Dr. Paul Conti: Therapy, Treating Trauma & Other Life Challenges | Huberman Lab Podcast #75

- Welcome to the Huberman Lab Podcast,

where we discuss science and science based tools

for everyday life.

[upbeat rock music]

I'm Andrew Huberman,

and I'm a professor of neurobiology and ophthalmology

at Stanford School of Medicine.

Today, my guest is Dr. Paul Conti.

Dr. Conti is a psychiatrist

who did his training at Stanford School of Medicine,

and then went on to be chief resident

at Harvard Medical School.

He now runs the Pacific Premier Group,

which is a collection of psychiatrists and therapists

focusing on solving complex human problems,

including trauma, addiction, personality,

and psychiatric disorders.

Today, we discuss trauma in detail

and the therapeutic process in detail.

For instance, we discuss what is trauma?

How do you know if you have trauma?

Dr. Conti shares with us, for instance,

that not every experience that we think is traumatic

is necessarily traumatic

and yet many people might have trauma

without even realizing it.

We also talk about the therapeutic process generally,

for instance, how to pick a therapist,

how to best approach and go through therapy

and how to evaluate whether or not therapy

and your relationship to the therapist is working or not.

We also talk about self therapies because we acknowledge

that not everyone has access to or can afford therapy.

And we talk about drug therapies,

for instance, antidepressants, antipsychotics.

We talk about alcohol, cannabis,

ketamine and the psychedelics, including psilocybin, LSD.

And we talk about the clinical use of MDMA

and what the future of that looks like.

The reason for bringing Dr. Conti onto this podcast

is because I see him as the person

who has the greatest and most holistic view of therapy,

trauma, drug therapies, talk therapies,

and how self therapy and work with others can be integrated

for both healing and growing from difficult circumstances.

Dr. Conti is also the author of an exceptional book,

entitled "Trauma: The Invisible Epidemic,

How trauma works and how we can heal from it."

That book describes trauma

and its many features and many tools,

some of which we discuss on the podcast today.

So whether or not you have trauma or not,

by the end of today's episode,

you will have a much deeper understanding

about what trauma is.

In fact, I'm confident that you will gain insight

into whether or not you have trauma or not,

whether or not people close to you have trauma or not

and the various paths to recovering and indeed growing

from trauma that we can all take.

As you'll soon learn Dr. Conti

is an exceptional communicator and has a unique window

into the trauma and therapeutic process

that I know that all of us can benefit from.

Before we begin,

I'd like to emphasize that this podcast is separate

from my teaching and research roles at Stanford.

It is however,

part of my desire and effort to bring zero cost

to consumer information about science

and science related tools to the general public.

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And now for my discussion with Dr. Paul Conti.

Paul, thank you so much for being here today.

- Thank you so much for having me.

- I've been looking forward to this

and I've received a ton of questions about trauma,

about therapy,

about how to assess where one is in their own

arc of problems and addressing

familial issues and relationship issues and so forth.

If we could just start off very basic

and just get everyone oriented.

- Sure.

- How should we define trauma?

We all have hard experiences.

Some of them, we might ruminate on more than others,

but what is trauma?

- To make the definition relevant,

I think we have to look at trauma as not anything negative

that happens to us, right?

But something that overwhelms our coping skills,

then leaves us different as we move forward.

So it changes the way that our brains function, right?

And then that changes evident in us

as we move forward through life.

- So how do we know if we have trauma or not?

I've heard before everyone has trauma.

For instance, I've heard

that if we are a child or when we are a child

and we request love from a parent or attention

from a parent,

if they dismiss us that that's a microtrauma,

is that overstating or unfair to the real issue of trauma?

Do we all have trauma?

What are micro traumas?

What are macro traumas?

- Right, I think traumas

that we might categorize as disappointments, right?

Or things that are are negative,

but not deeply impactful,

I think is not a helpful definition, right?

I think the helpful definition is something that rises

to the magnitude of really changing us and something

that we can see both in how we behave.

We can see it in mood,

anxiety, behavior, sleep, physical health.

So we can identify it

and we can also see it in brain changes.

So the fact that we become,

say more hypervigilant, right?

More vigilant,

and then we can see that different parts of the brain

are more active.

So that definition,

that definition captures how trauma,

if it rises to a certain level, like what we would say,

trauma that makes a post trauma syndrome, right?

Leaves us different,

I think is the helpful definition of trauma

because it's a clinical definition, right?

It's changes in us as people

and we can map those changes

to identifiable shifts in our brain function.

- So how do we know if we've been changed by something?

I mean, I can think back to childhood events

where some kid on the playground

or in the classroom said something,

I didn't like, something negative about me.

I think most people can do that.

We have a great memory for the kid

that said something awful,

or the parent or teacher that said something awful

that really felt like it hurt us or at least stuck with us.

So clearly one's brain,

my brain in this example has been changed

by that event such that I remember it,

but how do we know if something

has actually changed the way that we are?

Because of course we don't know how we would be otherwise.

- Right, right.

- That's difficult, right.

It's doable, but it's difficult because the response,

so if the trauma rises to the level of changing our brains

and I don't just mean, like we have a new memory, right?

So we can have memories

of something that was negative, right?

And in that sense,

it changes the brain because

now there's something we can call to mind,

but it doesn't change the functioning of the brain, right?

If trauma rises to the level

of changing the functioning of our brains,

then there's almost always a reflex of guilt and shame

around the trauma that can lead us

and often leads us to bury, right, to avoid it, right?

To feel that now there's something negative inside of me

and it feels shameful

or it feels like no one else would accept it, right?

So, what happens is people tend to avoid

looking at the change in them,

which is exactly the opposite

of what needs to be done, right?

The idea of in a viral pandemic, right?

We want to stay away from one another and isolate, right?

But with the trauma epidemic we need,

we need to communicate with other people.

We need to communicate and put words to what's going on

inside of us.

And very often a, a person knows, I mean,

I've done so much clinical work over about 20 years,

that has focused on trauma.

And a lot of the times the person knows, right?

But they're not admitting to themselves

because they're afraid of it, right?

They don't know what to do, but if they start talking,

then they'll talk about the event or the situation.

It could be something acute,

or it could be something chronic,

that really has been harmful to them, right?

And then they feel different afterwards.

Like, oh, after that,

I started thinking differently, feeling differently,

but that doesn't always happen.

Sometimes it's a process of exploration

through dialogue, right?

Whether it's written or whether it's spoken

of the person,

so of exploring the changes inside of themselves,

maybe changes to their self-talk inside,

changes to their thoughts about the world

and whether they can navigate

safely and readily in it.

And you know, it anchors as I talk about this,

the example I'll use at times is the example of my own life,

where, you know, when I was much younger

in my early twenties,

my younger brother took his life by suicide.

And the response of guilt and shame

and hiding all of it inside of me was,

it's very dramatic,

but I wasn't acknowledging it, right?

'Cause I didn't know what to do about it.

And I felt guilty and I felt responsible and I felt ashamed.

So there was an avoidance inside of me.

And then I wasn't saying to myself, hey, before this,

like you thought that you could be effective

and you could make your way in the world.

And you know, if you were a good person and you worked hard,

you could make a difference, right?

And then afterwards, I thought, I can't get anywhere.

The world's against me.

And I felt like, oh my, my options are all gone.

And you know,

I was like 24 years old, right?

So, I didn't see that the change was in me,

but I was taking care of myself poorly.

Like there was enough going on that was unhealthy

that I couldn't avoid the realization that like, hey,

I'm different now and in these ways that are automatic.

My reflex to, can I make my way in the world?

Can I have a good life?

Can I be happy?

My reflex is to that we're all different.

And they were coming through the lens of heightened anxiety,

heightened vigilance, a sense of guilt,

a sense of shame and a sense of non belonging

in the world

and was ultimately good and helpful people around me

and my own realization.

And hey, things are not going well, right?

That led me to then get some help

and to be able to talk about it

and realize like, oh my gosh,

I need to face these things

that are going on inside of me.

- From a psychoanalytic psychological,

and maybe even a neuroscience perspective, two questions.

Why do you think that when we experience trauma,

these things that we call guilt and shame surface?

Everything you're telling me is that in the end,

that's not adaptive.

- Hmm.

- [Paul] Why would we be built that way?

- Right, right.

- So that's the first question.

And then the second question is,

how should we conceptualize guilt and shame?

I think that we hear guilt.

We hear shame.

How should we think about it?

I mean, those emotions must exist in us for some reason,

but in this case, it seems like they,

they don't serve us well.

So maybe it that order or in reverse order,

what is guilt, really?

What is shame really?

And why is it that we seem to be reflexively wired

to feel guilty and feel ashamed when that's the exact

opposite of what we need to do in the case of trauma?

- Right, right.

No, I think these are great questions.

And I don't think anyone knows the answers for sure.

But my read of all of that is that there's something

adaptive that has happened in us

through evolution that now becomes maladaptive

in the way we live in the modern world, right?

So if you think of through most of human development,

people weren't living that long, right?

And the idea was to survive and reproduce.

So, traumatic things that happened to us,

it would make sense for them to stay with us, right?

So if you ate a new food and got really,

really sick, you better remember that, right?

If you see someone from the group of people,

a couple miles away, right?

And one of those people attacks you, right?

It's like, you better remember that.

So, the traumatic things

that are sort of emblazoned in our brain

are built to last, right?

Things that are positive will generate

some emotion inside of us,

but things that are profoundly negative

are much more likely to stay with us.

And I think that that was adaptive, right?

When all of that was about survival, right?

And I think the same thing is true with say shame, right?

So I think here, it makes sense to talk a little bit

and actually I'm interested your thoughts about this, right?

That the limbic system, right?

So the system often is called the emotion system, right?

In our brains has actually of course

varying function, right?

And one aspect is affect, right?

So affect is aroused in us,

which I think the meaning then

is it's created in us without our choice, right?

So if we're walking down the road

and someone jumps in front of us or pushes us, right?

Then there's a response of fear, anger, right?

Heart starts beating faster,

more blood to the muscles,

we're getting ready to fight, right?

Or run, right?

And then we become aware of it, right?

So, the aroused affect in us is also about survival

and it has a very deep impact upon us

and shame is an aroused affect.

So it can be raised in us without our choice

and it's very powerful,

which if you think about that

is an extremely strong deterrent, right?

So if you had, you know,

imagine a tribe or a group of people, right?

That are sheltered together, and, you know,

someone eats half the food at night or something, right?

And like there's a very negative response, right?

And that person feels shame because shame is so powerful

to control behavior, right?

So the way that trauma can change our brains

and stay with us in a way that says, be more vigilant,

look at the world in a different way,

act more defensively, right?

And how that links to shame and to guilt,

and then guilt in,

guilt becomes what gets called feeling technically

where we relate the aroused affect to ourselves, right?

So, shame the aroused affect and guilt,

the next step, right?

When the shame gets related to self are such profound

behavioral interventions and deterrents, right?

That you can see,

I think how evolutionarily kind of all makes sense

if we're fighting for survival

and we're an elder statesman if we make it to 20, right?

This makes sense.

But it doesn't make sense in a world

where we live much longer, right?

We navigate in all sorts of different ways.

And there's so much coming at us that can be traumatizing.

I mean, if you think about the news, right?

I mean, how many times have I written a prescription

for someone that says no more news, right?

- You've actually written those prescriptions?

- Oh, yes, yes.

So glance at the news, look at the news for news,

anything going on I need to know, right?

But what are people doing is looking at it

and they're clicking and they're clicking.

And there's a sense of being like enthralled

in a very frightening way with the horrors

that are in front of us.

And it shows how yes,

trauma can come through acute things that happen to us.

Trauma can come through chronic things, chronic denigration,

whether it's based upon socioeconomic status,

immigration status,

race, religion, sexuality,

gender identity, these chronic traumas, right?

Of being denigrated by the society around us,

or treated as less than can change the brain.

But vicarious experiences can too, right?

And we know this is not theoretical.

We know that the changes in the brain

can come from vicarious experiences too,

which is why people who are glued to the news

and then feeling like, oh my goodness,

like what is happening?

The mothers in the Ukraine who've

lost babies in the war.

And like, there are things that are so terrifying

that if we spend so much time with that,

it has a similar effect.

So our brains are built to change from trauma,

but not in the way we experience trauma

and not in the way that we live life

in terms of the nature of living life

and the duration of life in the modern world,

where these traumas that happen to us

are often so bad for us

because they change how our brain is functioning.

And then our entire orientation

to the world is different

and that could be for,

years and years and decades and decades.

It brings so much misery and suffering

and at times it brings death.

If you think about a hundred thousand overdose deaths

in this country in a year, 100,000,

I mean where is a,

so much of that arising from is a person who's treated

addiction very intensively over many years.

I think that, well,

I feel sure that the majority of addiction

that I see and treat arises,

ultimately the roots of it are in trauma and are in trying

to soothe something that's stuck inside that the person

isn't letting outside because of the guilt and shame,

but it's running around in their head

and tormented by it.

And now there's a pool for,

for these drugs or sometimes medicines to soothe.

So, the opiates

that were given after a minor surgery, right?

Are like, okay, yeah,

they help the pain for the minor surgery,

but what they're really helping is the pain inside, right?

But that very quickly turns into addiction, danger, risk.

And we see that over and over again

and not in a theoretical way.

Like I see that in people who have been in my practice

with addiction, arising from trauma

who have subsequently died.

So it's sort of, writ large in our existence,

in the modern world.

- Incredible to me that this is the way it works.

What I mean by that is

this idea that I've heard about before.

I think it was a Freudian concept

of a repetition compulsion.

- Yes.

- That this is what boggles my mind,

as I'm hearing this,

something happens to us or we observe something traumatic.

And instead of acknowledging that

and trying to distance from it,

there seems to be a reflex of shame and guilt

in many cases and stuffing it away

and then a repetition of behaviors

to continue to try and just stuff it away.

- [Paul] Yes.

- Like you're trying to pack, I don't know,

recently I was packing a home and trying to get a sleeping

bag back into the bag.

it seems like it's always trying mushroom out the top,

this kind of thing.

It takes a lot of ongoing effort.

And at the same time that if this thing really exists,

this repetition compulsion,

people will return over and over again

to the kinds of scenarios or at least the kinds

of emotional states that look just like the trauma.

- [Paul] Yes.

- Or resemble it in some way.

So the question I have for you is,

is the repetition compulsion a real thing?

And why would we be wired that way?

My understanding of this concept of the repetition

compulsion is that we all want to solve our traumas.

- [Paul] Yes.

- And it allows us to put ourselves into micro or again,

macro versions of that over and over again.

We get to run the experiment again and again.

- Right.

- In an attempt to solve it.

- Right.

- In the case of taking a drug

that it's clear certain drugs like opioids,

it's clear how that would not allow us,

to deal with it, right?

- [Paul] Yeah.

- It's just masking the emotional state.

But why is it for instance that somebody

who experiences sexual trauma,

then places themselves into circumstances

of more sexual trauma?

Why is it that somebody who is in an abusive relationship

goes on to have a second and third or fourth verbally,

or physically abusive relationship?

Yeah, I mean, on the face of it, you just go,

that makes no sense.

And yet we see this over and over and over again.

- Yes, the first thing I would say

about the validity of the repetition

compulsion concept, right?

Is a strong yes.

Like, yes, we see that over and over.

It's not necessarily in everyone, but boy,

it is in a lot of people who have suffered trauma.

And I think there's a very good reason on the face,

on the surface of it, it's like, it makes no sense.

But then if we think, well, how does the brain,

how does our brains actually function, right?

We're sort of trained at least in Western society,

I think, to think of ourselves as logical creatures, right?

That like, oh, we're logical.

And ultimately everything in us can just boil down to logic.

And if we think about it enough,

we're going to understand how to make the right decisions,

which is completely not true, right?

The limbic system, right?

The emotion system so to speak inside of us

always Trump's logic, right?

If you think about,

does it ever make sense to run into a burning building?

I mean, logic says no, right?

But if someone you love is in the burning building,

people run right in, right?

Because the limbic system says, yes.

So when logic and emotion come head to head,

emotion wins all the time.

If emotion is powerful enough,

it will always win.

And so the limbic system is so important and the limbic

system does not care about the clock or the calendar, right?

And that's the answer.

And also, say why

to the repetition compulsion.

So the limbic system doesn't know like,

oh, it's now, it's today.

It's may, it's 2022.

It just doesn't care at all, right?

So how I would relate that to the repetition compulsion

is when people are repeating,

what they're trying to do is to make things right, right?

With the idea that if we can repeat the situation

and make it right, it will fix everything, right?

Which makes perfect sense if we think,

well, where is that concept coming from, right?

It's coming from the emotional part of the brain

that wants relief from suffering of the trauma

and does not understand the clock or the calendar.

So if I can solve something now,

I will also solve something in the past, right?

Which is why I can't tell you how many times

I've sat with someone and say,

we're starting to do therapy, right?

And a person will say, oh gosh, like I know, look,

you just can't help me, right?

I mean, you know,

my last seven relationships have been abusive, right?

And I'll say back something sometimes like, well,

if you tell me that you've had seven relationships

that have been abusive in different ways,

I'll agree with you.

Like, I only say that,

'cause that's never what someone says, right?

But I think what you're going to tell me is you've kind of had

the same relationship seven times.

It's not seven things, it's one, right?

And that's always, I don't think one time yet

that has failed to be the case.

And that's how, so if you think about it,

that's how we start to elucidate what's going on.

So they make the light bulb that goes off.

Like I have not had seven different abusive relationships.

I have had one that I have repeated seven times

and now we start getting to what's really going on

and what needs to happen,

that person needs to face what happened in that original

abusive relationship

and it always comes down to the same sort of concepts,

of the person feeling terrified

while the abuse was going on,

feeling guilty, feeling ashamed, feeling like, oh,

they brought it on themselves.

They deserve it.

They don't deserve anything better, right?

Because the brain is trying to make sense of it, right?

Or I thought I could make that okay, but I couldn't, right?

And then there's more guilt and more shame.

And if that's stuck inside of someone,

like that's bundled up inside of someone,

like a medical abscess inside a person,

a walled off infection inside the body,

this is the same concept in the brain,

then of course the limb system is going to want to fix that.

And it fixes it by trying to let's recreate that situation

and make it right this time and that's, I mean,

I think that one of the best examples

of how the right approach of how like, let's look at that,

let's talk about that, right?

What's really going on there, wait, who should feel guilty

and ashamed is the person who is a abused

or the person who is abusing, right?

And we can get it what's going on inside the person.

And that's what changes that.

And then the eighth relationship can be entirely different

than the first seven, right?

And I see that all the time.

I mean, this isn't esoteric or soft.

Like I see that play out clinically over and over again.

And why do things get better?

Because we go to the trauma and we unlock it.

It's not hidden inside where it can control things, right?

We bring it to the surface

and we can take away its power.

- I keep hearing in this narrative

that so much of our reflexive response to trauma,

both emotional and in the repetition compulsion in terms

of behaviors is about some very deep attempt

to change the past.

- Yes.

- And in fact, in an offline conversation,

I recall you saying something about this, that,

the number of behaviors and thoughts and avoidance

of behaviors and avoidance of thoughts

that human beings put in to trying

and change the past.

- [Paul] Right.

- Is remarkable and eerie and maladaptive,

it sounds like.

- [Paul] Yes.

- And that really stuck with me

because I think we all want to feel like we're in control

of our future and how we feel in the moment.

And to some extent, it works for a brief while.

There's this thing that happened and it's just,

it evokes some internal arousal and then you have to know

what to do with that arousal.

And I think for many people,

including myself, there's this fundamental question.

Okay, the thought about the thing, the event or events,

plural, evokes this arousal,

this internal states, makes some people

feel sleepy and exhausted.

Other people feel really anxious.

Other people feel angry.

I mean that arousal has all these different dimensions

as you know,

and then there's this question of like what to do with it.

- [Paul] Yes.

And I'd love to hear a maybe even just

a top contour prescriptive of what do I, what does one do?

I'll even just put myself in it, what do I do?

So I'm feeling upset about something.

Should I feel like my options are healthy catharsis.

I could tell the story, feel it.

I could.

I can pack it down.

We hear that it's bad to pack it down.

But of course one has to be functional in life

and deal with things.

And we have responsibilities at work

and relational responsibilities, etcetera.

We need to sleep at night.

So catharsis, healthy catharsis,

packing it down at the other extreme.

Telling the story.

And yet I think a lot of people are afraid to tell the story

because in that telling

there is perhaps a reemergence of the arousal.

- Yes.

- The arousal can become greater, I mean.

- Yes.

- Is that what people mean when they say

things are going to get worse before they get better?

I mean, so I guess,

the simple version of this long-winded question is,

it's clear we need to confront these things.

We can't change the past by,

a reflexive response isn't going to do that efficiently.

And so how do we deal with arousal?

How does one take what they feel

inside about something shameful?

What do you do with it in a moment?

And does that have to be done in the presence of a skilled

trained therapist or as I'm driving to work

in the morning and something comes up,

I can't deal with this right now comes to mind,

what do I do?

Do I deal with it right then?

I know this is a big multidimensional question.

- Yes.

- But I think it's the one

that a lot of people grapple with.

We want to deal with things.

How do we deal with that internal arousal?

- Yeah, yeah.

We so often try and change the trauma of the past

in order to control the future

and what that really adds up to is the trauma of the past

dominates our present, right?

And it doesn't have to be that way.

And remember, we're talking about traumas

that rise to the level of changing the brain.

So as you're saying,

that involves re-experience, it involves hyper vigilance,

increased arousal.

It changes in mood states,

changes in anxiety, changes in sleep,

changes in behavior.

So these are all changes that in a sense,

push towards dominating our present, right?

And then we're not really living in the present, right.

As we're trying to control the future.

We're not going to do a great job of controlling our future

if we're not really living in the present, right?

And so the way to come at that again in the moment,

if we're saying, okay, in the moment,

if I need to fall asleep, right?

I might say, okay, let me try and put that out of my mind.

Let me try and thought redirect.

So there's short term strategies that can let us be

functional in the context of these changes.

But the answer is to go look directly at that thing, right?

Look at that trauma, explore that trauma, and sure.

That can be done with a professional.

And sometimes that's what makes sense,

but not always, right?

Sometimes it can be done

by talking to another person, right?

Writing it down, right?

Look at what's going on inside of me,

that my mind is so stuck to this.

Let's explore that because it's almost as if we're,

we're so afraid,

so often of looking at the trauma that has changed us,

that we'll look anywhere.

But at that, right?

It's like hidden in a closet

and we'll shine the light everywhere else,

but we're not going to open that door.

And that's where

people will say that same as I've heard over and over.

And I myself have thought this at times like, oh,

if I talk about that,

I'm going to start crying and never stop, right?

Or I'm going to just fall apart, right?

Which is never what happens.

No one ever starts crying and never stops, right?

What ends up happening

is when the person puts words to it, right?

It could be in writing,

it could be talking to a trusted other

or with a therapist, right?

Things start to change.

I mean, just the fact that you can talk about it,

you can put words to it

and other people don't recoil, right?

I mean, how many times has someone said

something for the first time, right?

And when they're telling me about the trauma,

there's such an anxious,

like looking like as if I'm going to be,

I'm going to recoil from it, right?

Meaning I'm going to recoil from them, right?

And then there's a sense of surprise if the person says,

well, you know, I was abused by

this coach when I was a kid, right?

And there's not a, okay,

there's not a response of recoiling.

You can see the change and people will say a lot, like, wow.

Like, I can't believe like you can like,

hear me say that and be okay with it, right?

I mean, so you think about what's going on inside of them.

Like how, what a sense of shame, a sense of,

this is something awful about me for people to recoil from

and it's just not true,

but here's where trauma is, it's insidious, right?

And it's pervasive, right?

Because if that convinces us to continually hide it away,

then how do we explore it?

That example of the person who says, okay,

I was abused by a coach when I was a child.

I mean, I'm thinking of a couple, very real cases, right?

People that I've taken care of.

And once they start talking about it,

then they start talking about how, ,

they were just innocent kids, right?

And like, they didn't know.

And like, they really wanted to be on the team

where this coach was treating them as special.

And now they can look at themselves from the outside, right?

They can look at themselves

like they would look at someone else, right?

You think it's so easy for us to see what's real and true,

if it's someone else, right?

If you ask someone,

what do you think of someone who's 10, 11 years old,

who's abused and manipulated and abused by an adult?

And you say, oh my goodness,

I feel compassion for that person, right?

But if it's us right then, oh no,

it's guilt and shame and we have to hide it away.

And when the person starts looking at it,

they can sort of see it from the outside.

And it starts to take the energy out of it, right?

Then, well, who should feel guilty about that?

Who's done something wrong?

And like, so now the conceptions come together,

which is often a reflexive, that was my fault.

Oh, I did it.

I went back to it.

I still stayed on the team.

I went back next season, right?

I let it happen again, right?

All the guilt and shame inside the person

gets juxtaposed to like, what really happened there?

And then they say, right.

I was a terrified child, right?

I didn't understand at all.

And they can come to a place of compassion.

And now we are working against the guilt and shame.

And if the person cries about it, then it's great, right?

I mean, crying is one

of the best coping mechanisms we have.

It doesn't hurt us.

And it lets us grieve things.

Yeah, we can't grieve if there's guilt

and shame inside of us,

it just blocks grief, right?

We have to,

there has to be a clean slate

in a sense in order to feel sadness.

And then you see that it shifts from anxiety, anger,

and frustration, usually directed towards the self,

the guilt and shame towards,

towards being able to process it and being able to bring

to bear some compassion and being able to direct

the negative emotions,

so to speak where they're warranted and my goodness,

the changes that happen.

I mean, it's not like people are miraculously cured, right?

But it's remarkable how just getting it out there

and having like one hour of talking like that,

like what we're talking about now

can leave a person feeling immensely better.

- It seems to me in hearing this,

that there's this weird wiring that we have,

because what I'm hearing is when traumas happen to us

or we observe them,

what we need to do most is to confront those

and the emotions around that directly.

- [Paul] Yes.

But instead our system defaults to guilt, shame.

- [Paul] Yes.

- And trying to hide it.

- [Paul] Yes.

And this repetition compulsion of placing us back

into things similar to those traumas.

Or even maybe even worse traumas.

- [Paul] Yes.

- In an attempt to resolve it.

It's like the most maladaptive.

- [Andrew] Wiring diagram.

I could possibly think of.

- Yes.

- Emotional and presumably

physiological wiring diagram.

- [Paul] Yes.

And this notion of trying to change

the past by doing things now,

when the exact opposite is what's going to be beneficial

also seems like the complete,

the whole system seems completely backwards.

And I'm, I'm chuckling as I say this,

not because I'm amused it's because I'm just baffled once

again at how our wiring can often not serve us well.

But it raises an,

what I think is an important and interesting question,

which is earlier, you were talking about how

people will seek out media that's really disturbing.

They'll traumatize and re-traumatize themselves

on a daily basis.

So that could be viewed as the repetition compulsion

or the person will have the same relationship

with seven different,

same abusive relationship with seven different partners

in sequence seems terrible.

And yet,

as I say this,

it also is becoming clear to me how this almost seems

like a poor, but desperate attempt

to resolve it in some way.

- Yes.

- And so the fork in the road, if I understand correctly,

is to really get to the seed incident,

really get to the thing that started it all,

as opposed to repeating it all.

- [Paul] Yes.

- Does that have to be done in the presence of a therapist?

Is there a benefit to taking a walk and thinking

about these things, breaking down and crying,

if that's what's necessary or feeling angrier,

if that's what comes up?

The reason I ask it this way is because I worry,

I'll just speak to my own experience,

I worry that in reactivating

or touching into the emotions around something

that is itself a form of the repetition compulsion,

because you're feeling it all over again.

- [Paul] Right.

- You're not seeking out something to evoke that feeling.

So I realize this is a little bit

of a circular argument, right?

Or question.

But I think it's one that I really struggle with

in trying to parse all the,

the outcome based therapies that I hear about

and the recommendations that people make.

I mean, how should we conceptualize this?

Something happens.

Sounds like we need to deal with that thing directly.

Do we need to do that with somebody else?

Can we do that on our own?

If we're,

we don't have resources and we have to do it on our own,

can't hire someone, can't pay someone to work with us.

- [Paul] Right.

- How do we do that in a way

that isn't retraumatizing ourself

in a major way, or in a minor way.

How do we know where we are in that landscape?

- Right.

Again, those are, I think, great questions.

And I think it starts with real introspection.

When things are bouncing around in our minds,

often, it's very, non-productive right?

It's the same thing over and over again,

and that's not helpful for us, right?

So there's an idea which sometimes

gets called an observing ego, right?

The ability to stop and look

at what's going on inside of ourselves.

And so if we're just thinking about it

and we're thinking in the same way,

we sort of, in a sense, always think about it,

then all we're doing is reinforcing the trauma, right?

But if we can distance enough to be like, huh, it's,

I'm interested in what's going on inside of me, right?

I can think of a certain person

who really loves music.

I mean, and at some point in our therapy work,

I learned like she was taking long drives,

but the, the radio wasn't on.

And I was like, well,

what what's going on, right?

And I asked,

and what was going on is she was running over

and over again in her head, like,

I'm a loser, I'm a loser, right?

And she didn't want the music on because the music would

drown out what she felt she had to say to herself, right?

And it was that like, wow, that's interesting, right?

And then her ability to observe that and to think,

why am I doing that when it comes into her mind?

Like, what does that trace to, when did I start doing that?

Like I say, you know,

I'm saying it for a point of exaggeration, we're like,

nobody comes out of the womb

programmed to think I'm a loser, right?

So we don't think that when we're born, right?

So where does that come from?

Then, we can think in ways

that allow us to have new thoughts, right?

That we weren't having,

It's not just bouncing around in our minds.

And if we speak or write,

there are even more mechanisms

that come online in our brains, right?

That are then sort of monitoring mechanisms.

We think in a different way, if we're using words, right?

And we are better able often to bring in that observing ego,

like what's going on inside of me?

So it can be very helpful to think,

it can be helpful to talk to someone,

to a trusted other, you know, friend, family,

clergy to write, I mean,

these are things that can be done

without expending any resources, right?

And sometimes it can make really a big difference, right?

It was a way, when did I start thinking that?

And like, interestingly, in this case, okay,

we did it in therapy,

but it became very clear what that was rooted to, right?

And then in the therapy,

which was still relatively young,

but we'd done several sessions

and we weren't talking at all

about what we needed to talk about, right?

But that's what got us to what we needed to talk about.

And when did that start,

and now we're in that same place of exploring that

and what was the reflex to it

and the sense of guilt and sense of shame.

And it's where all of that came from

that just got boiled down to I'm a loser, right?

Which this person didn't even have in their mind.

Like, I didn't think about myself that way, right?

And that's is so interesting, right?

That our memories don't in and of themselves have meaning

it's like they're flat or colorless, right?

And they're colored in by the emotions

that we attach to them, right?

So, the idea that certain memories now,

before the trauma were changed, right?

By the trauma.

So I tell the story,

sometimes of a person who like won an award

when they were in high school that they thought was,

oh my gosh, like it shows,

like I can do it, right?

I get out there, that after trauma,

they saw the award with the negative emotion attached to it.

That was like, oh,

it was given to me and I didn't deserve it.

And almost it was mocking.

Like, it was going to be the greatest achievement in my life

and I was 17 or so, and to have someone think like,

that's not how they felt about that at the time.

It's the trauma that changed, the self talk,

the internal state going forward

and talking about miraculous in a negative way,

also changed that going backward, right?

And when we can really look at that,

like where did that come from?

And we can start unraveling it, it changes.

So in those cases, you know, often it's helpful

to have a good therapist, it's not always necessary.

And it certainly, it's not always possible, right?

So we need other strategies.

And some of those,

I write about some of those in the book

of how can we sort of get at trauma

without those formalized mechanisms.

And sometimes if the symptoms are significant enough,

like we really do need to talk to somebody professional

who can help us get to the root of the trauma.

And there's so many times,

that's the answer to what's going on with people.

People I've seen have had five residential stays.

I'm not exaggerating this, for mental health reasons,

for substance reasons,

and no one's ever taken a trauma history, right?

And then when you take a trauma history, you say,

well, that's obviously where this is all coming from, right?

Like that's when the drug use started truly thereafter,

the negative self talk and the negative feelings

that led to the drug use.

Then you go after the trauma

and you can change things.

Whereas trying to change things without looking,

introspecting, talking about the trauma,

I think of course was futile.

- Do you think that people

can start to have negative fantasies?

I mean, you mentioned this woman

who would take these long drives to berate herself.

I'm not familiar with that, but I'll,

I'll give a little bit of personal disclosure here.

I've felt several times in my life

that I will start to create a narrative

about something that truly hasn't happened

about something terrible that somebody is going to do.

- [Paul] Yes.

- That's going to upset me.

- [Paul] Yes.

- And for the longest time,

I wonder why am I doing this?

And I have a couple ideas about why, one,

is that I was attempting to just avoid thinking

about other things.

It's just, you know, anger is such

an attractive emotional force in this.

It's an attracting, it's not attractive.

We don't like it.

And yet, oftentimes anger is a great way

to replace feeling something else.

- [Paul] Yes.

- Feeling sad or having to come up

or to do work or to do something useful.

So it has this kind of a like gravitational force to it.

That was one idea.

The other idea was in imagining kind of worst outcomes,

then actually that relationship were,

could actually seem a lot better in reality.

- Hm hm.

- [Andrew] It's almost like creating this negative contrast.

- Yes.

It's like, oh, well then it's not that bad.

And then the third possibility is I have no idea why,

but it seemed like a reflex.

And I spent some time thinking about it.

I can't say I've resolved it completely,

but why would somebody

have a narrative or a default narrative when driving

or when walking of I'm just going to spend some time

and think about how terrible this thing is going to turn out

or how someone's going to upset me

or harm me or how terrible I am.

It seems, again, like maladaptive thinking,

maladaptive wiring.

And yet I have to assume that it serves some purpose.

- Yeah, yeah.

I mean, I think there are three factors

there and they're all bad.

And I think you spoke to at least two of them, right?

They I think speak so powerfully

to how insidious trauma is and how these are real

brain changes inside of us.

So I would say that the three factors, punishment,

avoidance and control, right?

So the trauma inside of us,

that makes guilt and shame.

So often, so often leads

to a desire to punish oneself, right?

And the idea that, oh, that was my fault.

Or I deserve that.

Well, what do we do if something

is someone's fault and someone

now deserves punishment, right?

I mean, we we punish them, right?

We send 'em to jail, we give them a fine, right?

We punish them.

And so what, what we do is punish ourselves, right?

And if we tell ourselves we're a loser

or this awful thing is going to happen, right?

Then part of what we're doing is saying to ourselves,

see, right, you deserve that.

You're not going to have anything better, right?

It's a negative.

It's a very negative way that the brain tries

to make us in a sense,

to do better by hurting us more for the things

that we couldn't and shouldn't have been able to,

weren't expected to control in the first place, right?

The second is distraction.

As you said, anger,

that kind of fantasy can distract us

from affect feeling and emotion.

That can be much more negative.

Anger, it can be more gratifying

than certainly than guilt or shame,

although guilt or shame can serve a punishment purpose.

But if anger is directed also towards ourselves, right,

then it can serve punishment too.

So punishment, avoidance,

and the sense of control that if you think ahead

to something awful,

that you're imagining is going to happen,

well, maybe that will let you avoid it, right?

I mean, you can see the brain here in a sense,

really confused.

I mean, part of the brain wants to punish.

part of the brain doesn't want to think about it at all

and part of the brain wants to make it better.

And then how all of that resolves,

if we're not aware that,

hey, this is in the context of our brains

being deeply impacted by trauma.

So what's going on here is all maladaptive, right?

'Cause these negative fantasies of the future,

they may help us feel better about something in the present,

but they don't help us make anything better, right?

They don't help us make anything better.

So this is kind of the sequela.

This is where trauma and all this reflexive stuff

that happens after trauma ultimately lead us.

And you can see how we get lost,

how I've seen over and over again in my own life,

in the lives of other people,

how man we get stuck in those situations

and that's why I see people sometimes.

This has been going on for 30 years, 40 years, right?

And it's just been going on over and over and over again

because there's no natural end to any of this, right?

Unless we,

we look at it in a different way,

that we have knowledge and information like, whoa,

this isn't the way it has to be.

Let me bring a novel perspective to this.

It doesn't change on its own.

- I'm struck by your statement

that these thoughts or behaviors can make us feel better,

but they don't actually make anything better.

In that way,

this mode of imagining terrible outcomes

starts to immediately seem like taking opioids.

You feel better in the moment,

but it doesn't actually make anything better.

And it probably makes things worse.

- Yes.

- And just a question of how much worse

and in what direction, yes.

And so I just want to just pause on that concept,

because I think that concept of makes us feel better,

but doesn't make anything better.

I think it answers an earlier question

about what seems to be a totally maladaptive wiring diagram.

We need to confront the thing,

but we don't want to go into the repetition compulsion.

So it's a knife edge there,

to navigate through trauma.

- [Paul] Yes.

- Working with a very skilled clinician like yourself,

I think is the ideal circumstance for people.

And of course there are people who can't access support

from somebody, for whatever reason.

You've talked about journaling.

- Hmm, yes.

- As a useful tool.

Could you maybe highlight

some of the other things that people can do on their own.

And then I'd also like to talk about

what makes for a good therapist.

What should people look for

for those that are seeking therapy,

especially nowadays when a lot of therapy

is being done remotely, but let's just start with the,

let's just call them self-generated

or zero cost sorts of things,

journaling being the first

and then what are some of the others

and what kind of structure would you recommend

someone put around journaling,

carry a journal around all day and jot things down

as they come up or sit down

and spend an hour writing in complete sentences,

for instance.

- Yeah.

If I could add something to what you had just said

before the question, right?

That we have these short-term

coping mechanisms in us, right?

And in a way it makes sense, right?

If we find ourselves in just terrible situations,

then a short-term coping mechanism

can get us through them, right?

So our brains are built that way

and that's part of survival too, right?

And whether now in the modern world, whether it's food,

it's drugs, it's sex, it's alcohol, right?

Or it's negative thoughts, right?

This is short-term soothing.

Even the negative thoughts,

And anger is short-term soothing

at the expense of long-term change, right?

And that's where addictive pathways can come into play.

And that's where, again, our,

how we're built evolutionarily for survival,

doesn't help us, you know, in the way humans have evolved.

Like we haven't lived this way throughout,

99.9% something percent of human history, right?

So we're not adapted to this.

So I want to just make a point of saying

that about the short-term soothing

at the expense of any of long-term change,

And then the question you had asked about say journaling

or what can we do that's outside of professional.

I think the hallmark of it

has to be bringing new eyes to it, right?

Like thinking about self with a curiosity,

instead of just a simple automaticity or repetition, right?

Like, why am I thinking about this?

When did this start?

Why is this in me?

Right?

Whether it's words or whether we're writing,

that's so important.

So I think for journaling,

it depends on the person.

I mean, we don't want somebody carrying around

a journal all day,

if then there's a compulsion to,

I need to write about everything

that's going on in my mind, right?

Like that might be good to okay.

Write a little bit at night, right?

Or someone who might think,

sometimes this really comes into my mind in a strong way

and it could be unpredictable, right?

I want to have the journal with me.

So, ah, that thing is back in my mind now,

let me write about it, right?

Because then putting words to it

and then being able to read those words, right?

And when people read,

even do a little bit of journaling

and they read like, oh,

I thought again about how I'm a terrible person

who can't have a good life,

because I was in such a bad car accident

or because that person attacked me

or because when I was in school,

I was bullied because I looked different

than everyone else, right?

Or acted different from everyone else.

Wow, to actually see that written out.

It's a little bit of that,

it's a little bit of that.

Like when you're saying it to someone

as if it were someone else, right?

Because now there's enough distance from it.

Like I'm looking at the words I wrote, right?

That we get some distance and we can start to integrate

some of the, not just the compassion,

but integrating compassion and logic, right?

Of like, okay.

I feel a sense of compassion now, wait, what does this mean?

What really happened here, right?

And gosh, I did start thinking differently after that.

I started, that's where this came from, right?

That's why I'm saying this,

it's those kind of revelations that we can have

through again, the written or spoken word.

And I think again, that involves a trusted other,

or writing, right?

And I think that those are ways we can do this,

where we bring some de novo perspective to something

that often has been bouncing around inside of us.

And it's amazing to me that,

I can see such intelligent empathically, attuned people

who've had the same thing

running over and over again in their mind for years.

And it just points out that our brains

don't automatically say, hey, wait a second.

I've been spinning wheels here for a long, long time.

Like, was there another way to look at this?

We need something from the outside,

which can just be knowledge, right?

Which is why I think what we're doing here

or the reason I wrote the book that I wrote was like,

apprehending this like amazing surprise to me, right?

Which is like, wow,

like some huge percentage of everything I'm treating

is rooted in trauma and the opacity of trauma, right?

Which is why we don't see that, oh, the depression,

the panic attacks, the life change, the addiction,

the maladaptive choices like, oh,

this is all coming from trauma because it hides itself

in that opacity.

So we need a de novo perspective

if we're doing it on our own.

And we need that if we're doing it in therapy,

which might link like finding the right therapist, right?

Which is also part of your question.

- Yeah, yeah I definitely want to know

about how to assess and find the right therapist.

Before we cover that, however,

something came up in the course of your answer.

I can immediately relate to this idea that

certain behaviors are really maladaptive

and are stuffing things down or avoiding the topic

is problematic and bringing a curiosity

and an introspection and almost a third personing

of the experience

that we've had in order to try and address it

from a new, truly from a new perspective.

It occurred to me as we were discussing this,

however that some people, and yes,

maybe I'm talking a little bit about my own experience.

We have a sense of our own identity

and how people view us and our ability to be functional

in the world in ways that we like,

effective at work or a good brother

or a good mother or father, human being in the world.

We have relationships.

And I think that one thing that I have heard,

and maybe I've experienced is that sometimes those

maladaptive thoughts or behaviors,

the things that generate a kind

of a repetition of anger or of arousal or activation

or sadness, that we have some internal process

where we funnel that into a functionality in the world.

So we I'll give a more concrete example.

So in thinking about things that have upset me in the past

and in imagining bad outcomes in the future,

there's a certain internal state of arousal

that comes about.

And for many years, I was able to use that,

not to feel angry,

but rather to work an extra three hours a day

- [Paul] Right.

- Or to pack my schedule with work and social engagement.

So I could show up in a way that I,

hopefully was a very good brother to my sister for instance.

- [Paul] Right.

- So in a way it was a,

it was a transformation of something negative

inside of me.

- [Paul] Yes.

- Into a functionality in the world

that was actually very rewarding and beneficial.

- [Paul] Yes.

- And yet in describing it,

I can immediately see how it would be wonderful if I could

source from something else.

- [Paul] Hm- hm.

- And yet I, you can imagine,

and I can imagine how one would be reluctant,

maybe even terrified of giving up that source.

- Yes.

- [ Andrew] It's a fuel.

- Yes.

and I think in knowing some of the traumas of other people

and their reluctance to work through those,

obviously I'm not a therapist,

I sense this over and over again,

that one's positive identity

can often be linked to something difficult in their past.

- [Paul] Yes.

- And so people are reluctant to give up this fuel.

- [Paul] Yes.

- Because it it's in that sense, it's functional.

The only thing that allowed me to kind of start to address

this and why I'm still so curious about this,

'cause I don't think I've worked

through this process completely,

again, a little more self-disclosure there,

is that I was told that these words,

just imagine how much better it would be

if you could source from a different fuel,

a fuel that felt better.

- Right.

- Maybe it was on the, it was on this,

this sentence.

It was, maybe you could actually be

much more effective.

- [Paul] Yes.

- Maybe you could be 10 times the better brother.

- [Paul] Yes.

- Maybe you could have 10 times

more insight or work capacity, etcetera.

So it's on that hint of a promise that I,

at least I was inspired to start looking into these things

and reading about trauma in your book and elsewhere,

and start to think about this.

So again, I realize this is a long winded question

and a somewhat complex idea, but I think,

or I hope that people will be able to resonate with this

idea that sometimes we want to stay attached

to this short term soothing that the punishment

distraction or control because it evokes this arousal

and then we can apply that arousal.

- Yes, yes.

I think what you're describing maps

I think clinically to what gets called sublimation.

So there's something negative inside of us,

but we sort of transfer that energy,

we transfer that into something

that is adaptive or that is positive, right?

So the idea of the anger, right?

When I think of that thing and it makes anger in me,

I channel that into harder work, right?

Or I channel that into like,

I'm going to go be nicer to my brothers, some right,

something like that.

And there's validity to that, right?

But it can become like self justifying if a person thinks,

well, look at what this is doing for me, right?

I wouldn't work as hard without it.

Right now we start to become attached to the trauma.

Whereas I think what you had said is absolutely true

that just because we can sublimate

some of the negative affect, feeling, emotion

that comes from trauma into something

productive doesn't mean that that's best, right?

I mean we can get to our destination

by taking a very circuitous route, right?

We might waste an hour getting there, but we get there.

That doesn't mean that that's best.

And it also doesn't look at all the negative, right?

In this example, the wasted fuel, the wasted time, right?

We get somewhere, but we are not optimizing.

And I have yet to see one person

who has addressed the trauma

and become less functional, right?

It's always either, they're just as functional,

but they're happier, right?

Or more functional because as you said, like,

just because we may be able to sublimate, well,

maybe what's going on will be 10 times better, right?

If we weren't sublimating

because the sublimation limits us, right?

It limits our perspective to only what we can see

and do through the lens of the trauma.

And that is never better than the alternative.

- Thank you for that.

- Yeah, you're welcome, yeah.

- Let's discuss how one could

or should go about finding a really good therapist.

Typically in my experience, this is done by word of mouth.

There's this person you might want to work with them

and they're really great,

but what are some of the characteristics

that one should look for?

And should we take into account whether

or not we are a person who for instance,

I've heard this from listeners, although I'm clearly,

I'm definitely not talking about myself

here in cloaking something.

Some people will say,

I want to work with a somatic therapist because I've actually

heard someone say, I think in fields,

I feel stuff in my body.

So I want to work with someone

who can really acknowledge that

or someone else will say,

I want to work with somebody who has this orientation

or that orientation or is open to my particular lifestyle,

or isn't going to tell me that I have to leave my relationship.

I feel like people already show up to the question

of who to work with with all these, you know,

things internally,

some of which are voiced and some of which aren't.

So I'd love for you to talk about maybe some of the,

the core features of a really good therapist

and then how to look for a therapist.

And also how to think about oneself

in looking for a therapist.

- [Paul] Right.

- Because of these kind of predispositions.

- [Paul] Right, right.

Well, there's a lot of data about this

over the years,

if you look at what are the top 10

important factors to find in a therapist,

just repeat rapport 10 times, right?

I mean, that's the key.

And if you think about that,

it's pretty amazing, right?

Because therapeutic modalities can be so different, right?

And I think what that's telling us is, in a way,

something very obvious, right?

Like what does rapport mean?

Like, you know, it's somebody

that's paying attention, right?

It's trust, it's a back and forth.

It's like, yeah. even though I'm doing something difficult,

I'm doing it with someone who's really helping me,

someone who's in it with me, right?

Someone who's really paying attention.

Wants me to be better.

That's indispensable, I mean, it's just indispensable.

And I write in the book is someone,

a therapist not making eye contact

or this is the way they do it, right?

And you know,

you got to fit into the box of the way they do it.

That is not going to be helpful.

And then what I,

what I think about that is the different modalities.

It doesn't actually tell us that,

oh, the modalities are irrelevant.

I think that's not true.

I think that good therapists are not pigeonholed

by a certain modality.

They may come at the world largely

through a psychodynamic or a CBT or a DBT lens.

There's lots of different,

ways to do therapy.

But when you really talk to those people,

really good experience therapists,

it's all coming through the vehicle of the rapport,

but they're practically shifting to what the person needs.

I don't understand the idea that like, oh,

I just do this, right?

I don't do that.

And when people are pigeonholed that way,

I don't think they help their patients very well, right?

We have to be diverse enough to say, hey,

I want all the arrows in the quiver, right?

And even though there might be one that I favor and that's

the lens I see things through,

no, I can be versatile, I can shift,

I can adapt to what this person needs.

And I think if you have that, you've got to,

if you have that, you've got a winning combination.

- Great, so people should perhaps try a few therapists

and maybe have a session or two or three to see if they,

the rapport feels like it's taking root.

Is that?

- [Paul] Yeah.

- Do you have that right?

- Yeah, and I think that's why word

of mouth is important, right?

If someone you trust tells you,

hey, this is a good person that says a lot, right?

It already makes the pretest probability,

is quite high.

But yes, it's interesting to see

when like people have a therapist

or they called their insurance

and they're assigned a therapist.

This thought that like, oh,

that's the person I have to have now.

And it's like, no, you should look at that

like anyone you'd be interviewing, right,

for a job, right?

But you got to bring again,

the right set of thoughts to that to be helped, right?

Which is that I want someone who has rapport with me.

I don't want someone who's going to make it easy, right?

Who's like, well, it's, gosh, it's kind of pleasant,

because then that means they're not talking

about the difficult things, right?

So if one brings, like, I know this isn't going to be easy.

I got to talk about difficult things, right?

Even if one doesn't recognize

or I got to talk about the trauma in me, right?

But to go to therapy thinking, no, it's, I mean,

sometimes it's enjoyable, but a lot of times, right,

it's not, right?

It's hard work.

It can be excruciating.

We can cry during it, but to say,

right, that that's how I'm going to be helped.

And I want someone who's going to do that with me,

who's really looking at, what's going on inside of me,

how do we help me?

And I can feel sort of the robustness of that.

If one brings that approach and then looks at the therapist

through that lens,

you're very likely to then move on from someone

who's not a good choice, right?

And really stick with someone who is,

even though that doesn't mean it's always like pleasant

and enjoyable.

I mean, it has to not be that sometimes.

- Right.

Maybe we could drill a little deeper

into the mechanics of therapy.

I put out a few questions to audience asking what they want

to know about therapy and it was amazing.

I got hundreds, if not thousands of responses saying,

how should I show up to therapy?

So for instance,

should people take a five minute meditative drop in before?

Or should they just show up cold and let it emerge.

During therapy,

is it a good idea to take notes

or to not take notes and then post therapy,

how should clients,

patients as they're sometimes called, one or the other,

I never know which,

how should they process that information?

Should they take some designated time afterwards

and in an ideal world,

take a 30 minute walk afterwards and think about

the material or should they set it aside

and come back to it?

Of course there are constraints, work and family, etcetera.

But you know we,

there's a lot of knowledge out there about how to best show

up to a workout, warm up for five, 10 minutes,

then do this, etcetera and then the cool down.

I mean, here, we're talking about hard psychological work

aimed at bettering oneself.

So to my knowledge,

I've not ever seen this information anywhere.

It'd be very useful to hear, hear your thoughts on this.

- Yeah.

Well, I'm not trying to duck the question,

but I think it varies so much by person.

So if you think about the first part of your question,

I think was how to show up to therapy, right?

And I think the answer would be whatever

lets you be fully present when you're in therapy.

Now for some people that's going to be, I show up early,

I say it, I call myself, I meditate a little bit.

I mean, that's how then they're present, right?

For other people, you know, they just, they show up,

walk into the room, they can stop another present, right?

So it's whatever works for that person.

So that they're really there, their thoughts,

their energy is really in what's going on.

And the same thing applies on the other end.

There are people who are really well served by,

going for a walk if they can,

or sitting quietly after therapy,

kind of putting that in order, right?

Otherwise they lose some of it, right?

Or like some of the ahas, right?

Or the, oh, that's an interesting thought

that they really need to put it in order.

Maybe that involves taking some notes during therapy, right?

For other people, they need to do the exact opposite.

They need to like leave, not think about that at all.

And then they can reflect on it later and learn from it.

So we're so different.

Human beings, there's such a diversity in us

that there's no hard answer to that,

but it's like being present when it's happening,

then being able to sort of consolidate

and retain what's been gained is most important.

And I think we have to figure that out person by person.

I mean, I try and do that in the work of like

what's serving this person best.

And sometimes we,

sometimes it evolves and sometimes we talk about it,

but it varies so much.

- Hmm.

- If someone were thinking about embarking

on therapy or more therapy

to address trauma or just general issues of life,

what is the frequency that you recommend?

I could imagine two extreme models.

One is, okay,

I'm going to finally tackle this trauma.

I'm going to do therapy three times a week,

but for a shorter period of time, six months,

over and out versus this open ended model of once a week,

typically for as long as it takes.

- Right, right.

I think that also varies.

And I work with people in varied ways from oh,

someone who's doing well

and like we meet for a half hour every six months, right?

To doing week long,

hourly sessions, to spending three intense days

with someone in a row, right?

So I think as far as like kind of guiding principles,

what I have found in my own life,

'cause I value my own therapy tremendously.

So I found in my own life and in my own clinical work

that if it's less than once a week,

then it's hard for us to retain really.

We spend a lot of time kind of catching up, okay,

what's happened?

Let's get back to the place we were at before, right?

Which is why I think if we're really going to get somewhere,

we're not just trying to maintain something, right?

Then I think once a week for an hour

is really kind of the minimum, right?

But more intensive work.

It's like the more I intense it is,

it's not linear, right?

It's an exponential gain.

Like we do a lot of intensive work, right?

where someone will come and do 30 clinical hours

with us over the course of a week.

So five or six different clinicians, 30 clinical hours.

And you know,

we've found that the benefits of doing that are immense.

It's like let's say a year's worth

of therapy consolidated and you take well, 30 hours,

let's say, we go almost every week,

maybe that's 45 or 50 hours,

but 30 hours with that kind of intensity

is worth probably 60 hours,

done in a different way,

because then it's in us in an active way, right?

It's in the therapist in an active way,

it becomes very, very dynamic.

So I think turning up the intensity,

if there's something that we really need to process,

absolutely makes sense.

And I do that in my own life

is something now's like, whoa, it's really,

somebody is really distressing me

and it's linking into prior trauma

and I can see what's going on in me.

Now I start to have ruminative thoughts, you know,

with negativity, I'm like, I got to go more, right?

Because I got to do that processing.

So I can get to the place that I am,

which is not that,

it's not that the trauma has no impact on me, right?

It' that the impact is much less than it was before

the therapy and that I most often

and more often than not have an ability to see

when it's now intruding into my thoughts.

And it's taking me away from like

what I really think and believe,

or being able to draw logic and emotion together

and make good decisions.

Turning up the intensity then absolutely makes sense.

- This very deep, intensive work of 30 hours in a week.

What brings somebody to some, the type of work of that sort?

Is it a suicide risk or a severe addiction situation?

I mean, how does one gauge how much therapy

they ought to be doing and should it always be

on the therapist to decide that frequency?

What would bring someone

to a situation of five therapists in 30 hours

a week in one week?

- Right, right.

Yeah, it's usually a person who is really distressed

by something whether that's,

it's so negatively impacting their life

or sometimes a person comes to realization.

I just can't take this anymore, right?

I'm sick of the cyclical depression.

I got to stop having panic attacks.

I need help, right?

But it's usually some,

crisis point with the idea of crisis in the meaning of,

okay, something comes to a head and after it,

things are going to be different, right?

Not a crisis and things are going to be negative afterwards,

but a point where, where then that cognitive flexibility

comes to the fore of like,

well, I need to do something different, right?

So that's often what brings us.

Sometimes it's other people pointing it out

or somebody's had an intervention somewhere or yes,

that person's been hospitalized after a suicide attempt

or they've gone back to

rehab again for the third or fourth time.

And their life is really in danger.

Sometimes it's that.

And sometimes it's a person realizing, yeah, I just want to,

I want to look at myself, I want to understand myself better.

I know that what's going on in me,

isn't as good as it can be, right?

So I think people can come to it

for all sorts of different ways.

And I think, yes,

I think a lot of times it would be the therapist to say,

more work, more intensive work or can make a difference.

But I think the person also needs to,

take ownership, right?

Of their own therapy and say,

if I don't feel helped enough,

well, I have to think about that, right?

And talk to the therapist about that, 'cause it,

maybe that therapist isn't a match, right?

Or maybe you talk to the therapist and the therapist

can change his or her approach, right?

Or maybe you talk to the therapist

and increase the frequency, right?

But the idea is to be aware of it, right?

And if one's needs,

aren't being met to acknowledge that, right?

'Cause people can get into a rhythm of therapy

where it's really not helping them, right?

But they either feel sort of nihilistic about it.

Like, oh, I'm no better and I'm going to therapy, right?

Or sometimes there's a sense that while I'm in therapy,

so I'm kind of checking that box of doing something

for myself, but it's not really getting me anywhere.

And then the part of the brain that's controlled

by the guilt and shame and avoidance

thinks that's a great idea, right?

So again, this ability to observe ourselves

and like what's going on,

am I being helped in the way,

do I feel helped, right?

Am I in some ways,

even like happy that I'm not feeling helped.

'Cause I don't have to face

this thing I don't want to face, right?

Or am I too afraid to say I need more help, right?

Do we really need to look at ourselves?

And this is where the insurance systems

often are very difficult,

'cause it's hard sometimes for a person to say,

I need more therapy 'cause that may not be possible, right?

So there are sort of negative factors

in the world around us.

But ultimately I think the answer to the question comes down

to observing ourselves and taking ownership

of like what's going on in us and how we're feeling.

And then feeling that,

that commitment to self or to self-care to say,

I need to go change this.

- And for those that maybe don't have the means

or insurance or access to do even one day

a week therapy in the journaling model.

- [Paul] Yes.

- Could one perhaps take an entire day

as awful as it might seem,

to do a lot of journaling and thinking and walking,

do a self-generated intensive.

Do you think there's utility to that?

- I mean there could be,

but again it depends by person 'cause

there could also be something negative about that

if it's someone who's not at the point,

not ready for that, right?

I mean we don't come at,

we don't come directly at the trauma immediately,

at least most of the time we don't do that, right?

And we often don't explore it in depth.

Like this idea that, oh,

that person now has to go through every second of the trauma

is actually not true.

I mean sometimes it is, but that's,

that's not the common situation, right?

So more often that person has to acknowledge

like the example of like I was sexually abused

and have to acknowledge that and to, and say,

okay, like, gosh,

what has that done to me?

That doesn't mean,

well let's parse out every moment

of like how that was and the terror of that, right?

So that can lead people to a worse place, right?

So, I think the idea of biting off small pieces,

so to speak where a person is writing, right?

Or is talking.

But I think if one is writing,

it is good to communicate with another, right?

Another trusted person.

And if there's not someone in one's personal life,

there are clergy members,

even if one isn't a affiliated with an organized religion,

you could probably go places

and get clergy to want to help you, right?

I mean, there are people out there

who want to help other people.

So we say, what if someone has no one, I mean,

almost never do we have no one here, right?

'Cause we could probably go find someone,

but we need to kind of take that in pieces.

So there's some risk like trying to do the intensive thing,

you know, on one's own.

And that's where I would put in,

if a person's having suicidal thoughts

or even thoughts of death, of not wanting to be alive,

I don't deserve to be alive.

I mean, these are warning signs for really getting help.

So there are some signs that say, hey,

don't try and do that on your own, right?

Go try and find a resource.

And it's things that get to that level of severity of,

and often a person knows that.

I mean, am I in a place where I know

I'm not healthy

and I'm having kind of scary thoughts,

then we need,

that's a person who really shouldn't be doing

that on their own.

- Great, thank you for that.

- Yeah, you're welcome.

- So we've been talking a lot about talking.

- Huhm.

- And now I'd like to talk a little bit about chemistry.

- Yes.

- Drugs.

- [Paul] Yes.

- So maybe first we could talk prescription drugs.

I mean you're a psychiatrist, so you're approved to,

and presumably do prescribe medication where appropriate.

I mean, this is a vast landscape of course.

We've got ADHD and I should just tell you,

I get more questions about ADHD and the drugs related

to ADHD and dopamine than any other topic, any other topic.

So there's ADHD, there's OCD, there's depression,

there's antidepressants and so forth.

Is there some way that we can,

wrap our arms around all of that

as a way of waiting into this,

this drug question and just address,

how does one decide when medication is useful?

Because in the end,

the dissection tool that the psychiatrist

or therapist has is language.

And at some point,

one has to make an assessment about dopamine or serotonin

or whether or not a given drug would help.

And most therapies,

I believe don't involve putting someone in a brain scanner.

And to my knowledge,

there still is not a very good blood test to assess,

oh, is this person's dopamine low or high,

correct me if I'm wrong.

And ultimately that,

and I know there are companies out there,

so I'm not trying to undermine those companies.

But if I happen to do that in this statement,

if you take a blood test and find that your serotonin

metabolites are low,

my understanding is it's possible that you are too low

in serotonin in the brain,

but that's a very indirect window

into what's really going on.

So how does,

how do you think about prescription drugs in the context

of treating trauma and other conditions and then maybe

we'll drill into some of the more specific conditions?

- Sure, I mean,

I would first comment that right there aren't tests

for these things.

And I think the tests for metabolites,

I mean, things are so different.

By the time, what we're talking about has been metabolized,

often to some very significant extent.

Left the brain,

now it's in the peripheral blood

that we really don't learn from that, right?

I think that we tend to over utilize medicines in this

country because we have a healthcare system

that often that's so based on throughput that we want to

polish the hood when there's a problem in the engine, right?

So we overutilize medicines often as an end point, right?

Oh, we're going to make that person's depression better

with an antidepressant.

Well, I mean maybe, right?

But most of the time for the person's depression

to really get better and stay better,

they need to unravel what's driving the depression, right'

So the first step is I think

they're cut two steps to it, right?

The first assessment step is,

is there a diagnosis that,

that the vast majority of the time,

if not sometimes, all the time, really warrants a medicine?

So the bipolar disorder, OCD, ADD, right?

These are diagnoses that we,

we understand more about them and what's going on

in the brain and how medicines can treat or stabilize them,

which doesn't mean the medicine is necessarily,

it's not a substitute for therapy, right?

But sometimes the medicine and therapy can go hand in hand.

So for OCD, for example, warrants therapy, but it almost,

not always, but it almost always warrants medicine too,

so that you can ease the systems that are making

the rigidity and the repetition in the brain.

So the first kind of branch point can be,

what is the diagnosis?

What is the level of severity, right?

And I think that's very,

very important where I think it's a little more,

maybe even interesting is using medicines

to help the person engage in the therapy

as productively as possible.

And here's where I think we're so limited

by how we categorize medicines

and this sort of pharmaceutical

insurance driven medical system

we have that I think throws us off in tremendous ways.

So you think about how medicines are categorized,

so antidepressants.

And the vast majority of people who are

helped by antidepressants,

they're not, they don't have

clinically severe depression, right?

Those medicines create more distress tolerance in us, right?

And if you think about how helpful that can be,

if you're going to go,

now you're going to do something difficult, right?

You're going to bring that trauma or the stressors

to the surface and you're going to process

and you're going to try and make life change.

If we can make more distress tolerance in us,

that can be so, so much better, right?

And think about the category of medicines that are called

antipsychotics, which really puts people off, right?

But most of the prescriptions for antipsychotics

are not for psychosis, right?

And there are ways in which low dosing of some of those

medicines can help intervene in negative pathways, right?

In pathways that are about distress.

And sending out those tendrils

of neurons that are about hyper vigilance

and avoidance, right?

In in our brain.

And we can often get at that.

And if you can improve someone's distress tolerance

and you can use medicines

that take away what clinically is rumination, right?

Not the standard meaning of that word,

but the clinical meaning of it,

where there are distress centers in our brain

that are overactive.

And then we get stuck in these maladaptive negative pathways

where we think about something over and over and over again,

with no real chance of solving it because that's not what's

going on inside of us.

So medicines can help that,

but we have to have some flexibility

around their conception

and the modern medical system of like 15 minute visits,

to a psychiatrist that are weeks apart.

I mean, I don't understand how that goes well, right?

In the vast majority of times,

I think it doesn't go well because it's not enough time

to do the therapy, even generate the understanding.

So then medicines get thrown into the person.

This is how,

we use, I think approximately five times as much medicine,

I think across the board as say the Dutch population, right?

Then you think, well, why is five times more,

is a lot more medicine, right?

And you know, they have a healthcare system

and a cultural system that to the best of my understanding

is more rooted in taking responsibility for oneself, right?

So if a person comes in and cholesterol is high, right?

The first order of business is,

hey, you could take better care of yourself, right?

Like this person really needs to lose

some weight exercise more, right'

They're not just jumping to like,

let me give you a medicine and you know,

and shift you through the healthcare system

and out the other side of the door, right?

And the same thing is true in mental health,

and I'm not trying to be critical

to the psychiatrists or the nurse practitioners or people

who are practicing in that way,

because oftentimes there is no choice, right?

If they're working in a healthcare system that,

that the standard is highly spaced or spaced apart,

15 minute visits, what alternative is there, right.

But to look at, okay,

I'm going to use medicines because I don't have another

tool to bring to bear.

So I think the healthcare system and its focus on throughput

and it's short term talk about,

we talk about short term response, right?

Short term soothing at the expense of long-term health.

And I think that is the metaphor for,

that applies to our healthcare system, right?

Where if we,

if we are going to try and treat a symptom in a short term,

we're going to do it in a 15 minute visit,

that we're going to do it in a way

that maybe it soothes a symptom,

maybe it doesn't, but it does not get at the problem.

We need to invest more resources to get at the problem

and I think that's where a sort of protest,

if people, as a society, we say,

look, we don't like the way our healthcare is going.

Like, we need more focus on what the actual problems

are that yes,

we would spend more money,

to treating people and taking care of people

'cause it's more human time,

but ultimately about less suffering, less death, right?

And ultimately more productivity.

I think as an economy,

we would save so much money if we spend money on the human

aspects of mental healthcare,

because people would be more functional.

They're spending less time in the hospital, right?

They're more productive when they're working.

There's less entry into the criminal justice system.

So I think medicines get overused

in part for systemic reasons,

in large part, for systemic reasons.

And also for some of these categorization reasons,

oh, that person meets some technical criteria

for depression.

We got to give them this medicine instead of really thinking,

wait, what's going on in this person.

And I see this over and over again.

I see one who is on seven medicines

and they're on seven medicines

to treat seven different symptoms.

And now they have side effects

from all those seven medicines.

Maybe two of them are to treat the side effects

from the other five, right?

And that's bad, right?

And if you really get at what's going on in them,

now they're doing much better

and maybe they're on two medicines, right?

So I dunno if that's a helpful answer to that.

- It is, it's a very helpful answer.

I mean, I think at least in the spheres

that I run these days,

I hear a lot of negative statements about antidepressants.

I think, I'm old enough to remember

the book, "Listening to Prozac."

I remember when Prozac and its

and things like it first started showing up

and the excitement.

And then nowadays I hear more about the problems with all

these drugs and maybe that's just,

'cause I have arms in the, both the scientific,

but also in the kind of wellness community

where people think a lot about behavioral change.

Fortunately I think that's that they do that.

But of course these drugs, as you mentioned,

can have enormous utility as well.

- [Paul] Yes.

- I'd like to just pick up on one theme

that I haven't heard a lot about anywhere else,

which is the short term versus

the long term use of these drugs.

'Cause I could imagine,

someone feeling like they're finally going to tackle something

that's been inside them for a long time either

because they're really struggling

or because they're just done with

not working it through

and they decide to start a medication

that would give them higher levels of distress tolerance

for a short while.

I mean, is there anything to say

that someone couldn't take a properly prescribed medication

for a week or for the first three months of the work?

- Yes.

- And then know that they can come off it

because I think that the black and white model of, okay,

you're either going to start this drug and stay on it forever

or be taking some drugs forever.

- [Paul] Right.

- Or you're not going to take anything.

I mean, that just seems to,

life doesn't have,

does life have to work that way?

- [Paul] Right.

Is there a short term use that can be effective?

- Yeah, absolutely, yes.

In American medicine we are so much better at starting

medicines than we are at taking them away, right?

And part of that I think is driven by such a strong

presence of the pharmaceutical industry

and the pharmaceutical industry

does a lot of very good things, right?

But you know,

there's such thing as too much of a good thing, right?

And then as a society, when something seems positive,

this I think also is human nature.

We can overinvest in it, right?

So you think about when Prozac and those kinds of medicines

came out, they were safer medicines,

they're billed as antidepressants and the thought was,

well, they're going to fix depression, right?

And it's not how that works, right?

So if we look at them as tools, right,

then we can deploy them sometimes for the longer term

'cause sometimes that's necessary.

But absolutely for the shorter term, absolutely.

If we thought of Prozac and those kind of medicines,

not as, oh they're antidepressants, we think, look,

what they do is they,

they seem to make there be more serotonin in certain

circuits that are important for mood regulation,

anxiety regulation, distress tolerance.

So those medicines can really help somebody

if they're very severely depressed

and we want to sort of get them feeling better.

They can also help someone if they could use more distress

tolerance in a discrete period of time, right?

When we think about them that way,

we think about them as tools that we could apply

for short term or long term.

We don't see them as fixes, right?

And we don't see them as then substitutes

for the human to human work

that needs to be done.

I mean, I've been sort of in my training

at times in healthcare systems

and I've seen in many other circumstances

that look at medicines as answers and this idea that,

that person is a, and a lot of times

there'll be a number, right, right?

And the number is the diagnosis

and that number gets this medicine.

And I'm not sure we could be more misguided than that

and that's what leads to adding medicines, adding medicines,

it's not working.

Of course it's not working,

because no one's really paying attention to what's going on.

So add more medicines and then medicines for the medicines.

And I mean, we know this is true.

We know this is true,

but we haven't had the wherewithal as a society

to say like with a lot of things in society,

to say like this isn't okay, right?

I mean, we need more.

Like give these people who are trying to help us.

They need more latitude to help us.

We need more human to human contact

to get at what's really going on, and yes,

that's an investment of time and energy and money

in the short term and sometimes that's money

from the systems, right?

But if we do that, my goodness, look at the,

look at the payoff of that.

- What is your thought about anxiety

and ADHD as a separate phenomena,

in terms of medication.

Again, ADHD is the thing

that seems to come up most in questions.

I can't tell you the number of especially students,

but also young working professionals

and even people who are

outside those categories who are interested or taking

Ritalin, Adderall, Modafinil or Armodafinil or Vyvanse,

because they seem to struggle focusing without it.

Or, and I don't know,

'cause I'm not one of those individuals,

or because they seem to just like how well they can focus

when they do take those compounds.

And so my understanding is these compounds mainly increase

dopaminergic transmission in the brain,

also adrenaline, epinephrine in the brain.

So they're more or less stimulants.

They look a lot like, at least chemically,

they look a lot like cocaine and amphetamine,

although they're not quite cocaine and amphetamine.

So should we be concerned about this?

Is this a different sort of epidemic?

Can these drugs be used to train the brain

to focus and then people can withdraw from these drugs?

I mean, I think this is a huge topic

and one that maybe warrants its own episode entirely,

but as long as we're on the topic,

what are your thoughts about medication for ADHD?

- Sure, I think medication for ADHD

can be extremely effective

and the studies show us that, right?

They show us that if there is ADD,

then medication for ADD,

is very, very helpful and that's true in youths,

it seems to be true if adults have adult ADHD or ADD,

we kind of know that's true,

but all attention deficit

is not Attention Deficit Disorder, right?

And there we go to the reflexive 15 minute visits,

throw medicines at things, right?

Attention deficit can come from many, many places.

And one of them is anxiety, right?

There's so many other reasons depression affects attention,

poor sleep affects attention,

poor diet can affect attention,

stress in life can affect attention.

So, and, and certainly trauma.

And the thing,

the problems that trauma spins off can affect attention.

So this is really the,

this is really the truth that while teaching once about

medicines and pharmacology,

I was frustrated about how the answer to everything

was like, what medicine do we use?

What medicine do we use, as opposed to like,

this is just one piece of the puzzle.

And I told an anecdote, which,

I think it was a clinical anecdote,

like what do you think is going on?

And I think that if I told that to, I dunno,

middle school students or something,

they would probably say,

you just told a story of a person with a rock in their shoe,

which is what I, the story

that I was actually telling, right?

But several people I was talking to,

they're physicians, right?

ADD, right?

It's like, no,

every time the person steps down the rock hurts

and they're not able to maintain attention, right?

Like that's what's going on.

But we're so programmed to think about medicines

and inappropriate use of ADD medicines, as you said,

there's dopaminergic impact.

There's epinephrine, norepinephrine impact.

We're affecting what are called

prefrontal alpha 2 receptors

that like really need to be helped if there's real ADD

but if there isn't, that is not a good thing to do,

which is why it is quite fascinating

that when people have ADD,

they tolerate generally stimulants very well,

without the other problems that can come of stimulants.

And again, I don't know, I don't claim to know why that is,

but we see that phenomenon.

But when people are being treated for ADD

and they don't have ADD,

which sometimes they know they don't have ADD,

but the stimulants make them function better.

So they go to somebody and get the stimulants.

That's not a good thing to do, right?

'Cause stimulants, when they're not needed over time,

they do affect our physical function.

They affect our judgment, right?

There are a lot of negative things that come from that.

They can affect the vigilance inside of us.

So, yes, it's a valid diagnosis,

but it gets made when it's not present very often,

which we see with a lot of diagnoses

that you can throw medicine at.

We see the same thing with bipolar disorder.

True bipolar disorder is extremely important

to utilize medicines effectively,

but how many people are diagnosed with bipolar disorder

who have, they absolutely don't have bipolar disorder,

but it can be a catchall diagnosis

because there is in a sense,

"something to do for it," right?

And you can throw medicine at it, right?

So I mean, what do we expect, right?

If we have a healthcare system where you get 15 minute

visits with your psychiatrist,

of course we're going to throw medicines at everything.

And then the training paradigms

are going to look at it through that lens.

And then very often again,

I give the example of seeing somebody on seven medicines.

I mean the first thought I have is how many of those

medicines are actually counterproductive?

And a lot of the time it's not like, oh,

every now and then one is counterproductive.

No, that's the case.

That's the case a lot of the time.

And again, I come back to,

if we're not putting thought into it,

what other result would we expect?

- Thank you for that answer.

I'm very curious what constitutes negative effects

of stimulants.

So if somebody's taking Adderall or Ritalin in order

to work longer hours or focus

because they have attention deficit,

but not necessarily ADHD.

And again, I'm not recommending anyone do this.

I've just heard the numbers that have come back at least

from surveys and discussions

with colleagues at Stanford and elsewhere,

other college campuses that upwards of 75% of college

students use semi regularly, these drugs off,

not by prescription, just to study and to learn.

- [Paul] Yes.

- I can imagine sleep issues because people,

because these are stimulants,

what sorts of other issues can they create for people

problems that they can create?

- Sure, I mean,

I think a touchstone maybe

that's running through our conversation, right,

is prioritizing the short term benefit

over solving a long-term problem, right?

Which we might say is a human tendency

and we see it across the topics that we're discussing.

So, short-term use of stimulants.

Sure, people are more alert.

They can stay awake more,

they can study more intensely and longer.

Okay, there's some short-term benefit of that,

over there, even there, there can be problems, right?

But we can say,

let's just say for sake of argument that in the short term,

there's something to be gained by doing that, right?

But oh my goodness, there's so much that is,

there's so much risk to that, right?

And how many times have I seen someone

who they're doing that

and they're just doing that to study, right?

And now they're addicted to the amphetamines

and their behavior changes and they don't know it.

Talk about shifting our brain towards a more defensive,

sort of suspicious, outward look,

view of the world that we see a lot of that.

So we see judgment impairment,

we see heightened levels of anxiety.

We see more impulsivity in decision-making.

And sometimes we,

it can get to the point of seeing Frank psychosis.

Now, that's not common,

but have I seen young people

who've done exactly what you're describing, right?

They're using Adderall or they're using Ritalin to study.

And then I see them when they're coming into the hospital,

they're screaming about how someone's trying to hurt them.

Boy, it's the worst case scenario,

but it shows like that's where that can go.

And how much is there between the,

oh, I'm just using it to study and that severe,

outcome that is actually quite negative for a person

and it might change how they think

about that friendship or that relationship, right?

A lot negative happens when we change our brains

without an ability to see like,

what is it actually doing to us?

So, which is part of my whole theme about trauma, right?

It changes our brains and we don't know it, right?

Well the same can be,

the same is often true of amphetamines used inappropriately.

It shifts our brain.

And we don't realize that we're a little bit more impulsive

in our decision making, a little bit less trusting.

These are significant negative things

that if we don't know it,

the person will just say, yeah,

oh, I'm just using it to study.

I'm using it to work more.

That's not, you know,

that's not without it's high level of risk.

- What are your thoughts on cannabis?

I've said it many times on this podcast

before and I'll say again,

I feel fortunate that I've never really been attracted

to alcohol or drugs of any kind ,

so much so that if all the alcohol and all the marijuana

and all the cocaine amphetamine disappeared,

I wouldn't notice any change in my life, right?

And I feel lucky in that way,

'cause I know a lot of people feel

an attraction to these things

that it is almost a gravitational force.

- [Paul] Yes.

- From their first drink, they just feel,

I once heard it described in this,

I think it was an Augusten Burroughs book, "Dry"

where he was an alcoholic.

He said that the first drink he had,

it felt like this magic elixir

that meshed with the physiology of his blood

in the most seamless way

and as I was reading this, I thought,

oh my goodness, first of all,

that's the most foreign experience

for me in terms of alcohol.

And second gosh, that must be terrible.

And you can,

but at the same time you could really understand

why someone would be drawn to that.

- Yes.

So cannabis nowadays is legal

or decriminalized in many areas of the U.S.

A lot of people seem to use the argument,

it's better than drinking

or they only do it for sleep or anxiety management.

I'm not looking to demonize or support the cannabis.

So what are your thoughts about cannabis

for anxiety management, depression?

And maybe even for ADHD for that matter.

Sure.

- If I could make an alcohol comment, right?

The number of times I've seen alcohol

like having been a good idea for coping

with something approaches zero, right?

Like the alcohol for coping is just never good.

And there's an additional risk factor that there's certain

genetic profiles where people respond strongly to alcohol.

Like, as you're saying, it's not just,

oh, there's a little bit of short term relief of distress,

but there's this sort of euphoric response

and those genetics,

we don't understand them completely.

They seem to be in Northern European populations,

more prevalent as you head west in Northern Europe.

So we understand where risk factors are demographically,

but we can't pinpoint that for any one person.

And there's a tremendous risk of that,

when a person responds so strongly to alcohol or habituates

coping to alcohol.

Cannabis is a little bit of a different story.

I mean, how I have seen that play out,

and again, this isn't coming from any expertise

around the neuro the neuropharmacology of it,

like how is this really working in the brain?

But it comes from an observation

that what it seems to do is to narrow our attentional

perspective, right?

So it's why people will say, well, they want to,

they want to use cannabis

before like watching a movie with friends

or something, right?

And, and I think, okay,

I think why people are doing that

is because our cognitive spectrum narrows.