 trauma, because it's the most obvious. And as you said, if, okay, there's a suicide, and gosh,

00:37:10.240 the family members are traumatized, and we can see that. But what we pay less attention to and less heed to

00:37:16.920 are two different factors. One, the variables inside of us that determine what pushes our coping

00:37:23.020 skills over the limits differ. It differs by genetic characteristics. It differs by early life

00:37:28.400 experience. It differs by, for example, how finely tuned one's emotional compass is. It differs by

00:37:34.580 the chronicity of trauma. So the sort of multiple hit hypothesis, which we've seen that if there are

00:37:39.660 multiple traumas, it might be, oh, it's the fifth trauma that now pushes that person into a post-trauma

00:37:45.520 syndrome where the brain is different, even though the fifth trauma might seem less traumatic than the

00:37:49.860 first four, but the weight of the first four are there. So we tend then to paint with this broad brush

00:37:55.580 that ignores the richness of human diversity and how we are impacted differently by different things.

00:38:03.020 And then it also ignores that not all trauma is acute, that there are traumas that are chronic. So you

00:38:09.700 think of the trauma of neglect. Neglect of a child is not defined by an acute incident. It's defined by

00:38:17.260 the impact upon that child of the neglect over time. The same thing with the aspect, for example,

00:38:23.720 of systemic racism, of a person who gets messages over time that they're less than, that they look

00:38:29.440 different, they dress different, they worship different, whatever is going on in them is less

00:38:33.640 than, and that's inculcated into the person over time. And that can have exactly the same effects

00:38:39.420 on the brain. And the same is true with vicarious trauma. I mean, we are fortunate, of course, as a

00:38:45.500 species that we can be empathic with one another. We can experience the emotions of another person

00:38:50.840 in a way that's connected as if they're our own. But the other side of that coin is we can be traumatized

00:38:56.820 by what happens to other people. And sometimes that might be someone we're very close to. Or it might

00:39:03.200 be a person who develops such a strong interest because they're sort of horrified by things they see

00:39:09.240 going on around the world, and then are paying very, very close attention in a way that overwhelms that

00:39:15.040 person's brain's ability to cope with that. And then, you know, for example, a person who was so deeply

00:39:22.020 impacted by the crisis in Syria that then develops post-trauma symptoms. And that person never left

00:39:28.480 their home in the United States, but was so appalled and so distraught by what was going on and didn't

00:39:36.240 know to divert their attention. There was too much attention to something coming from a good place in

00:39:42.660 their heart, but that ultimately leaves that person manifesting the same post-trauma signs and symptoms

00:39:49.260 as people who suffer from an acute assault. And whether the DSM likes that or not, it is true.

00:39:56.600 It's true and it's identifiable in human experience. So the truth of human experience reflects the

00:40:02.600 diversity of how we can be traumatized in acute, chronic, and vicarious ways, and that how traumatic

00:40:09.660 things impact us and whether they push our coping skills over the limits is also unique to each human

00:40:16.720 being, which doesn't mean we don't follow patterns. And of course, the discipline of psychiatry following

00:40:21.820 patterns and identifying patterns is very, very important, but we also need to acknowledge that

00:40:27.160 we're different and we can't understand what's going on inside of a person without paying attention

00:40:32.400 to that actual person. Using that example, it seems that at the risk of oversimplifying,

00:40:39.980 there are at least two variables at play. There's the individual's susceptibility,

00:40:44.220 and then there's the event or events, which again, can be acute, chronic, or experienced by others

00:40:52.760 that you witness. Yeah. Maybe circumstances. I would think of that as circumstances, right? Because

00:40:57.460 event still in my mind implies something more acute as opposed to circumstances, which could be an acute

00:41:02.920 event or something chronic or vicarious. So using that extreme example of a person who,

00:41:09.620 you know, witnessing events in the news rises to the level of the definition of trauma, those events,

00:41:16.700 which are not being experienced by this individual over a prolonged period of time, produce the state

00:41:23.040 you describe, which is to say they are pushed beyond their manners of coping and they themselves begin

00:41:29.040 to internalize shame and these feelings we're talking about. So does the DSM look at that and say,

00:41:34.840 that's not trauma, or it says there's something wrong with that person because they shouldn't be

00:41:40.880 feeling that way based on that event? I think it just excludes them because they just don't meet

00:41:47.220 the criteria for what validates the trauma, which is interesting. So the book has to validate the

00:41:54.180 trauma, right? And that doesn't really make sense. I mean, we should be looking at people and saying,

00:42:01.080 do you present with the signs and symptoms of trauma that has pushed your coping skills over

00:42:06.980 the limits? Is your mood chronically lower? Is your anxiety chronically higher? Are you having

00:42:12.100 panic attacks you didn't have before? Is your sleep disturbed? Are you more hypervigilant? Do you

00:42:16.980 feel less safe in the world about maybe yourself or people that you love? Like these are clearly

00:42:21.160 identifiable things. And if we're taking stock, like what is your human experience and has something

00:42:27.640 changed in you, then the idea is we would honor that. And I wouldn't say, well, oh, wait a second,

00:42:33.220 that happened to you, but you were vicariously traumatized in the course of something occupational.

00:42:39.800 So now, okay, so you get, I'm going to put the stamp of approval on you. Would that happen to you?

00:42:44.060 But you were just so horrified by what was going on, say in Syria, that you couldn't take your attention

00:42:49.780 away from it. And it woke you up in the middle of the night and you went on the computer for two more

00:42:53.460 hours. And now all of a sudden you really can't sleep well. And you're fearful about your children

00:42:57.800 in ways you weren't for, wait a second, that wasn't occupational. Now we're not, now you don't

00:43:01.580 get the stamp of approval. The idea is we have to anchor to the truth of human experience because

00:43:07.240 it's not that extreme that people are traumatized by vicarious things. And I absolutely see this.

00:43:13.620 I mean, I've written many more times than I can count on a prescription pad. Like I'm going to write

00:43:17.340 your prescription and the prescription I'm writing is no more news. Because I see that that person's

00:43:23.040 health or maybe that person I've known for years, their health has really deteriorated

00:43:27.540 over a couple months of paying attention to something so intensely distressing. And we've

00:43:32.120 had more than we can shake a stick at in recent years that you could pay attention to the point

00:43:37.420 of like utter despair. And then who is that person? Like is that person someone who's had three or four

00:43:43.660 really acute traumas, but they don't have a post-trauma syndrome, but boy, they're really a setup for it.

00:43:49.780 So they start paying intense attention to traumatic things they're seeing in the world around them.

00:43:55.600 And now they have a syndrome. We're not doing justice to that if we're making a set of criteria

00:44:01.960 that try and treat us like robots or machines instead of, hey, these are human beings and we

00:44:09.020 have to know like what's come before in your life. Where were you at when you experienced an acute or

00:44:15.320 chronic or vicarious trauma? And if we look at the manifestations, what's going on in a person

00:44:20.200 and how do we help them understand it, then we can help people. I mean, part of the message of the

00:44:25.200 book is this is not rocket science. There's a lot about this that's very simple and very grounded to

00:44:30.700 common sense, which is pay attention to what's going on in people and help them understand it.

00:44:36.840 And if we have an entire paradigm of helping that's around symptom inventory and putting a label or not

00:44:42.180 putting a label and then schlepping some medicines at someone without really trying to understand,

00:44:47.320 then we often, even the first step we take down helping pathways is misguided. And then it is

00:44:54.240 really a surprise that the mental health treatment system is not serving well the majority of people

00:45:01.320 that it is supposed to serve. And I think it's very clearly true. I don't think this is an overly

00:45:06.680 strong or exaggerated statement that accessing mental health help often leaves someone feeling

00:45:12.620 worse. And I'm not trying to be overcritical of the people working in the system. There's so many

00:45:17.200 good people that are trying to help other people, but the system often doesn't let them do it. I mean,

00:45:22.760 you have panels of more patients than you can count in 15 minute appointments. How are you supposed to

00:45:27.220 understand and help someone? So I think the entire system is misguided towards this,

00:45:33.180 how little money can we spend in the short term? How can we get human beings out of the equation

00:45:38.540 because human beings cost more money to deploy than medicines? We are misguiding ourselves in a way

00:45:46.160 that's away from common sense. And we do often leave people worse than when we found them. A classic

00:45:53.060 example being going to a hospital and trying to get help, where maybe 15 or 20 years ago, when a person I

00:46:00.380 was taken care of might be in crisis, I would think if I don't send that person to an emergency room,

00:46:04.960 like that would be malpractice. They're in crisis, they need help. Now I have to stop. And the vast

00:46:10.460 majority of times I do not do that because I worry, or I know for sure, if they show up at a hospital,

00:46:17.660 they're going to wait 36 hours, 40 something hours before they see someone. They're going to be put in a

00:46:22.940 place that's going to feel very shameful and very stigmatizing. There's a locked room and people are

00:46:28.040 watching that person in a way that makes them feel like they're being treated like they're crazy when

00:46:33.720 they're in distress. And when they finally get help, there's some short term stabilization,

00:46:38.980 give them a little medicine, they fall asleep, they wake up, they feel a little better because

00:46:41.560 they slept, now send them home. And we're not serving people well with this short term view

00:46:48.020 of how we're supposed to help them. I mean, there are not enough beds in emergency rooms,

00:46:52.700 in mental health units, there's not enough time with practitioners. I mean,

00:46:55.880 the fact that the system is broken is to me as obvious as one plus one is two. I mean,

00:47:02.680 I just see it in front of me day after day. Where in the last 20 years did the

00:47:10.260 matrix come together for you with respect to trauma? I mean, the first time you and I ever spoke

00:47:16.060 about this was four years ago, 2017. And not surprisingly at that time, I didn't really know

00:47:25.580 what you were talking about. I only thought about it in the most literal sense, which is something

00:47:32.100 that is so obviously physically harmful that that could be traumatic. But it was clear you had been

00:47:39.520 thinking a lot about this because you had a lot to say on it. And you had already been sending

00:47:45.600 patients to inpatient facilities, residential care facilities that specialized in trauma care.

00:47:54.280 So when did this occur for you? When did you start to integrate these other modalities? When was the

00:48:01.300 first time you sent a patient to a residential program that specialized in trauma, such as

00:48:05.400 the Bridge to Recovery or a place like that?

00:48:08.000 I would have been sending patients to residential facilities for trauma since very early on in my

00:48:14.960 career, but not having the understanding like, you know, like when you do anything for a long time,

00:48:20.820 like, you know, you internalize aspects of doing it that become reflexive, and then it frees up parts

00:48:25.900 of your brain to learn more. And as I got, I think, just learned more and got more experience and more

00:48:31.480 ability to spend more time with people and try and just always have a venue where I could try and

00:48:37.260 understand that person led me to realize like, wait, I'm doing the same things all the time.

00:48:43.120 If you present to me with panic attacks, you present to me with obsessive compulsive disorder,

00:48:46.840 you present to me with depression, you present to me with addiction, what I'm ultimately doing

00:48:50.740 is the same thing, is I'm trying to help you understand why. Because that's what's going to

00:48:57.280 make the difference. And maybe along the way, we can treat symptoms. Maybe I have you on a couple of

00:49:01.920 antidepressants, or even someone who has psychosis, something like so dramatic, that we're trying to

00:49:07.680 decrease that with medicines. But ultimately, how to really help that person is to try and

00:49:12.600 understand what their experience is of it, right? And their sense of vulnerability is of it. And I

00:49:16.820 realized, I'm doing this all the time is trying to help people understand where the problems are

00:49:24.080 coming from, because that's how they get better. Which is the same as what I saw in myself. It was

00:49:30.320 anger, frustration, resentment, underlying depression, like all of these problems were in me.

00:49:36.080 And you know, a very negative and oppressive internal dialogue. And in my own psychotherapy

00:49:41.660 of exploring this, we weren't trying to treat like, what symptom is it spinning off now? We're trying

00:49:47.100 to understand like, what's going on inside of you that you're doing this? And so I saw in my own,

00:49:51.720 the process was to help me, my own psychotherapy, and what I was doing with others, that it was all

00:49:57.800 about the same thing, which were the roots of what ails us. And those roots are the seeds of trauma

00:50:05.480 falling into a soil that lets those seeds grow and trying to understand what is that soil inside of

00:50:12.820 you? How is it unique to you? How does it follow patterns that impact all of us? What was that seed?

00:50:18.500 How has it grown? I, at some point realized, oh, that's what I do. That's what I'm doing.

00:50:25.080 And I stopped thinking, oh, like how many depression cases do I have? Or how many is that? I didn't

00:50:29.080 think about that. I said, oh, I kind of have all trauma cases. And that was such a revelation. And

00:50:35.680 then in the practicality of starting to do my work more intentionally that way, I could see that it was

00:50:41.680 more effective. It was very, very clear that it was more effective. And then I started working with

00:50:46.020 really great like-minded people and their knowledge and experience with what I was learning really came

00:50:52.120 together in a way that this lens of trauma seemed not like, oh, some esoteric discovery,

00:50:59.160 but, oh, I'm just rooted back to the obvious. It rooted back to the obvious, which it's really

00:51:05.060 some of the older literature in describing human behavior knew all the time, but just wasn't at the

00:51:11.000 forefront of the discipline in terms of its education and training.

00:51:15.200 If you had to hazard a guess, what fraction of mental health providers, psychologists,

00:51:20.840 psychiatrists, counselors, et cetera, have never referred one of their patients to a residential

00:51:26.860 trauma facility? What would be your guess? It's an unknowable thing, of course.

00:51:30.840 Probably a pretty high percentage because trauma gets defined as, does that person have PTSD?

00:51:36.340 PTSD. And people aren't going to even say all the things that would leave them to be diagnosed,

00:51:42.760 right? Because they're ashamed of the symptoms. When you go to one of these facilities, and I've

00:51:47.360 been to two of them, the word PTSD almost never comes up. It's usually you have this addiction,

00:51:54.040 you have this maladaptive coping strategy, you're angry, you're depressed. Let's find out why,

00:52:00.860 let's find out what's underneath the surface. So given that the facilities themselves don't position

00:52:06.260 themselves as PTSD treatment centers necessarily, although there are people there with PTSD,

00:52:10.940 but it's interesting to me that practitioners aren't more aware of this tool. Let's take something

00:52:18.060 like an eating disorder. You take care of many patients with eating disorders. What fraction of

00:52:23.000 those patients would you say have an underlying trauma as a significant contributory factor in their

00:52:31.120 illness? Approaches 100%. Even if you look at trauma through that appropriately broad lens,

00:52:37.220 because we're looking at what causes the outcome. So I'm not trying to look at what factors do I want

00:52:41.920 to be part of it. I'm looking at the actual truth of what causes the outcome. So the chronic trauma of

00:52:49.700 immensely high expectations of self, right? Often placed upon self by self, but often that process being

00:52:57.540 aided and abetted by external forces, which sometimes are the expectations of the people

00:53:02.060 around that person, or just the expectations of society of how you're supposed to look and how

00:53:06.280 you're supposed to act and how you're supposed to present yourself to the world and what you're

00:53:09.740 supposed to achieve can create immense senses of insecurity and of vulnerability. And people

00:53:16.740 laboring under that for long periods of time can find an outlet for control. I mean, in many ways,

00:53:22.500 that's often what the signs and symptoms of so many mental health issues are. It's an attempt to

00:53:28.160 find control. And maybe somebody finds control by tapping five times when they think they have a

00:53:32.720 negative thought. Someone else finds control by restricting what they eat and they can control

00:53:36.980 what goes into their bodies. And what are the roots of that? The roots of that are always trauma. I can't

00:53:42.200 think of an eating disorder situation. A person suffering from an eating disorder who did not have

00:53:48.900 trauma as a root of that eating disorder with the trauma being discovered and talked about and

00:53:54.900 addressed at least to some degree during the treatment. And that's why the facilities understand

00:53:59.860 this. I mean, it's interesting. The facilities know because when you show up at a trauma facility,

00:54:04.680 they want to understand and treat your trauma. They're not concerned. You have the magic card of

00:54:08.500 entry of PTSD. But because medicine, how many times this gets said so often, but it's true, right?

00:54:15.200 The doctors are treating the computer, the chart, the paperwork. So much of it is about,

00:54:20.500 does that person have trauma or not have trauma? I got to determine if they have PTSD. It's so

00:54:24.420 busying around with things that don't matter that are about establishing a diagnosis. So the insurance

00:54:29.700 company will pay for the 15-minute appointment or will pay for the medicine that's going to treat

00:54:33.520 the symptom but not the problem, right? That there then become a gating mechanism. And PTSD is some

00:54:39.140 magic gating mechanism that doesn't get talked about when you're actually treating trauma

00:54:44.040 because it actually makes no sense as a gating mechanism. And I think what you're pointing out

00:54:49.320 is very, very powerful that the world we live in says, we have to have PTSD and meet these criteria

00:54:55.260 where you don't have trauma. But what happens if you get to somebody who's treating trauma? They never

00:54:59.460 talk about that. They talk about the reality and truth of what you've lived and what that has done

00:55:05.400 to you in ways that are then counterproductive to your life. And that's the truth and the realness

00:55:11.440 of it as opposed to a false sense of surety that comes from all those guidelines and box checking

00:55:17.860 that is really divorced from the human experience. It seems to me that part of the problem,

00:55:24.580 I mean, there's so many problems to the recognition of this. The first is there's medicine works in the

00:55:30.640 sphere of biomarkers and objective measures of illness or disease. So we can look at a biomarker like

00:55:39.180 a person's ApoB or LDL cholesterol or a hormone level and it's subjective. We can understand what

00:55:45.260 that implies. Or we can look at a CT scan that shows an injury here or there. But psychiatry has

00:55:51.080 none of these things. Psychiatry, doing an MRI of a person's brain offers you no more insight into

00:55:57.300 their plight or their suffering than rubbing a towel on their head and dumping some hot wax on it.

00:56:03.580 Again, there are exceptions. Of course, there are exceptions where certainly a nutritional

00:56:08.600 deficiency, like a B12 deficiency or something that can show up in a biomarker can explain a

00:56:12.780 psychiatric illness. But for the most part, that's not the case. So that's, I call that kind of

00:56:16.180 macro problem one. I think macro problem two is the heterogeneity of the soil that you'd describe.

00:56:23.420 You could take 100 individuals and simultaneously expose them to the same traumatic event,

00:56:30.940 but without knowing what their antecedent history is, what else has this person experienced?

00:56:39.260 So in other words, what else has been dropped in the soil and without knowing the composition of each

00:56:45.420 of their soils, you really have no idea how those 100 people are going to react to an identical stimulus.

00:56:52.620 And that, of course, is very uncomfortable for medicine. It's uncomfortable for science. You think of

00:57:00.140 Koch's postulates. We really love it when we can say, add this microbe, get this disease, subtract this

00:57:08.540 microbe, subtract this disease. Medicine is so good at that type of thinking. And again, I'm not saying this

00:57:15.740 to be critical of medicine or to be critical of psychiatry. It's just an observation of maybe this might explain to

00:57:22.380 somebody who's listening to somebody who thinks you're out to left field. This is a very hard

00:57:27.980 problem to quantify because of these, A, again, the obvious, the lack of biomarkers, et cetera,

00:57:34.380 the lack of diagnostic criteria, and the incredible heterogeneity of the individual and their history.

00:57:40.300 And those are actually not the same thing. Yes. And I think on the one hand, look, we need to

00:57:45.020 acknowledge that complexity and also that lack of specificity. But on the other hand, there are aspects of that

00:57:53.740 that I think simplify in ways that are very, very compelling. So in the book, I interview Stephanie von Gutenberg,

00:58:02.220 who's an expert on understanding and prevention of child abuse, and Darren Richerter, who's a professor at Stanford,

00:58:09.020 who's done a lot of trauma work and trauma research around the impact of trauma on identifiable markers and

00:58:17.020 what that means. So for example, his work draws at times from the field of epigenetics, which shows that

00:58:23.980 gene expression changes after trauma. And his testimony was instrumental in jurisprudence on an international

00:58:32.460 level, recognizing that, for example, rape as a tool of war is not a one event criminal act, which was how it was being viewed.

00:58:42.460 Okay, that thing happened on that day, in a way that circumscribes it. And the epigenetic research around trauma shows

00:58:50.460 that not only is it not a one event limited to a day experience, but that it carries on throughout that person's life.

00:58:58.460 It impacts the society in which that person lives, and it gets passed on to the next generation. So now

00:59:06.460 we start having that kind of powerful science that can show that woman who was raped has a child three

00:59:12.300 years later, and the genetics that are expressed in that child are impacted by the trauma that happened

00:59:18.300 three years, say, before conception. So we do have, in a sense, the scientific proof to hang our hats on

00:59:25.180 these days. We do have that in a way that tells us, right, we kind of knew all this was true because

00:59:29.980 we saw it obviously in front of us. Now we do have what science wants to have to hang our hats on.

00:59:37.180 And even though, let's say those hundred people have different soil and will be affected in different

00:59:41.900 ways, we can understand how that may sort of disperse across those hundred people, right? Like what is the

00:59:49.180 trauma? A certain number of people, a percentage of people are likely to respond in certain ways if

00:59:54.700 it's a dramatic trauma. Like if there's some dramatic acute trauma, it might not matter so much what the

00:59:59.660 soil is, people are going to be, the majority are going to be very deeply affected. Or there might be other

01:00:05.020 kinds of trauma where you can only understand by really understanding that person. So we do fit patterns, and we

01:00:11.660 can understand how those patterns unfold, just like we can understand the aspects of basic science that we've

01:00:17.980 learned now in a way that says, yes, this is very, very complicated. That's why it can't be deployed

01:00:24.380 in some checkbox kind of manner. But we can understand it well enough to say, okay, it's actually not

01:00:30.700 that complicated to try and understand like, what has your experience been or what's going on inside

01:00:36.140 of you, right? If you present as depressed, like, well, what's your history, right? And what are you saying

01:00:40.700 to yourself inside? And has that shifted over time? Like we can understand that in a way that says,

01:00:45.980 do I think that your brain is different because of trauma? It's like, it's not that hard to do that.

01:00:51.500 And then to say, well, let's try and understand your trauma so we can help make it better.

01:00:55.020 So there's an aspect of this that's also kind of simple too, that we don't deploy because we're

01:01:01.100 lost in the complexity of all those other things, all that box checking. And we don't know,

01:01:05.580 we don't understand, and psychiatry wants to be like the rest of medicine. And then we get lost in the

01:01:09.500 complexity. And that complexity very often prevents a person from being understood,

01:01:16.140 feeling understood, feeling help, getting any help at all.

01:01:20.060 Are there checklists that provide value? So for example, the adverse childhood event,

01:01:25.820 is that what it's called, ACE? It's a series of questions, right? It's 10 questions, 20,

01:01:30.540 how many questions is it?

01:01:31.500 I don't know. There are different versions that get utilized in different realms,

01:01:35.260 and I don't know what the standardized version is now. Yeah, yeah, yeah. But it's in that ballpark.

01:01:40.540 So sometimes these tests are really good at catching, they have a high positive predictive

01:01:46.540 value, but they seem to have a low negative predictive value. In other words, there's lots

01:01:50.460 of people who don't score highly on the adverse childhood event score. But nevertheless, there is

01:01:57.820 significant trauma in their lives, but it might only account for one of the 10 checks. But again,

01:02:04.380 for them, it was very instrumental in how their identity was formed. So is this something that

01:02:12.540 can be automated or is this something that can only be done by someone who has the ability to

01:02:18.860 dig and really get deep into it? So let's take an example. Let's take a person who grew up in a

01:02:25.500 family where they simply weren't paid attention to. They would check the box of neglect, but none of the

01:02:31.020 other boxes would get checked. Now, let's say there are multiple kids in that family, five children

01:02:37.980 neglected because the parents are working like crazy or for whatever reason. Those five kids could

01:02:44.060 completely internalize that in different ways. Some of those kids could go on to become the most

01:02:49.660 successful people in the world because, at least externally, because of a drive that gets instilled in

01:02:55.740 them to prove their worth. One of their siblings could easily go in the exact opposite direction

01:03:03.260 and turn to a life of substance abuse and addiction. We see this all the time. Exactly.

01:03:08.380 Let's explore that a little bit more because, again, there's two things I want to explore there. One,

01:03:13.340 something as innocuous as neglect can produce such vastly different phenotypes.

01:03:20.300 And secondly, the heterogeneity of the soil problem, again, which is how is it that two

01:03:28.140 siblings, and you and I have both seen scenarios like this, two siblings in the exact same family

01:03:33.500 exposed to the exact same stimulus or environmental factor, in this case, neglect, can have such vastly

01:03:40.700 different responses. And one of them society frowns upon, and the other one actually society is pretty

01:03:45.900 impressed with. Right. And so you're getting questions around the heterogeneity of it, or how

01:03:51.100 do we understand it? Well, I think it's both, right? It's how do we explain the heterogeneity?

01:03:55.500 And two, how would both of those people even rise to the level of coming to the lens of trauma,

01:04:02.620 given that, again, I'm using this very specific example where on an ACE score, neither of them would

01:04:08.540 rise to the level of concern? Right. Well, we are different even if we are siblings. The

01:04:15.660 genes are different, and their manifestation can be very different based upon aspects of early

01:04:21.180 childhood experience that may have nothing to do with trauma. So I think where it leads us is

01:04:26.700 inventories of signs and symptoms can be useful, but they're just one element of data. I mean,

01:04:32.140 one aspect of it is accuracy of reporting. People will often under-report because trauma creates

01:04:38.380 shame in us. I mean, I can't tell you the number of times, say someone comes to care with me and

01:04:43.740 they're checking, oh, they have depression and panic attacks and say there's some intake form,

01:04:47.740 then they don't check the trauma box. Okay. And maybe I meet with them and maybe there is like

01:04:54.140 a purely biological depression. It comes out of the blue and I can't find trauma associated with,

01:04:59.660 like that happens. It's rare, but it happens. More often than not, when you start talking to the

01:05:05.020 person, it's remarkable. Sometimes I have three sessions worth of trauma history that's intrinsic to

01:05:11.740 all aspects of that person's life and they check no on the trauma box. Well, because they didn't

01:05:15.820 really think this was trauma and they really think that was too long ago to be trauma. And like,

01:05:20.460 that's not as bad as what other people have to deal with. So that can't be trauma. I mean,

01:05:24.460 this happens all the time. What you just described strikes me as the norm, right?

01:05:30.540 It is. Yes.

01:05:31.580 The majority of people who come into kind of a trauma diagnostic scenario with an astute provider,

01:05:39.900 but it's the comparisons. Well, I mean, come on, that's what happened to me is not that bad.

01:05:46.060 Look at what happened to so-and-so. That can't be trauma. And that was a long time ago.

01:05:52.860 All the time. Absolutely all the time because, and this is really a crux of the messaging of the book,

01:05:58.380 because trauma changes the instrument that we use to understand our trauma. It's changing our brain.

01:06:05.020 So you combine that with how much shame is evoked and how hard it can be to discuss that. Because

01:06:12.140 if we're ashamed of something, we don't want to reveal it to somebody else. And we often don't know

01:06:15.900 just because it's a professional. Is that person going to feel okay about me? Or are they going to

01:06:19.660 look at me differently because they see that shameful thing in me? We feel this. And absolutely,

01:06:24.780 I felt this after my brother's death. I'm going to go see this therapist. I don't

01:06:27.580 even know this person. And what's she going to think of me? Here I wasn't around enough. I only

01:06:32.940 lived two hours away and I wasn't home enough to see this. And I thought maybe she was going to say,

01:06:39.420 shame on you for what happened. I didn't know. And I think that is the norm, which is why we can't

01:06:46.060 replace humans. We understand this, that we can't replace humans in our helping endeavors with something

01:06:52.860 that's computerized or mechanized in some way. So sure, we want to take inventories. And if we can,

01:06:59.260 if it makes sense, take an inventory of trauma sciences, but realize that you have no idea what

01:07:05.100 that data means until you sit with the person. And why should it be strange to say that human beings

01:07:11.900 are a necessary part of this helping process? Because often I may look at all the data I have

01:07:18.780 from someone. And a lot of times I have data even from other providers or other facilities, or I have

01:07:24.060 a lot of data and I'm like, okay, it tells me something, but I really don't know anything really

01:07:32.220 about that person until they sit in front of me. Because once they sit in front of me, I can anchor that

01:07:37.900 data to something. And very often what I started seeing over getting more experience in the field

01:07:45.020 was when you talk more with a person about what's going on in them, it is indeed linked to trauma,

01:07:50.860 whether they've checked that box or not. And it's all those barriers, it was too long ago,

01:07:55.420 or they feel ashamed of it, that lead them not to recognize that the trauma is driving all of the

01:08:01.580 problems. And I think that the last story in the book about the woman who, it's a true story,

01:08:07.180 who 10 years later is 10 years younger. And I got her permission before writing it because I didn't,

01:08:12.380 that's not a composite, right? It's this person who just didn't understand like how her life had

01:08:18.700 changed. So she had had a tragedy in her life and it was years before. And just standing from the

01:08:27.260 outside and hearing the story, there was such a disjunction of how she felt about herself and felt

01:08:34.860 about her life and was living her life that changed after the trauma in a way that was so stark.

01:08:41.580 This is the woman whose daughter died.

01:08:43.260 Yes. Who, without realizing it, was living this life that was so changed. And her thoughts

01:08:52.140 about herself were through such an unfair lens, who really had no, despite being intelligent and

01:09:00.140 personable and like all these wonderful qualities, couldn't see it. And like, that's not the exception,

01:09:05.740 that's the norm. And those rationalizations inside of herself that, no, it was too long ago,

01:09:11.180 or, or even feeling so badly about it that, that being unable to let it to the surface enough to see

01:09:17.660 what it was doing, had driven all of this change in her. So despite attesting to not having trauma,

01:09:25.180 it was 100% of the cause. How did she come into your care? To treat some of the symptoms

01:09:30.620 that had spun off, which is often the case, like, oh, this person is depressed or, you know,

01:09:34.300 there's just so many things. I'm like, okay, that's, that's just the card of entry. Like,

01:09:37.820 maybe that I will find there a pure biological depression, but I have ceased to believe that

01:09:42.460 that is what I will find because 20 years of doing this intensively has taught me differently.

01:09:47.260 So then the best case, the person comes in and I see whatever the presenting, I don't remember,

01:09:52.620 right? Because like, that's not where the money was at, so to speak, where the money was at was

01:09:56.540 in trauma, right? And is this that leaf at the end of the tree that caught the person's attention?

01:10:00.940 I want that leaf to be a little healthier, a little bit better, right? That then brings her in

01:10:05.980 where we look at what's going on in the roots that's affecting all of the leaves. And it then gives us

01:10:11.500 a chance of actually getting at it and developing an understanding of trauma

01:10:15.820 and of reflexive shame and what that does to us. And what a change in internal dialogue from

01:10:20.940 feeling a sense of pride in oneself as someone who works hard and does good things for other

01:10:24.700 people and in the world around her to someone who didn't, couldn't see her own worth anymore.

01:10:29.340 And you want to see an absolute disjunction of oneself from before and after that will do it. And by

01:10:36.300 understanding it, it could get better. Does it take away the grief? No. In fact, it let her begin to

01:10:43.420 process the grief. Because if we're blaming ourselves, we can't grieve. That's why it can

01:10:48.700 be 50 years later and be just as immediate as when it happened. Because if the grief gets walled off

01:10:54.620 under this layer of shame, like an abscess medically would be in the body,

01:10:58.380 then it can spin off symptoms for years and years and years without anything ever getting any better.

01:11:04.300 And in fact, with things getting worse, because the trauma then brings new trauma.

01:11:08.140 It brings the shame of losing jobs and losing family and all the ways in which feeling bad

01:11:13.100 about ourselves makes us feel worse about ourselves. So it's a great example, but it's not,

01:11:18.700 oh, that's one in a million. It's just a great example of something that I see all the time,

01:11:22.220 which is like, let's get to the truth of what's going on in the person, help them understand it,

01:11:26.300 and things get better. And it's not that hard and complicated, but it requires an approach that

01:11:32.860 actually wants to understand what's going on. Actually, I've always found the analogy of the

01:11:39.580 abscess to be quite helpful, especially for folks who understand what an abscess is, how it's formed,

01:11:47.020 and what the implications are of it. So for maybe folks who aren't familiar, an abscess is a walled off

01:11:54.220 infection. So a great example of how one might get an abscess is if they had a ruptured appendicitis.

01:11:59.260 And a ruptured appendicitis carries with it a very high mortality, but there are some ways to survive

01:12:05.580 it without antibiotics, without anything. And this was even known hundreds of years ago when people

01:12:11.580 were making long haul journeys across the ocean. If you had a ruptured appendix in the middle of the

01:12:16.220 Atlantic Ocean, when you're halfway between Spain and the Americas, kind of SOL. But what they realized

01:12:22.380 was if you put the person on their right side down, tilted slightly head up, all of the

01:12:29.100 pus that was coming out of that ruptured appendix would at least wall off in the lower part of the

01:12:33.980 right abdomen as opposed to spread throughout the entire abdomen. And there was at least you'd increase

01:12:38.700 the odds that it would form this fibrous capsule around it that would wall off. So you'd have all

01:12:45.100 the pus and all the nastiness inside there, but it was sort of walled off. And if you could get this

01:12:50.460 right, that person might just might survive. Now they weren't going to be perfectly healthy,

01:12:55.260 but they'd survive. Now, today we still see people that show up with abscesses from a ruptured

01:13:01.260 diverticulum or something like that. And they're not well. They're not dead though, but they're just

01:13:08.460 not well. Well, the first thing that has to happen is they have to come into the medical system for

01:13:14.620 treatment, which I guess the analog would be here. They have to at least present for help in some way.

01:13:21.820 The second thing is they have to be willing to get help. They have to acknowledge I have

01:13:26.700 an abscess. Now it's a lot easier with an abscess because we have a CT scan that is stark. I mean,

01:13:32.700 an abscess is an unmistakable thing. You don't even need to be a radiologist or even a medical

01:13:38.780 student to spot the abscess on a CT scan. It's the easiest thing to see. Literally, there's nothing

01:13:43.740 easier to see on a CT scan than an abscess. But nevertheless, there's got to be some component

01:13:48.300 of convincing the person that you have this abscess. But what's interesting is the treatment,

01:13:53.820 you often get a little worse before you get better. Because when you open that abscess and you

01:13:59.180 release all of the bacteria, even though you're doing it in a manner to clean it up,

01:14:04.620 the patient will initially have an inflammatory response to that that is probably worse than the

01:14:11.660 condition that brought them in. Now, of course, you have the luxury of doing this in the hospital.

01:14:15.500 You're giving them antibiotics. You're giving them IV fluids. You're monitoring them.

01:14:18.940 So this is rarely a fatal event, but it's nevertheless uncomfortable. And in many ways,

01:14:25.020 that just strikes me as a great analogy for what has to happen here, except it's harder in the case

01:14:30.380 of trauma because one, they might be less likely to come in and seek help. Two, you have a really big

01:14:38.300 hurdle to actually convincing the person that you have this abscess. And three, the treatment is much

01:14:45.820 harder. In many ways, the treatment of the abscess is really quite simple. You're going to be under

01:14:49.740 anesthesia for the next couple of hours, and we're going to do all this stuff, and we're going to give

01:14:53.180 you a bunch of antibiotics. Well, it's a lot harder to do what you did with that woman than what I would

01:14:59.580 have done with that patient. Yeah. And I think as I'm listening to you, what it makes me want to focus on

01:15:04.780 is the really big hurdle. Because I think the abscess, it's a remarkably good analogy.

01:15:11.420 It saved you. Your response to the trauma saved your life.

01:15:15.580 Right. We're built to recoil and protect ourselves from dangerous things, which is why if you think

01:15:22.300 about trauma leading to avoidance and hypervigilance, and people become more afraid of the world and

01:15:27.420 less likely to engage and less likely to take chances, even if it's the chance of a job that seems

01:15:32.540 better or the chance of dating someone who seems like they could be a great partner, taking chances

01:15:37.740 in good ways, that person becomes much less likely to do that. And if you think about how these systems

01:15:44.460 grew in us, that trauma raises a lot of negative emotion in us, and then we recoil to protect

01:15:51.820 ourselves. And it may be that even a depressed mood or a lot of panic attacks and disturbed sleep,

01:15:58.220 this may all go hand in hand with hypervigilance and avoidance to say, look, that is better than

01:16:04.060 death. And when these systems grew in us, where a lot of the trauma that happened did tell you to

01:16:10.140 stay close to home. Human development, right? And we're in small groups. And if you eat something that

01:16:15.100 makes you sick, like never, never, never eat that again. Or if you go over that hill and someone from

01:16:20.300 another tribe attacks you, like don't go there again, right? You stay closer to home. They're there for a

01:16:24.940 reason. They're part of the evolution of human beings psychologically, right? Over time in order

01:16:31.100 to stay alive. But then in the modern world, those things don't always make sense anymore.

01:16:38.220 And that walled off, say, psychological abscess that is indeed better than death is spinning off

01:16:44.700 symptom after symptom, right? It's making that tendency towards a little too much alcohol

01:16:49.420 soothing that that person does a couple of times a year. Well, now they want to do it a little more

01:16:53.820 because there's a desperation in them to not feel so terrified or have panic attacks when they're

01:16:58.620 falling asleep. And now they're drinking three, four, five, six, seven days a week.

01:17:03.340 Or that tendency towards avoidance is now they can't get out of bed or leave the house. Like,

01:17:07.740 these are things I see all the time. And often, what brings a person to care is a symptom. Just like

01:17:14.620 the person with the abscess might come to care because they're having night sweats or something.

01:17:17.980 No, they have an abscess. Exactly. They just don't feel well.

01:17:20.780 Right. So the parallel is so strong there. And I think the difference is in the hurdle that even

01:17:27.180 though I might say, okay, wait, I'm going to feel a little worse before I feel better. But like, oh,

01:17:31.660 I see that bright thing on the CT scan and you're telling me you're going to go in and take it out and

01:17:36.620 I'm going to feel a lot better. Not just this thing that brought me in, but 50 more things I didn't

01:17:41.580 know about, I'm much more likely to say yes to that. And the problem I think is in how high the

01:17:48.460 hurdle is for trauma. And I guess, actually, I think the problem is twofold. It actually is in,

01:17:54.460 it's not as easy to recognize as the abscess, but I think that it should be. That our mental health

01:18:00.940 methods of helping should look for this. In looking for abscesses, we have 256-bit CT scanners that

01:18:09.420 can produce a resolution of one by one by one millimeter. And the analog of what you have in

01:18:16.220 psychiatry to do this is pre-CT scan era when you have to just palpate somebody's belly and surmise

01:18:23.980 that they have an abscess. There's a huge, I mean, I don't want to use the word technology to imply that

01:18:28.940 you will need technology to do this, but it is effectively the difference between a catapult and a

01:18:34.860 cannon. But I think maybe the beautiful answer to this is in this example we're setting forth,

01:18:41.740 psychiatry is choosing to use the, oh, let's palpate the abdomen instead of the CT scan.

01:18:47.020 I completely agree. Yes, yes, yes.

01:18:48.540 Because the human brain has more sophistication than even that finest CT scan, right?

01:18:53.900 That's right.

01:18:54.300 So if we apply the trained human brain to say, look, I want to try and understand what's actually

01:19:00.140 going on in you instead of saying, oh, oh, you're depressed. You checked all the depression

01:19:03.820 boxes. Let me give you an antidepressant and I'll see you again in two months and we won't

01:19:07.740 make eye contact. I mean, that's not helping. That's not understanding. But if we apply the

01:19:13.500 human brain like we apply the CT scanner, then we will identify way more trauma and say, look,

01:19:19.180 how many times I tell a person, here's the great news is you do not have five problems.

01:19:24.860 Because people will present saying, you can't help me. There's no way you're going to help me,

01:19:28.860 right? It's been going on to me for years and I have four different problems, right?

01:19:33.260 How are you going to help me, right? So here's the great news. It's been going on for years because

01:19:37.500 it's never been looked at. So it's not surprising it goes on for years and you don't have four

01:19:42.140 problems. You have one. You don't have depression and sleep disturbance and panic attacks and alcohol

01:19:47.340 abuse as entirely different problems. They're arising from trauma. And I may be, why would I be saying

01:19:53.340 that? Because we've had a couple of conversations where the person told me how none of those things

01:19:57.340 were present before the trauma and all of those things are present after the trauma.

01:20:00.700 And then that's not rocket science. So we could stop palpating the abdomen and bring in the

01:20:07.180 equivalent of the CT scan or even better, right? The human brain. And then we can identify what's

01:20:12.300 going on and we can also decrease the hurdle. Like why is it so daunting to get help for trauma,

01:20:19.500 right? I mean, in many ways it is scary because the person often has been keeping it inside. And I hear

01:20:25.100 this all the time too. They're like, I can't talk about that because then they realize and often

01:20:29.660 they knew all along, not always, but often they knew all along that that's what was going on because

01:20:34.940 they could tell the whole world inside of me is different now. But look at what it's doing to me

01:20:39.340 and I'm not even talking about it. They don't realize, look at what it's doing to you because

01:20:44.460 you're not talking about it. But when you can get someone to understand that, and often that comes

01:20:50.860 already that's right there waiting, because you're talking at least enough about it that

01:20:57.180 the person has disclosed that there's been some trauma. They put words to something. They maybe

01:21:02.060 never put words before. And guess what? The world didn't end. And I didn't lean across the table and

01:21:07.180 say, what? Like get out of my office. Things that people are afraid of. Like I was afraid after my

01:21:12.220 brother's death. Already there's an experience. People, this happens all the time, we say,

01:21:16.700 I feel better now. I already feel better because, because literally after just 40 minutes say of

01:21:23.740 talking about like, yeah, you know, I really have felt different since that car accident,

01:21:28.860 or even since my, that thing happened to my friend's child. They know, but because of the

01:21:34.860 shame and the idea of, what are you going to do with that? They don't know that there's helping

01:21:38.220 resources. So we don't put it out there that there's helping resources. And people have way too many

01:21:43.740 experiences of going to get help. And then they come out with a prescription for an antidepressant

01:21:47.980 from somebody who didn't really talk to them. And they know that's not going to help or they've

01:21:51.580 already done it four times and it hasn't helped. So we create these barriers by like so many things

01:21:57.260 in modern medicine by stepping away from common sense. Like let's use the right helping mechanism.

01:22:02.940 Let's use the equivalent of the CT scan to find the abscess. And let's make the barrier lower

01:22:08.860 so the person doesn't have to feel that it's utterly terrifying to go through this helping

01:22:13.660 process. Once people start doing it, even though it's difficult, people feel good about it. They

01:22:19.340 feel good about it. Like you feel good about doing something that's hard for you. Like, you know,

01:22:22.620 like working out is really hard, right? But like, you know, you're getting healthier,

01:22:25.820 so you don't mind going and doing it. And that's often how the experience is. It's not

01:22:30.940 miserable. And it often surprises people that like the clinic that the whole group of us have

01:22:36.140 together, like it's not a miserable place to come. And people are often surprised by that, that,

01:22:41.980 you know, this is supposed to be miserable. It's supposed to make them feel bad. And if you

01:22:45.500 come to a place that's like just reasonably nice and you meet people who are like, hey,

01:22:49.660 I'm in the soup with you too, right? Like I know things, I'm trained, that's why I can help you. But

01:22:54.780 you know, I have the same problems. But don't you find that in the short term,

01:22:57.580 it can be quite distressing to go back and revisit these things? I mean,

01:23:01.900 I think that's been more my experience than not, both personally and with others, that

01:23:06.620 it really does feel a little bit like that abscess where in the days after that surgery,

01:23:11.980 in that case, the patient actually looks worse. Yeah, absolutely. Like, absolutely, yes.

01:23:18.460 But because you know why and you know that it's helping you, it's much more tolerable. And this

01:23:25.020 happens in my own therapy. I'll think, gosh, I've got to talk about something from the past that

01:23:29.020 is now being triggered, right? Like something happens in my present and it links me to a trauma

01:23:34.060 of the past that really shook my confidence. And like, now my anxiety level is higher. And I know

01:23:39.500 it's going to be hard to go in and talk about that. I know it. I know it's going to be painful, but

01:23:44.860 I'm not afraid of it because I know that it's helping me. Just the way that people perceive pain

01:23:49.900 differently in medical settings if they know why. I saw a study you've probably seen about gunshot wounds,

01:23:56.060 right? And like people's pain being so different if they see that there was some reason, right?

01:24:00.700 Like they're trying to help somebody, right? And now they know that even though this is terrifying,

01:24:05.020 they're going to survive it, right? And their level of pain goes down. So yes, it's painful,

01:24:09.580 but the perception of the pain, is this pain that threatens me, menaces me with destruction?

01:24:14.780 Or is this pain that, although painful, is in the service of doing right by myself? And that's often

01:24:21.100 what we'll anchor to, like, look, I don't see a reason for you to have a dialogue running in your

01:24:26.140 head where 500 times a day you tell yourself that you're worthless. Really, that doesn't seem fair

01:24:31.820 or right to me. You know, not even sometimes you joke, or I don't know if you've been kidnapping

01:24:35.820 buses of school children I don't know about, right? Like, is this it? That there's something

01:24:41.020 to feel ashamed about here, but it's the person who did that thing to you. Or maybe there's nothing to

01:24:45.820 be ashamed about here because like something just happened in life. And it's that change inside the

01:24:51.180 person that gives us all the bravery to go and do difficult things because we see that it's aligned

01:24:57.500 with truth. And I think often people see psychotherapy as like, oh, we're trying to shift towards

01:25:02.380 something that feels better. Like that's not the purpose of it. The purpose is to shift towards

01:25:07.020 something that's true. Oh, and by the way, that true thing feels better.

01:25:10.940 What do you think are the impediments to a person once they're presented with

01:25:19.340 a plausible explanation for their symptoms in the roots of trauma? What are the impediments to them

01:25:26.140 doing the work that's necessary? Because again, here's the second huge difference from the abscess.

01:25:33.020 The abscess, you get to basically put an IV in your arm, take some propofol and wake up and have it be

01:25:38.780 over. When you're confronted with these events of your childhood, though seemingly completely

01:25:46.540 disconnected from the problems you're having today as an adult are probably causally linked and we need

01:25:53.100 to go back and talk about them and we need to go back and process them and we need to go back and

01:25:57.500 disconnect your shame from those things. There's a lot of resistance that's met there. I mean, last night

01:26:03.660 over dinner, you and I were talking about common patients whom you get the feeling that they might

01:26:11.260 not take treatment. Yeah. I mean, I think the biggest problem, because you said what are the

01:26:16.300 problems, right? And the biggest problem is presenting to a system that is not looking to

01:26:23.740 throughput and minimal short-term cost as the primary metric of success.

01:26:29.260 Because that brings the frustration of not finding what's needed. And what's needed, of course, are

01:26:35.900 skills that are learned through education and training, right? They're neurobiological knowledge

01:26:39.740 and pharmacological knowledge and psychotherapeutic modality knowledge, right? But most importantly,

01:26:46.300 it's presenting in a setting where there can be what's called a holding environment.

01:26:49.980 The reason that we can do these things that are very, very frightening is because we establish

01:26:55.100 rapport with someone who we feel and believe wants to help us, is capable of helping us,

01:27:01.100 doesn't want to look down on us, and can help us hold the distress of it. And that's the commonality,

01:27:06.300 like the psychotherapeutic modalities are so very, very different. But if you look at primary

01:27:11.100 predictors of success, it lies in the rapport. Because of the rapport, the trust, the mutuality that's

01:27:17.340 generated is what creates that, again, that thing that's called a holding environment, which is like,

01:27:21.420 I'm really scared of this and it's intimidating, but like, I'm going to come here and this is a

01:27:25.900 safe environment and you're a safe person and you want to help me. And I don't feel bad when I'm

01:27:30.460 sitting across from you, which is why me and most of the people I work with, if not all,

01:27:35.660 acknowledge our own trauma. I mean, we're not talking about it in a way that serves ourselves

01:27:39.740 when we're supposed to be serving someone else, but I'm not pretending that I'm not a person for whom

01:27:44.620 trauma isn't deeply ingrained in my life. And that sense of mutuality leads a person to feel

01:27:51.180 the trust and to be able to tolerate the distress because they're not tolerating it alone. And when

01:27:56.300 I pack up my trauma at the end of my psychotherapy sessions, I'm going to carry that until the next

01:28:01.500 time I'm going to go back in part because the person I go to for therapy makes me feel helped

01:28:07.340 and understood. And I know that he's going to carry it with him and he wants to help me. And he feels

01:28:12.140 a sense of respectful camaraderie in the work that we're doing. And then I can bear the distress of

01:28:18.300 it. I can take it home with me, even if it causes me some symptoms thereafter and know that I'm going

01:28:22.780 to come back next week and I'm going to make more progress. But our hoping systems have to be set up

01:28:27.580 to do that for people. Let's assume those are in place.

01:28:30.780 Okay. Big assumption though, right? Big assumption.

01:28:32.860 Big assumption, but let's assume that that is in place. Why is it that 10 people who have childhood

01:28:40.540 trauma or early life trauma that is producing very maladaptive responses in their lives,

01:28:46.860 either with respect to self-care, care of others, any of the other manifestations of trauma,

01:28:53.260 what are the things that stand in the way of them accepting that information and moving forward?

01:28:57.420 Mm-hmm. So first three answers are shame, shame, and more shame. Trauma makes a reflexive

01:29:05.420 shame in us. And that's what tells us to make the abscess. What's interesting is in the appendix

01:29:11.100 example, the abscess happens because a biological process happens and now the appendix bursts.

01:29:16.220 And then maybe the body can figure out a way, especially if the person's leaning on the right

01:29:20.940 side, we can figure out a way. So like that walls off. But the difference here is like the creation of

01:29:26.140 that abscess occurs inside of us through our defense mechanisms that say, I've got to wall this off.

01:29:32.300 I can't think about this. I can't talk about this. I didn't want to go to therapy after my brother's

01:29:36.700 death because I was ashamed to go to therapy on top of the shame I felt about his death.

01:29:43.180 So we do it to ourselves because that's what seems like the course of action that's safest. And that's

01:29:50.860 very, very powerful when we're promoting that process. And then because things aren't going well,

01:29:56.460 we sort of wall off that abscess more and more and more because other shameful things happen.

01:30:01.660 Like after my brother's death, when I wasn't functioning super well, and I didn't feel like

01:30:06.780 I was taking good care of myself, I felt ashamed of that too, which then makes it harder to get help.

01:30:12.540 So shame, which is like the primary henchman of trauma, right, in my view,

01:30:16.460 comes along with all these other accomplices. Like shame loves alcohol excess. Shame loves an internal

01:30:23.580 dialogue that tells you that you're not worth anything. You're not going to get anywhere,

01:30:26.540 right? There are all these things that shame loves that we then cultivate in ourselves and

01:30:32.060 we apply to further walling off, further pushing that problem down. And that's why the best route

01:30:39.500 is not just, okay, let's shift how we're handling the care. So if you go to see someone about whatever

01:30:45.020 your symptom is, that person is actually thinking about you. But we do need, in my very strong belief,

01:30:50.780 to change the sociological aspects of this, to look and say like, look, many, many, many of us

01:30:57.180 have really significant trauma that has overwhelmed our coping skills, changes how we view about ourselves

01:31:03.740 and the safety of the world around us. And it really behooves us to look at this. And there's

01:31:08.700 no shame in this. I remember this was a bunch of years ago, but I was talking to a group of about 300

01:31:14.380 physicians from mixed backgrounds, mixed disciplines. And I said this, right? I said that I've had

01:31:20.060 like really significant trauma in my life and like psychiatric care and psychiatric medicines have

01:31:25.100 really helped me. And I could see out in the audience, like probably about a third or so is

01:31:30.700 a rough estimate of people were like, like shocked, like that I had said something that was so shameful

01:31:36.700 as if, you know, the next thing that was going to happen is like someone's going to fly through the

01:31:40.220 air and tackle me, right? And, you know, pull my medical license out of my pocket and

01:31:44.220 put me someplace where people go who need those things. And I said, I mean, look, this is a problem

01:31:49.500 because I can see, and I hadn't planned on this. I said, it's a problem because I see a lot of you

01:31:56.140 really recoiling from this, right? And I'm saying something that I don't think takes away from my

01:32:01.980 ability to be a competent physician or a competent person in the world. And I think, in fact, being able to

01:32:07.820 say it is what helps me navigate the world. But if we recoil from like, oh, you might need help,

01:32:13.260 right? Or you might need medicines, like what is going on inside of us that means how likely are

01:32:18.380 any of those doctors to get themselves help? And how likely are their patients to feel comfortable

01:32:23.180 if they broach something traumatic to hear something back that even if the person is not in mental health,

01:32:29.020 right? But just say, wow, okay. Look, we know that way more than 50% of complaints to general

01:32:34.060 medical providers come from mental health conditions. I mean, the studies show, you know,

01:32:38.620 a bottom of 50% and a ceiling that's significantly higher than that. So non-mental health providers

01:32:44.780 have to be aware and not respond in this way. And again, I'm not trying to be critical, but you see

01:32:49.980 that response even in mental health. Like some of those people who were coiled were almost certainly

01:32:54.140 in mental health. And we have to change the, so to speak, the soup we're swimming in toward the

01:32:58.780 soup that says like, what do we have? Why should we be ashamed of this, right? Like,

01:33:05.020 don't we have to acknowledge this? Otherwise the negatives inside of us, including the anger and

01:33:10.220 frustration that I think promotes all the dysfunction in our political discourse, for example, like all of

01:33:16.380 this comes to the fore in sociological ways. So if we don't look at this, how likely are we to help

01:33:24.060 people get help? And then if we don't do that, do we make everything worse in our inability to come

01:33:29.740 to even a decision about like what's factual and what's not factual as we all as a society try and

01:33:35.260 navigate things like racial issues or discrimination based upon gender or sexuality or the climate crisis?

01:33:41.980 Like, how are we going to look at that if we don't look at what's going on inside of us that often

01:33:46.940 involves the anger and frustration that make people just say, need to be right. And like, I'm not saying

01:33:51.660 this is always where it goes. A lot of the dysfunction and the misery, most of it gets

01:33:56.620 turned inward in people, but some of it does get turned outward. And I think we see the manifestations

01:34:03.500 of that in the real degeneration of our discourse as a society. What is the antidote to shame?

01:34:11.020 The antidote to shame is understanding. And I view that the lancing of the abscess or the surgical

01:34:16.460 excision of the abscess. That's the equivalent of shining a light on shame. That shame is so

01:34:22.460 powerful. It's like, you know, the old, it kind of gets told a lot, but it actually happened when I

01:34:26.380 was a kid. Like there was a clothes tree in the room where me and my brother slept. And if you turn

01:34:31.740 the lights off, it could look like a monster. And like, I know it was a clothes tree, but as a little

01:34:35.500 kid, like it gets scary. And is that really a clothes tree? It looks like a monster. It gets scarier and

01:34:39.820 scarier and scarier. And then if I start screaming and crying and my parents come in and turn the light on,

01:34:44.460 oh, I see that it's just, it's not a monster. That's shame. If we turn our eyes away from it,

01:34:51.020 which is exactly what it tells us to do. You can't share that even with yourself,

01:34:55.260 let alone with someone you love, let alone someone professional. It's your fault that that happened to

01:35:00.260 you, right? You should have dressed differently. You should have not been in that place. You should

01:35:03.700 have been better and someone wouldn't have hurt you. You should have been different and people

01:35:07.040 wouldn't have treated you so poorly when you were way back when in school. These are the things that

01:35:11.920 shame tells us, like the devil on the shoulder, telling us why we have to hide it away. And then

01:35:16.940 it gets scarier and scarier. And when we go and shed light on it, we have never worked with one

01:35:22.760 person. I cannot call to mind a single case where shedding light on shame, all around it, right?

01:35:28.740 Looking at all the dark corners of it, right? And really bringing it to light in a process that has

01:35:34.040 its moments of fear and misery, but also has its moments of levity. And also has its moment of

01:35:40.120 bringing good memories to the fore, like being able to shed the light on that has never been

01:35:45.500 anything but extremely helpful to the person doing it. But all the impact of shame tells us

01:35:52.620 not to do that. And society really kind of goes along with that. And the health systems that want

01:35:57.460 to shuttle us through with a prescription for Prozac collude in that. So society colludes with shame

01:36:03.180 in preventing way too many of us from ever getting a handle on our trauma when it's actually not rocket

01:36:10.140 science to do so. So if you shine that light on shame and the person now realizes why they feel

01:36:18.760 a certain way, the reason I feel so inadequate is because of these events or this event. And because

01:36:29.840 of this inadequacy, I go and do this other thing. How do you change the feeling? So step one is

01:36:36.700 understanding why, but then step two has to be, you have to actually change that feeling, don't you?

01:36:42.800 Yes. The answer to that is you work on it across time. We live in a society that so wants rapid

01:36:49.140 results. And it's why we throw medicines at so, so many things throughout the whole field of medicine

01:36:53.760 that we shouldn't throw medicines at. Oh, you're not healthy. Well, take this medicine,

01:36:57.980 this medicine, this medicine. We don't say like how to change your diet, exercise. I mean,

01:37:01.020 things that you understand as well as anyone on the planet, right? We don't do that. So we look

01:37:06.880 to short-term fixes. And we all, well, we know through our just even basic education in brain biology

01:37:13.180 that the neurons that fire together wire together. So if you and I picked a word out of the blue and we

01:37:19.620 decide, let's say it over 500 times, then of course, like we'll each be saying it like tonight,

01:37:25.040 right? It'll be in our heads tomorrow morning. What if we say that word 5,000 times? It'll be in

01:37:30.320 your head next week. So if we say things to ourselves and we have a way of conceptualizing

01:37:36.360 ourselves that we've overly reinforced, it will not go away overnight. But we don't tell people

01:37:42.620 that. So when a person comes to it, like a really say, an understanding milestone of like,

01:37:47.800 oh my God, the shame, is it mine? Like I was six years old. The shame is that person who hurt me.

01:37:53.240 And that part of how I make sure we end that session is all those thoughts and the feelings

01:37:59.480 attached to those thoughts, and it's the feelings that make the difference, are not going to go

01:38:04.440 away. They will still be there with you because the only way they go away is they attenuate over

01:38:10.400 time. And you've scored a victory today that disempowers them. That when those thoughts come

01:38:16.820 like, oh, you're worth nothing and that was your fault. And if you'd been better, that wouldn't

01:38:19.940 have happened to you. Like, you say, wait a second. I don't actually believe that. I can't

01:38:24.060 keep it out of my head, but I'm going to put you back thought. I'm going to direct my thoughts away

01:38:28.320 from you more quickly. And there's a whole bunch of strategies around that. And then I'm going to

01:38:31.540 put you back a little bit less powerful than how you came. And we don't, as a rule, we do not

01:38:38.520 talk to people in that way. And then people feel terrible and they feel ashamed. And often their

01:38:43.640 practitioners think they failed the treatment. And like everyone now looks at this negatively

01:38:48.020 because, oh, two, three, four weeks later, they're not better. There's no way on God's

01:38:51.720 earth they were going to be better after two, three, four weeks. Like something that's developed

01:38:55.120 over years doesn't go away that quickly. But if we engage in that process and we take

01:39:00.320 away what? The fear. Because otherwise, if the person feels better, they have this aha moment

01:39:05.060 and then they go home and they're getting in bed and the same thought goes, you know, tomorrow's

01:39:10.380 going to be better than today because you're not worth anything, right? No, now they feel awful

01:39:14.060 that that thing that happened today doesn't mean anything. So you have to prepare that

01:39:17.960 person that like, absolutely, you can be better, but it's going to take place over time. You

01:39:23.040 don't have to be afraid when those thoughts are still in your minds. I've had people I've

01:39:27.340 worked with who say started their treatment even before I met them. And they had among the

01:39:31.640 most severe repeated negative thoughts and feelings inside of them. And they may have been

01:39:36.340 doing really well for 10, 20 years, but you put them under enough stress and enough triggering

01:39:41.880 and it'll still come in that, oh, you're nothing and you should kill yourself. Still

01:39:45.860 comes into their mind. But now they know well enough, they'd be like, wow, that stuff dies

01:39:50.480 hard. As one person said, that stuff dies hard. Not afraid of it one little bit. Because

01:39:54.300 that person understands that he said that thing to himself a hundred thousand times. And guess

01:39:59.060 what? It's still going to come back every now and then. It doesn't mean anything. They

01:40:02.100 have anything to say to that person. It doesn't carry one little bit of information. And

01:40:06.520 now that person isn't afraid of it. Not saying, oh my gosh, am I going to hurt my... They

01:40:09.400 don't... They know. But we have to educate people. And the mental health field doesn't

01:40:15.020 put very much value in what's called psychoeducation. Let's help you understand yourself. And I think

01:40:19.720 that's also a lot of what I do. Psychoeducation through the lens of understanding trauma.

01:40:25.300 I think if you told me I could only do one thing. Maybe I can't prescribe medicines anymore.

01:40:29.180 I can't do depth psychotherapy. I can't use multiple modalities. I can only do one thing

01:40:33.740 and I got to choose. I think I would choose psychoeducation about trauma. Because then, man,

01:40:38.220 you arm people with knowledge they didn't have before. And they can go help themselves. They

01:40:42.920 can get help from people who are close to them. They can maybe get professional help. But it's

01:40:47.000 that knowledge that helps us even if there's no professional help to be had. Which is also

01:40:51.360 a point of the book. That I want anyone who picks that book up to be able to read their

01:40:55.420 way through it and to end up on the end of it with knowledge and education they didn't

01:41:00.180 have before. Because that, I think, is what is most impactful. And whatever a person does

01:41:05.720 with that, which may be limited by time, circumstances, resources, all sorts of other

01:41:09.380 things, they're now equipped to do something good with it. And the field generally does not

01:41:14.320 do that.

01:41:15.660 You know, when I think about our practice, I think about all of the dimensions of health

01:41:21.500 span. So when I use the word longevity, I'm referring to two things. Lifespan, how long

01:41:26.260 you live, and health span, how well you live. And within health span, there's really three

01:41:30.340 dimensions. There's a cognitive dimension, which I think most people kind of understand,

01:41:34.500 right? How sharp is their brain? And most people can understand what the extreme loss

01:41:37.940 of that looks like in the form of dementia. Then there's a physical dimension, the structural

01:41:41.940 dimension, your ability to be free of pain, your ability to carry out activities of daily

01:41:46.780 living, and your ability to do the things that you enjoy doing physically. And then there's

01:41:51.480 an emotional component to this. Even though some people would touchy-feely call this mind,

01:41:55.680 body, spirit, I really like to think of it as cognitive, physical, slash exoskeleton,

01:41:59.740 and emotional. I think it's that emotional bucket that is the hardest one for us in our

01:42:06.800 practice to help patients with. Because one, we don't have a great set of screening tools.

01:42:14.560 We have really good screening tools for these other ones. And by the way, on the whole lifespan

01:42:18.580 side, we have lots of great screening tools. We have biomarkers and MRI scanners and liquid

01:42:23.800 biopsies and colonoscopies. I mean, we're very good at trying to identify the things that will

01:42:30.680 end your life in a binary fashion from a cardiorespiratory standpoint. We're not very

01:42:36.860 good at identifying the things that are going to end your life emotionally. And in my book,

01:42:44.260 which is obviously not written yet, but it's, I mean, it's the draft is there, but I write about

01:42:47.780 these four types of death. The first one being the one that people think of, cardiorespiratory pulmonary

01:42:53.340 death, what I call death certificate death. But then I talk about these three other deaths,

01:42:57.660 cognitive death, the death of the ability of the brain, the decline of the ability of the brain

01:43:02.440 with respect to processing speed, short-term memory, long-term memory, executive function,

01:43:09.080 the physical or exoskeleton death or demise, which is basically that which leaves a person in pain and

01:43:15.820 unable to carry out these activities of daily living. And then this emotional death.

01:43:20.800 And these three types of other death types, two, three, and four often precede one. In some ways,

01:43:29.400 the perfect life would be a long life that just goes straight to type one death without detouring

01:43:35.560 through type two, type three, and type four. But tragically, that's almost never the case.

01:43:41.460 And so we think so much about how to identify and treat type two, type three, and type four,

01:43:48.200 but by far the one in which we are the most limited is this identification of type four.

01:43:54.360 And part of it is, I think, shame. There's no question. Part of it is inadequacy of tools.

01:44:01.040 For example, when it comes to identifying type two or type three, let's use the physical one,

01:44:06.680 we have so many ways that we assess people for movement and strength and balance and stability

01:44:12.460 and stamina and all of these things. And usually once people are confronted with how bad they are,

01:44:18.660 because almost always relative to our standards for where we want people to be, most people fall

01:44:23.840 woefully short, but they can see, oh, this is where I should be. If I subscribe to your ethos that

01:44:31.280 to be a really kick-ass hundred year old, I need to be a doubly kick-ass 50 year old.

01:44:36.600 And here are the steps that we're going to take to train to get you there.

01:44:41.040 But I've, for years now, wanted to think, how could we do that same sort of screening

01:44:47.240 around emotional health? And how would it be received? And how would we then implement

01:44:53.680 therapy? Because really, a person who's doing very well on the type one, type two, and type three,

01:45:00.500 meaning they have no chronic diseases, they have no acute diseases, their mind is sharp,

01:45:05.040 their body is great. But they're a slave to some shame that's rooted in trauma. They can often have

01:45:12.860 the most miserable life. And really, how long they live becomes completely irrelevant. In fact,

01:45:19.420 it almost becomes paradoxically a curse. It's just more time to suffer. A lot of these people,

01:45:26.880 of course, are not obviously suffering. So it's very easy to see a person living in a crack house

01:45:34.160 with needle tracks in their arm and say, are you suffering? Yes. That's not a huge cognitive

01:45:41.220 leap for that person. There are enough external markers that we can make that conclusion with a

01:45:44.660 high degree of injury. And they're probably self-aware enough. But when you take somebody

01:45:49.820 who's actually quite successful by all the metrics of the external world, they're successful

01:45:54.780 financially, they have a wonderful family, all these other things, it usually takes a bit of

01:46:00.400 prodding for them to acknowledge. And you have to be astute enough to prod and realize that actually

01:46:08.500 all is not well. Yes. So I'm not a psychiatrist. How do I bring our evaluation of what I call type

01:46:19.100 four death or demise up to the level of our ability to evaluate the other three?

01:46:24.160 The first thing I have to say is you've been kind enough to share with me some excerpts

01:46:28.080 from the book. And when your book comes out, it will be anything but a day late and a dollar short.

01:46:33.780 And I think you're talking about these aspects of life that are just so, so important in ways that

01:46:40.660 we can understand. Am I taking care of myself in the way I want to? Am I paying attention to my life

01:46:46.380 in the way that I want to? And yes, that emotional aspect of it is the hardest to identify. As you

01:46:53.300 said, there aren't serological markers for it. And often the truth of what may be going on is

01:46:58.820 underneath the surface. And I would say that you already do the things there are to do. And we could

01:47:05.640 talk about how might it be formalized. But I think of when you may refer someone to me, right? And why is

01:47:12.520 that? I guess I would say this. I think we do a better job than most. I guess what I'm really

01:47:17.700 getting at is why can't we be doing better? Why is it that there are some patients whom I suspect

01:47:25.240 there's an issue, but as I broach it, there's complete denial? Or there's other patients who

01:47:30.700 on the surface will accept it, but then we can't get them to engage in it?

01:47:36.500 Right. The processes that you're going through. So again, what do I think you're doing?

01:47:40.800 You can tell me, does this make sense? I think that you're looking for people

01:47:44.580 whose actual behavioral choices are running countercurrent to what they're presenting for.

01:47:50.720 And people are presenting to you because they want to be the healthiest they can be.

01:47:55.100 So it's a little bit maybe the health systems are less like that, right? People are presenting

01:47:58.640 just with problems. So you will see if someone presents to you, says, hey, the reason I'm here is

01:48:03.720 I want to be as healthy as I can be. And then you see that they're not actually behaving that way,

01:48:07.400 right? Or they're behaving in a way that kind of thwarts that. And then that will trigger like,

01:48:11.820 ah, something is going on here, right? Because otherwise, why would those vectors not all be

01:48:16.440 heading in the same direction? Good mental health is always consistent with simplicity in all of us.

01:48:21.840 So if I would like to be healthy and I come to a health assisting resource, one would presume I'm

01:48:26.760 going to act in ways that assist that resource in assisting me. Pretty straightforward, right?

01:48:30.680 If we're not acting that way, then it points like there's something going on that's not consistent

01:48:35.280 with that sort of simple, almost common sense understanding of how to make our lives better.

01:48:40.780 And that will point towards something in the mental health spectrum, which the vast majority

01:48:45.160 of times has its roots in trauma. So if you see people running countercurrent to their stated goals,

01:48:51.700 or the second, I think there are kind of two occasions on which we see people coming from your

01:48:57.440 practice, right? The other might be if on discussion, the person is sharing something about their inner

01:49:02.680 world that's not consistent with what you're necessarily seeing on the outside. And then

01:49:07.480 their sharing of that dissonance then leads to, ah, there's something going on here that it's

01:49:13.200 affecting them emotionally, even if they are still trying to be healthy. But there's some toll that's

01:49:18.400 taking then under the surface that you want to understand better and guide in the right direction.

01:49:22.620 And the thought would be, we could deploy that in sort of formalized manners in our medical health

01:49:29.820 settings. So the person who really wants to stay alive because they love their grandkids,

01:49:34.820 but they have diabetes and this is their third hospital admission in two years, right? And you

01:49:40.340 say, okay, like that, that person doesn't want this to happen. Like they like their life and they,

01:49:44.960 and they have their ground to these reasons of being healthy and staying alive, but they can't act that

01:49:49.960 way. And to look at that and say like, maybe there are logistical barriers, right? Like maybe there are

01:49:56.080 non-trauma related barriers to them, like getting to care, taking medicines. Like we can look very

01:50:01.800 hard at that. And then very often I think where that process can arrive at is there's something

01:50:07.540 that's preventing that person from taking care of themselves. And then there's the light bulb that

01:50:12.780 says, ah, there's something here for the mental health aspect of helping. Or if, and actually talking

01:50:18.740 to someone whose life appears to be going well on the outside, but like, is your inner world consistent

01:50:24.280 with your outer world? And there are ways of formalizing this potentially in your own practice

01:50:29.240 setting, but then in the broader settings of non-mental health helping. So look for vectors

01:50:35.560 that run countercurrent to the person's stated and healthy intentions and try and get some assessment

01:50:41.780 of what's going on in the person's inner world. Because even if things are going well in the outer world,

01:50:47.340 but these problems are there in the inner world, they represent risks for the future.

01:50:52.440 And again, I come back to like, it's not that hard to do. And I think that you're just reflexively

01:50:57.820 doing this because you're in a sense, applying common sense of, in the practices, if there's

01:51:02.620 something here that seems outside of the fold I'm operating in, that seems mental health, then you

01:51:07.260 make a referral. But the health systems in our society as a whole can be doing this to help people

01:51:13.680 because it's not that hard to take stock of someone's inner state. If you sit down and talk with

01:51:19.960 them and you establish the right rapport or to call out when they're acting countercurrent with their

01:51:24.940 stated intentions. And a lot of times the general medical systems kind of push that under the rug

01:51:30.280 because they don't know what to do about it. So they keep trying to treat the diabetes as best

01:51:33.960 they can with some knowledge in their head that like this lovely person who wants to be healthy

01:51:38.760 isn't really on board with this. But if you don't know what to do about that, or the last 10 referrals

01:51:43.940 you've made to mental health haven't yielded anything because three months down the road,

01:51:47.500 the person got a Prozac prescription and they're no better, then there's a sense of futility

01:51:51.660 to it. And again, I think if we come back to well-grounded common sense approaches,

01:51:57.100 it's not all that complicated and it doesn't have to be that esoteric.

01:52:02.760 Do you think there will be a day when shame is out in the open? Because I mean, that's really

01:52:08.520 what this comes down to. You have the stigma of trauma and then you have the vector of shame

01:52:13.700 that works so effectively at keeping it in the dark. What does a world look like in which the

01:52:20.580 light switch gets turned on and shame has to retreat to the corner and cower as opposed to

01:52:25.960 let its cape sit over that which needs to be exposed? I think a big part of that is an education

01:52:32.580 process in our societies. And when you say education, what do you mean? Is this something

01:52:37.360 that occurs in schools? Is this something that occurs in medical schools? Is this something

01:52:41.640 that is for doctors only? I mean, should police be aware of this? I mean, like how broad a net do

01:52:47.680 you cast? I think you cast a very broad net. And I think it's not that hard to do that. So I think

01:52:53.360 it starts in early education. When you talk about what goes on in people when they feel bad,

01:52:59.060 when something makes them feel bad, what happens inside of you, what do you do with that feeling?

01:53:02.940 Help the bully understand why he or she is bullying when we're in first or second grade.

01:53:08.200 Let's help that person understand and look at that person.

01:53:10.480 How would that be done? I mean, that would require teachers now understanding this, right?

01:53:16.360 Yeah. I think we do educate the professionals. We educate the doctors. We educate the teachers. I

01:53:20.760 mean, there's so much that we do in the education processes that I don't think I'm saying, well,

01:53:26.000 let's bolt on some process that tries to turn everyone into a therapist. But there's so many

01:53:31.960 things that are done. You think about in medicine, like how many checklists, how much paperwork?

01:53:35.820 We've done this utterly and completely non-contributory and everybody knows it.

01:53:40.500 Why not an approach that's not paperwork intensive or time intensive, right? That just looks at,

01:53:46.520 look, a part of trying to understand somebody is thinking about them through this framing

01:53:50.860 and structuring the mental health resources so that there is a place to send someone.

01:53:56.520 There's a place where we're going to have basic conversations about what's going on inside of

01:53:59.520 that then gates the care. There are ways we can do this that involve pretty basic education

01:54:05.240 that can change, again, this idea of the whole soup that we're swimming in, where we start with

01:54:10.500 early education and we run that through educating professionals, educating police, educating legal

01:54:16.740 systems, right? There are mental health courts now. They're not nearly as widespread as they should be,

01:54:21.640 but we are trying to educate doctors in the legal process and the education process, but we're not

01:54:27.520 prioritizing it with a sense of urgency. It can be different, but we've got to look at it and we've

01:54:34.580 got to say, yeah, this is worth paying attention to. Is this what's in large part or in very significant

01:54:40.740 part driving that we have now over 100,000 drug deaths in this country over the course of a year?

01:54:47.100 Like, why do we not feel a sense of urgency and want to look at the way that we provide help and

01:54:53.860 to say, does what we're doing that drives doctors to burnout, which is a term that I can't stand.

01:55:00.620 I mean, when I grew up, burnout was a negative term to say about somebody, well, they couldn't handle it

01:55:05.480 and now they're just in a corner smoking cigarettes doing their own thing. Like that was an insult to

01:55:09.800 someone. And now we level that at doctors who are often traumatized by the health systems that they

01:55:16.400 work in and the unreasonable expectations and that they're treating charts and computers all the time

01:55:21.880 and don't have enough time with their patients. Like, why do we not look at this and say, has this gone

01:55:26.320 mad that we spend more money than any developed country on healthcare, yet we have the worst outcomes

01:55:32.600 and we're the worst about things that involve direct contact with humans, preventive aspects of healthcare,

01:55:38.700 treatment over time. Like, why can't we look at this with a sense of urgency that says, oh, this isn't working.

01:55:45.200 And then I think at the other end, people who other people look to and have a sense of respect for

01:55:52.960 that will talk about their own trauma as, you know, in some very small way, like I'm trying to do,

01:55:58.620 and you do, and Tim Ferriss has done, and even Stephanie Germanotta, so Lady Gaga, who is kind to

01:56:04.620 write the foreword for the book, that she talks about her humanness, that we all, no matter who we are,

01:56:11.720 are susceptible to this. So from the one end, people who have any power whatsoever and authority

01:56:17.460 need to not shrink away from this. So if I'm giving a talk to a bunch of doctors, I'm not going

01:56:22.600 to pretend that I don't have any trauma. So yes, we need, I think, have a responsibility to be open

01:56:28.880 and honest about the things that have impacted us if we have any public presence whatsoever,

01:56:33.800 let alone if a person has a big public presence, if that can be done safely and reasonably for the

01:56:38.960 person, of course. So that's one aspect of it. And the other aspect is the most important is on

01:56:44.900 this grassroots level of changing how we frame mental health in the world around us and starting

01:56:52.340 to get us curious about it at very early stages of life. When that bully tells you that you're lousy

01:57:01.600 because of what you look like or where you come from, what does that make you feel? And let's start

01:57:06.080 looking at that reflexive sense of shame. Okay, can you stop and think about that? Like you feel bad

01:57:11.660 when that happens. And what happens next? Well, you feel bad about yourself. Okay, let's put a full

01:57:17.720 stop there. That person's hurting you because he feels bad about himself. So then you start to put

01:57:23.420 a barrier between the reflexive shame and the person feeling bad about themselves. Because how

01:57:28.320 many people don't actually logically feel bad about themselves, but they do actually feel bad about

01:57:34.640 themselves. And it's the feeling that matters, not the facts. And we've got to start looking at that

01:57:39.600 because that is the plain and obvious truth that pervades the society around us. And we are doing a very

01:57:44.900 poor job of developing understanding in us as individuals at any stage of life and as a society.

01:57:52.300 And I can't believe that we're not seeing the dysfunction in the social rifts that we're having,

01:57:58.340 in the ineffectiveness of the whole of our medical system. These are big, all-encompassing aspects of

01:58:04.100 our society. And we see, hey, these things are not going well. And if we look at the roots of it,

01:58:09.420 I think it's clear where a lot of it is coming from and also what we can do about it. Which is

01:58:14.860 why I feel the book is ultimately uplifting. I mean, I'm pointing out problems, but I'm not

01:58:19.500 pointing them out in some way of like pointing them out and then, well, we don't know what to do

01:58:23.080 about it. I mean, I'm pointing out solutions that I think are quite simple and well-grounded. And if we

01:58:28.600 just follow them through, it's resonating with people because I think it does resonate with common

01:58:33.000 sense. A moment ago, you alluded to a statistic that I think for many people is just almost impossible

01:58:38.940 to fathom, which is the United States has just for the first time ever surpassed a 100,000 person

01:58:45.800 mortality for a 12-month period. So 100,000 people have overdosed in the United States for the first

01:58:51.560 time in 12 months. Do you see this as an epidemic of trauma and shame? Or do you see this as really

01:59:01.440 just a new escape valve for it based on the availability of cheap and unfortunately highly

01:59:08.440 potent opioids? I think it's a combination of both. And I think the data tells us that, that more and

01:59:14.040 more people are feeling desperate and disenfranchised. They're feeling like, look, I can't make my way in

01:59:18.900 the world. Whatever my chosen route of endeavor is, I can't make a living in that. I can't support a

01:59:24.740 family in that. I can't get ahead. I can't feel good about myself. And we see that in aspects of

01:59:30.000 almost the entire service industry, which has changed to a place where people can't have

01:59:35.420 careers that then support their lives and support a family like was the case even 20-something years

01:59:41.500 ago. We see that even people who have good jobs, who feel like, okay, I finally got my way for it,

01:59:47.640 work hard if I have a good job, that often that job is running them ragged in a way that they can't

01:59:51.780 take care of themselves and they can't take care of their families. And they feel the same

01:59:55.220 desperation as a person who doesn't have a job. And this desperation builds anger and frustration

02:00:00.920 and resentment and all of these other symptoms, depression and panic that spin off of it. And

02:00:07.200 that makes it much more appealing to soothe in the short term. That's a basic psychological fact

02:00:12.720 of human beings. The more pain you're in in the short term, the more you're going to choose a

02:00:17.380 short term solution without any consideration to the long term. I mean, if I'm absolutely desperately

02:00:22.980 miserable and you've got something that can make me better right now, I'm not going to ask what

02:00:27.520 that may do to me tomorrow. So we have developed a society that has become more and more and more

02:00:35.420 hard-hearted towards people's attempts to make their way in the world. And I think we see that with

02:00:41.460 the response to the pandemic of, I'm going to respond in the way that I want and I don't really care

02:00:45.900 about you. And we've seen enough of that that I cringe at times at our inability to even have

02:00:53.440 basic compassion for others, which of course isn't everyone. But I think that's present in

02:00:58.840 society in ways that it wasn't before. And I think it's reflected in the rhetoric and the dialogue

02:01:03.240 that's acceptable, right? That not that long ago, the way people often behave who have a public

02:01:09.400 presence would have led to censure by everyone. That would say, hey, I don't even care that you're

02:01:15.220 advocating for what I want or even for me directly. I can't support you if you're going to behave that

02:01:20.340 way, talk that way, denigrate people that way. We've moved far away from that. And we need to look

02:01:27.800 at what are we doing in the world around us? How are we handling ourselves? And are we indirectly

02:01:35.500 promoting this ethic of not really caring that leads to the desperation that leads people to soothe

02:01:44.060 drugs? There's a very macabre, it's not even a joke, it's a tragic atrocity, right? That people

02:01:53.380 will say, oh, gosh, I have four people who are drug addicted in my practice. I'm going to see this

02:01:58.360 afternoon or 10 people, right? And it's not who it used to be, right? Because before it was people

02:02:04.120 who'd sifted down to places in society where societies really turned their backs on them.

02:02:08.520 And now it's people from all walks of life. And we see that socioeconomic demographic, educational

02:02:13.360 demographic, geographic demographic, racial, religious, or ethnic concepts, we've gone beyond

02:02:20.000 that. Where now we're all menaced by this because there's often a desperation to soothe that there

02:02:26.380 wasn't that shot through every demographic we have. And if we continue to turn away from that fact,

02:02:33.480 we continue to look at statistics like that and say, oh my gosh, how horrible. Okay, right? Like

02:02:39.740 we don't do anything about it, right? Which is a tacit acceptance of it. If we don't look at what

02:02:45.560 are we doing to people that drives them to desperation, then we're not going to make that

02:02:49.800 statistic better. And how much has gone on behind closed doors in the pandemic? How much violence

02:02:54.440 behind closed doors, neglect behind closed doors, drug and alcohol abuse behind closed doors? Are we

02:02:59.200 going to look more at this? Or are we going to just pay lip service to looking at it while we don't

02:03:03.680 actually change anything? And then we'll be going, oh my gosh, it's so terrible. It's three years from

02:03:08.040 now that number is 140,000. Well, if we don't really care now as a society, we just want to marvel at the

02:03:14.200 number and say how bad it is and do nothing. Well, it's exactly where we're going to go. That's why the

02:03:18.240 number has been increasing, right? I mean, it's not rocket science to say that either. You just extrapolate

02:03:22.920 that line ahead and that gets worse and not better unless we look at it in a way where we accept like,

02:03:28.580 we got to do something different because this is staggering in the human misery that it speaks to.

02:03:36.240 Not just 100,000 people lost, not just. I mean, what about all the people who love those 100,000

02:03:42.060 people? Like, what are we doing? Which is why when people would say, oh, sometimes I'll get approached

02:03:47.740 like I'm doing something that's very niche, like I'm interested in trauma, right? And I say,

02:03:52.580 no, this is not a niche, right? You get up to numbers like that, there's a cascade through the

02:03:58.100 population. And it doesn't have to be like this, that our burdens of trauma just grow and grow and

02:04:04.400 grow. We should be appalled by that number, appalled enough to do something about it.

02:04:12.040 Paul, a lot of times we treat people based on the symptom of their trauma, or we at least

02:04:18.800 categorize them that way. And this is even within the lens of helping people and acknowledging their

02:04:24.120 trauma. So for example, addiction is a very common manifestation of trauma. And the most obvious

02:04:30.720 of those, or at least the one that probably gets most people's attention would be substance addiction,

02:04:35.740 alcohol or drugs. But there's work addiction, there's process addiction, there's gambling addiction,

02:04:40.920 there's sex addiction. There are actually lots of other types of addictions, but we could bucket

02:04:45.420 those as addictions. There's codependencies, there's anger, perfectionism, other means of control.

02:04:54.120 We talked about eating disorders. It seems that one way to think about this is treating people

02:05:02.860 together who have similar end states. So you go to a 12 step meeting because if it's AA, it's people

02:05:11.180 with alcohol, if it's Al-Anon, it's family members of people with alcohol, if it's NA, it's narcotics,

02:05:16.820 if it's SA, et cetera, it's sex. Has anyone ever thought about doing the opposite? Which is rather

02:05:22.260 than take everybody whose issue is alcohol addiction and having them come to a meeting, which by the way,

02:05:29.380 I'm not advocating against, what if we bundled people together through the common lens of what

02:05:33.980 the trauma was? Is that something that's ever been thought about? And would that be more or less

02:05:38.360 efficacious than the current approach? In other words, you have a meeting which has lots of people

02:05:44.460 in it who have very different manifestations of their trauma. You're going to have someone who's

02:05:49.700 addicted to alcohol, someone who's a workaholic, someone who's a rageaholic, someone who's a

02:05:54.160 completely codependent, someone who's got debilitating anxiety, someone who's got debilitating

02:05:57.940 depression. But what they all have in common is they were completely neglected by their parents.

02:06:03.160 That's their common theory. Would there be any advantage to doing that? Or is it better the way

02:06:07.400 we typically think of doing it? Yeah, I think there's a huge advantage

02:06:10.820 to that. And when at one point I was medical director for a clinic and we had programs running

02:06:17.580 for helping groups. By and large, it was all around substances, but I wouldn't separate it by

02:06:25.360 what the substance was. I think we even get that fine. Now we're going to separate by what the

02:06:29.600 substance is. Alcohol versus narcotics.

02:06:31.900 Right. And even at that level, let alone at the higher levels of this person is angry,

02:06:38.280 this person is addicted to unhealthy foods. There's so many ways in which the addictive

02:06:43.100 processes can take hold of our brains in order to provide some short-term sense of control

02:06:48.180 or short-term relief from the desperation of feeling out of control. And when we parse that

02:06:54.820 out too much, then again, we're just trying to check boxes. And we're telling that person

02:06:59.380 that what you have, this thing that is in a sense your burden to carry is so much about you, right?

02:07:07.300 I'm an alcoholic and I'm a rageaholic. And just the very language we use about that is often so

02:07:12.980 stigmatizing. That's the thing that's bad about you. That's often the message. And again, not always,

02:07:18.240 but that's often the message that it sends as opposed to like, none of us comes out of the womb

02:07:23.780 an alcoholic or a rageaholic or addicted to unhealthy foods. Then you have like, look,

02:07:28.480 what's happened to us along the way that leads us to this place? And that's how we make a search

02:07:33.440 for commonality. So we have a set of processes that want to further parse things out, right?

02:07:39.560 We're so overly reductionist that oftentimes we would see where the person who was an alcoholic

02:07:46.080 would feel like, well, I don't want to sit in a room with the person who's addicted to cocaine.

02:07:50.060 As if there's like nothing in common, as opposed to like, yeah, what is in common? Because I knew

02:07:56.000 the health histories of those people, right? Because I was the medical director of the clinic.

02:08:00.300 And I would say, right, what is 80% commonality as a driving force amongst everybody is trauma.

02:08:07.480 And that's just here, if you step further back, you see that across the things that we get short-term

02:08:13.440 relief from at the expense of our long-term health. And the over-reductionism, I think,

02:08:19.520 is a facet of wanting to just put things in little buckets and then gaining some satisfaction from

02:08:24.460 that. But now, okay, now all it is is in a bucket and actually being in that much of a bucket,

02:08:29.960 you know, like a marble that goes down, right? Is like, now you can't get to it or you can't get

02:08:33.780 to what's real about it instead of like, you know, what's going on in a lot of people say,

02:08:38.340 at least is trauma. Can we put those people together and look at trauma, which ironically is

02:08:43.980 what the real sophisticated helping resources around trauma are doing? I mean, that's often

02:08:49.440 what, say, the bridge to recovery is doing. It's looking at like, hey, what is your trauma?

02:08:53.440 And like, okay, now let's go forward from there. But, you know, that's because they're bringing a

02:08:58.220 sophistication to it. And people who do that work just reflexively know that. They know that that's

02:09:03.600 not different. You can look at people who are addicted to one thing versus another,

02:09:06.920 and you're not finding massive differences between them. And, you know, the aspects of our,

02:09:12.560 the science of it all catching up with it shows that. It's hijacking the same machinery in the

02:09:17.400 brain. And, you know, you can't tell the difference. It's not like one substance looks

02:09:20.660 different from another in the brain or one thing a person is addicted to for relief of distress. So

02:09:25.780 it's like, we know all of it, but we have these entrenched ways of looking at it through the lens of

02:09:31.940 how medical care is or how society views it. And we're so far beyond the science.

02:09:38.300 And I will say this a fair amount that if you're in a very well-defined field of medicine,

02:09:44.780 let's say cardiology or so, where we kind of know how to assess people, how to understand people,

02:09:49.160 there's a lot of data behind the interventions. If you're practicing even just a couple of years ago,

02:09:54.160 like that's not okay. And one will identify that and that's not okay, right? We'll have to change

02:09:58.660 that. But in mental health, the practice within individual practitioners and the systems can be

02:10:05.400 antiquated by a half a century, you know, or a couple of thousand years in some cases. And like,

02:10:11.100 we don't come in and look at that. There are programs that are taking care of people for opiate

02:10:16.360 dependence that don't even talk to them about a medicine that you can get a shot of that prevents

02:10:21.420 you from overdosing when you leave. Like it's somehow okay not to even talk about that

02:10:26.660 because we let all of this lag behind. And yes, part of it is I think how the field has handled

02:10:34.440 it and the sciences and is well-developed, but it's not like there's no science. And it's not

02:10:38.780 like there's no obviousness to what we could be doing that we're just simply not doing. And I think

02:10:45.760 a big part of that is the stigma, the shame that we don't want to come in and look at all of it

02:10:50.540 and say, there's an obvious here that we're just not paying attention to. Because if the shame is

02:10:55.380 shot through humans, then it is also shot through the humans who are making those decisions around

02:11:00.620 resource allocation and how do we approach the helping process.

02:11:07.580 Changing gears for a second, Paul, the final thing I want to kind of ask you about is

02:11:10.900 the role of two substances in particular, psilocybin and MDMA, both of which I've talked

02:11:16.760 about in previous podcasts as they pertain to trauma. I'm curious as to what your experiences

02:11:22.600 with this and maybe more importantly, what is your optimism around these two molecules,

02:11:29.940 both of which are really moving quite along a pathway towards a clinical approval, a legalization

02:11:37.740 for clinical use. In the case of MDMA, it is for in fact PTSD. So kind of curious as to whether you see

02:11:45.960 that as an amazing adjunct to what we're talking about or a slight adjunct or potentially less.

02:11:54.080 I see it as among the brightest sort of shining hopes for the future. And I think the data,

02:12:02.920 both from decades ago and the more recent data and the clinical experience in trials and the firsthand

02:12:10.240 reports, they tell us things that are so incredibly powerful and that fit with a lot of what we've

02:12:18.420 thought about and understood about brain biology and about psychology, right? There's a way in which

02:12:24.320 it provides so much greater potential for understanding and helping. And of course,

02:12:31.220 the process is in place so that these very, very powerful tools can be understood and deployed safely

02:12:36.460 and effectively. And in the context of all of that, I think that the hope is immense. And a story I'll

02:12:43.340 tell sometimes to try to capture that is where I grew up was close to the Delaware Raritan Canal.

02:12:49.440 In colonial times, it ran between New York and Philadelphia. It was part of a network. And I was

02:12:55.340 always fascinated that artifacts would be found. There's somebody to be fishing and find a vase or

02:13:00.180 something, right? And I was amazed, right? These barges went up and down. I'm like, what's in there,

02:13:04.500 right? And people would find things and that was interesting. But then at some point in time,

02:13:09.920 they drained a whole section of it. And when the section was drained, my goodness, what they found

02:13:14.700 and what they saw, right? And it's the same kind of analogy that I think the helping powers of these

02:13:20.020 substances are so strong that they can get us to places of really seeing what's going on inside of us

02:13:28.200 and shifting how those brain pathways, which have been so changed. And again, the science tells us

02:13:34.000 this. This is not esoteric. We have more science that is similar to what the CAT scan can do for the

02:13:40.780 appendix to see that being able to do that with these helping modalities allows for understanding

02:13:48.360 and is so predisposed to and is permissive of change in ways that can let people reorient much,

02:13:56.520 much faster. So I think there's a potential here for even a revolution within the field,

02:14:01.520 but we have to safely and effectively incorporate those arrows into the quiver.

02:14:07.640 And then we see, of course, what is often seen, which is many of the people or organizations wielding

02:14:13.260 that have the magic amulet of like, I am the source of the helping resources don't like this.

02:14:19.360 So we see some aspects of traditional psychiatric care that don't like this. And I think that's

02:14:24.640 through a sense of threat that I think the power of these resources make a lot of the tools that I

02:14:31.100 wield seem maybe a little bit paltry in comparison. Now, that's not always the case. And if that is the

02:14:38.580 case, wonderful, right? There are new powerful tools coming to the fore. We need to approach it,

02:14:44.960 those of us in Western medicine, through a lens of being respectful of what that is and wanting to

02:14:51.980 understand the new modalities and approaching it from a lens that says, look, if I'm going to help

02:14:57.060 people or I'm going to hold myself forth as knowing how to do so, then I better know what all the arrows

02:15:02.740 in the quiver are and understand them enough that I can either deploy them or I can understand who can

02:15:08.060 deploy them in a way that does justice to the person coming in the door. If I'm coming in the

02:15:14.460 door for help, I don't care what it is. I want the person who's going to help me and have all the

02:15:18.440 possible arrows in their quiver. And I think we can get to a place of incorporating this.

02:15:24.560 But again, society and the helping systems have to bend a little bit to acknowledge the incredible

02:15:31.280 potential. And then we work towards integrating instead of splitting. And we're in a societal mode in

02:15:36.620 this country that's very much splitting, whether it's sociological, it's political, even medical,

02:15:42.400 right? Again, I come back to the basic theme of, I think it's trauma that leads us to reject new

02:15:47.860 helping resources because they may be threatening to our power within a discipline. And that by regrounding

02:15:53.440 to really the first principles of knowledge and of helping, then I think we again come back to an

02:15:59.720 urgency to ground ourselves to the basic common sense of understanding everything that can be helpful

02:16:05.340 and having all of those arrows in the quiver of health systems or of, to the extent possible,

02:16:11.120 individual practitioners. Paul, as always, it's great to sit down with you, especially in a case

02:16:16.400 like this where it's not just me you're talking to, but so many other people who I suspect will

02:16:20.740 really benefit from this. Tell people again the title of your book and other places they can

02:16:25.800 look to find resources. Sure. So the title of the book is Trauma,

02:16:30.000 The Invisible Epidemic. And you can find it if you just Google me, Paul Conti, or the clinic I work

02:16:36.040 in, which is Pacific Premier Group. You'll come up with links that talk a little bit about the book or

02:16:40.160 the principles contained therein. And there's so many good helping resources around. NAMI

02:16:46.420 is one of them. And sorry, what is that NAMI? What's that?

02:16:49.940 Yeah. So N-A-M-I. So a great access to resources often on a local level. There's so much help to be

02:16:57.620 had. And some of that help we can access in our own homes. We can access through people that we love

02:17:03.380 and who love us. We can access by thinking about what's going on inside of us and others. And I think

02:17:09.280 that's such a part of the message that I want to deliver that it just isn't esoteric. And if we ground

02:17:15.580 to what's really going on inside of us and paying attention to it, and in a sense, being brave enough

02:17:21.100 to face it because we see hope in facing it, that we can begin a process of really helping ourselves

02:17:27.540 and others. And I've just seen that unfold so, so many times, including in myself, that I really

02:17:33.060 believe in it. And I'm so glad that we've had this conversation that is about some of the real big

02:17:38.660 picture of it and the more kind of rarefied medical aspects of it. And I think a real understanding

02:17:43.920 of it runs the whole gamut, but is ground in that simplicity of what's really needed and what's

02:17:50.700 important to help ourselves and to help other people. And I so appreciate you having me on and

02:17:56.060 having such a good friend who's also such a good colleague and helps this discussion unfold in a

02:18:00.920 way that really helps get the message out there because we all need the message.

02:18:06.220 Thank you, Paul.

02:18:06.880 You're welcome. Thank you.

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The Peter Attia Drive - January 10, 2022

#190 - Paul Conti, M.D.： How to heal from trauma and break the cycle of shame

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